NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?
Correct Answer: B
Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.
Question 2 of 5
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?
Correct Answer: B
Rationale: Surgical incisions or the loss of a body part can alter a client's body image. The onset of problems coping with these changes may occur during the immediate or extended postoperative stage. Nursing interventions primarily involve providing psychological support. The nurse should encourage the client to express how he or she feels about these postoperative changes that will affect his or her life. Option 1 is an incorrect statement because open grieving is normal. Option 3 indicates disapproval, and in option 4, the nurse is giving advice.
Question 3 of 5
A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
Correct Answer: D
Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.
Question 4 of 5
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
Question 5 of 5
A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
Correct Answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.