NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, 'I really miss eating dinner with my family.' Which statement from the nurse is the most therapeutic?
Correct Answer: B
Rationale: The nurse assists the client with expressing feelings and dealing with the aspects of illness and treatment by clarifying and helping the client to focus on and explore concerns. In option 1, the nurse characterizes and classifies the feelings on the basis of an assumption. Option 3 provides false hope and option 4 blocks communication by giving advice.
Question 2 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 3 of 5
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.
Question 4 of 5
When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option
B), confirming that the client has voided (option
C), and providing extra towels (option
D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing.
Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
Question 5 of 5
The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. Based on this information, the nurse determines that the client is experiencing which type of dysfunctional communication?
Correct Answer: A
Rationale: Mutism is the absence of verbal speech. The client does not communicate verbally despite an intact physical and structural ability to speak. Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to a rapidity of speech that reflects the client's racing thoughts. Poverty of speech involves diminished amounts of speech or monotonic replies.