NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?
Correct Answer: A
Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.
Question 2 of 5
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
Correct Answer: A
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.
Question 3 of 5
Which of the following mental health situations is considered a psychiatric emergency?
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SA
D) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
Question 4 of 5
A female client with the diagnosis of mania emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety for the client. Insisting that the client go to her room may cause the nurse to be met with a great deal of resistance. Confronting the client and offering her a consequence of time out may be meaningless to her. Asking other clients to ignore her is inappropriate. A quiet but firm approach while distracting the client (walking her to her room and helping her to get dressed) achieves the goal of having the client dressed appropriately and preserving her psychosocial integrity.
Question 5 of 5
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
Correct Answer: B
Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (
B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.