NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
Correct Answer: D
Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.
Question 2 of 5
A client is very anxious about receiving chest physiotherapy (CPT) for the first time at home. When planning for the client's care, which concept about CPT should the home care nurse use to reassure the client?
Correct Answer: D
Rationale: CPT is an intervention to assist with mobilizing and clearing secretions to enhance more effective breathing. CPT will assist the client with coughing if the secretions have been mobilized and the cough stimulus is present. There are risks associated with CPT, including cardiac, gastrointestinal, neurological, and pulmonary effects. It will not resolve all of the client's respiratory symptoms.
Question 3 of 5
The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?
Correct Answer: C
Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration.
Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.
Question 4 of 5
Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
Correct Answer: D
Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery.
Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified.
Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase.
Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.
Question 5 of 5
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
Correct Answer: D
Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option
A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.