Psychosocial Integrity NCLEX Questions Quizlet

Extract:

Question 1 of 5

Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:

Correct Answer: B

Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (
Choice
A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (
Choice
C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (
Choice
D) can introduce bias and may not lead to an objective evaluation.

Question 2 of 5

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour D. Drink approximately 4 ounces of water every hour

Correct Answer: C

Rationale:
To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

Question 3 of 5

Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:

A. document the other worker's assessment of the patient. B. assess the patient based on data collected from all sources. C. validate the worker's impression by contacting the patient's significant other. D. discuss the worker's impression with the patient during the assessment interview

Correct Answer: B

Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (
Choice
A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (
Choice
C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (
Choice
D) can introduce bias and may not lead to an objective evaluation.

Question 4 of 5

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?

A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the healthcare provider of a possible obstruction.

Correct Answer: C

Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option
A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option
B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option
D) as the catheter could be inserted easily.

Question 5 of 5

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward from underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct Answer: B

Rationale: Option B is the correct procedure for assisting a client from the bed to a chair. By positioning the nurse's feet apart and aligning the knees with the client's knees, the nurse maintains a stable base of support while pivoting the client into the chair. This technique minimizes the risk of injury to both the nurse and the client. Placing the chair at a 45-degree angle to the bed, with the back of the chair toward the head of the bed, provides a clear path for the client to move. Option C is incorrect because lifting a client under the axillae can potentially cause nerve damage and strain. Option D is also incorrect as it involves an unsafe method of moving the client and can lead to injuries or accidents.

Psychosocial Integrity NCLEX Questions Quizlet - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN