NCLEX-PN
Psychosocial Integrity Nclex PN Questions Questions
Extract:
Question 1 of 5
Support-system enhancement includes all of the following except:
Correct Answer: C
Rationale: Support-system enhancement involves various strategies to strengthen the support system. Determining the barriers to using support systems, discussing ways to help others who are concerned, and involving spouse, family, and friends in the care and planning are all essential aspects of enhancing the support system. However, exploring the life problems of the support-team members is not directly related to enhancing the support system. This approach could potentially invade personal boundaries and may not be necessary for improving the support system, making it the correct answer in this case.
Therefore, option C is the correct answer as it does not align with the appropriate methods of support-system enhancement.
Question 2 of 5
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
Correct Answer: B
Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death.
Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.
Question 3 of 5
When assessing a client with amyotrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?
Correct Answer: B
Rationale: ALS causes progressive muscular weakness and wasting, while cognitive function and sensory abilities remain intact, though grieving may occur.
Question 4 of 5
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
Correct Answer: C
Rationale: Explanation: Ashley is displaying symptoms of severe anxiety, including confusion, trouble focusing, dizziness, nausea, rapid pulse, and hyperventilation. These somatic symptoms, along with changes in vital signs, indicate severe anxiety. In severe anxiety, individuals are unable to solve problems and have a poor grasp of their environment. On the other hand, mild anxiety may lead to mild discomfort or even enhanced performance, while moderate anxiety results in difficulty grasping information and minor changes in vital signs. Panic, the most severe level of anxiety, involves markedly disturbed behavior and a potential loss of touch with reality.
Therefore, based on Ashley's symptoms, her anxiety level should be assessed as severe.
Question 5 of 5
Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?
Correct Answer: A
Rationale: The correct statement is that fat emulsions have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories, respectively, for each milliliter. In comparison, a milliliter of 5% dextrose only supplies 0.17 kilocalories.
Choices B, C, and D are incorrect.
Choice B is false because fat emulsions are essentially pH neutral and isotonic, not hypertonic.
Choice C is incorrect because fat emulsions are not basic solutions; they are essentially pH neutral.
Choice D is incorrect as fat emulsions are not alkaline; they are pH neutral, making them compatible with most medications.