NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
Correct Answer: C
Rationale: The most important health promotion brochure to provide to an obese client newly diagnosed with arteriosclerosis is one focused on decreasing cholesterol levels through diet. Arteriosclerosis is significantly influenced by excess dietary fat, especially saturated fat and cholesterol. Monitoring blood pressure at home, while important, does not directly address the underlying cause of arteriosclerosis. Smoking cessation and stress management are crucial for overall cardiovascular health, but lowering cholesterol through diet takes precedence in this scenario.
Question 3 of 5
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
Question 4 of 5
The nurse plans care for a client diagnosed with anorexia nervosa. Which goal will the nurse make a priority for this client?
Correct Answer: A
Rationale: Gradual weight gain (0.25 lb/week) is the priority goal for anorexia, addressing malnutrition and physical health risks. Electrolyte balance and meal consumption are important but secondary, and identifying normal weight is a long-term cognitive goal.
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.