NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry.
Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
Question 2 of 5
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option
A) or increasing fluids (Option
D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option
B) is premature without understanding the client's baseline.
Therefore, assessing the client's medical record is the priority before proceeding with any interventions.
Question 3 of 5
A client diagnosed with severe preeclampsia is admitted to the hospital. The client is a student at a local college and insists on continuing her studies while in the hospital, despite being instructed to rest. The client studies approximately 10 hours a day and has numerous visits from fellow students, family, and friends. Which intervention should the nurse use to best assist the client with promoting rest?
Correct Answer: B
Rationale: Option 2 involves the client in the decision-making process. In options 1 and 4 the nurse is judging the client's choices and asking probing questions; this will cause a breakdown in communication. Option 3 persuades the client's significant other to disagree with the client's actions. This could cause problems with the relationship between the client and the significant other, and it could also cause conflict in the client's communication with the health care workers.
Question 4 of 5
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
Question 5 of 5
The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. The nurse should recognize that which client objective is an unrealistic short-term goal?
Correct Answer: B
Rationale: Short-term goals include the beginning stages of dealing with the rape trauma. Clients will initially be expected to keep appointments, participate in care, start to explore feelings, and begin to heal the physical wounds that were inflicted at the time of the rape. The resolution of feelings of anxiety and fear is a long-term goal.