NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
Correct Answer: D
Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification.
Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.
Question 2 of 5
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
Correct Answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.
Question 3 of 5
The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?
Correct Answer: B
Rationale: Respecting the veteran’s need for space by keeping the environment quiet and maintaining distance reduces stimulation and potential escalation, especially during possible PTSD episodes. Approaching or touching may increase agitation, and reassurance is less actionable.
Question 4 of 5
The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?
Correct Answer: B
Rationale: When changing the route of administration from PO to IV, the absorption process is bypassed, leading to a more rapid onset of action of the medication and consequently a quicker effect.
Choices A, C, and D are incorrect. Increased drug tolerance and higher doses are not typical outcomes of changing the route of administration. Protein binding does not increase with a change to IV administration; rather, it is the bioavailability and onset of action that are affected. Moreover, an increased therapeutic index reduces the risk of drug toxicity, contrary to what is stated in choice D.
Question 5 of 5
The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
Correct Answer: D
Rationale: The priority action for the nurse is to gently lower the client to the floor (Option
D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option
A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option
B) is impractical as the client is already falling. Calling for help in a loud voice (Option
C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.