NCLEX-RN
NCLEX Patient Needs Psychosocial Integrity Therapeutic Communications Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.
Question 2 of 5
The nurse is preparing a client for a parathyroidectomy when the client states, 'I guess I'll have to wear a scarf after this surgery.' Considering this statement, which concern should the nurse address?
Correct Answer: C
Rationale: The client's statement reflects a psychosocial concern regarding his or her appearance after surgery, so option 3 is the correct option. The remaining options identify unsuitable problems that are not supported by the provided client data.
Question 3 of 5
While providing care to a 12-year-old client, the nurse observes small round burn scars on the client's arms and legs, bruising on the buttocks, and tenderness of the right jaw. The client is anxious, has poor eye contact, and denies being injured at home when the nurse asks questions. Based on these observations, the nurse suspects victimization. Which is the next priority question the nurse should therapeutically ask the client in providing a safe environment for the client?
Correct Answer: D
Rationale: Based on the nurse's assessment data, the suspect of victimization needs to be analyzed to determine how the client received the old and new injuries. Option 4 offers the therapeutic approach for obtaining information using an open-ended question. It is important to determine if the injuries resulted from a family member or someone else outside the home. There are many forms of abuse besides physical abuse to consider such as sexual, emotional, and psychological abuse. Identifying the victimizer is important to stop the abuse and avoid further injuries. Safety is a priority concern for the client while in the care of the nurse and then after discharge from care. Option 1 implies that the nurse is challenging if the client is telling the truth. Option 2 could be perceived as demanding and a threat to the client to answer the question. Option 3 focuses on outside the family but there is not enough information given in the question to determine whether a family member is not suspected.
Question 4 of 5
An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate?
Correct Answer: B
Rationale: Option 2 is open-ended and makes no assumptions about the client's psychological or emotional state. Option 1 is incorrect because males in traditional standard Hispanic cultures practice 'machismo' in which stoicism is valued, so this client may deny any pain when asked. False reassurance is never therapeutic, which makes option 3 incorrect. Option 4 is incorrect because an assessment is necessary before administering medication for pain.
Question 5 of 5
A client diagnosed with nephrotic syndrome asks the nurse, 'Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!' Which should the nurse identify as the most appropriate concern for this client?
Correct Answer: B
Rationale: Powerlessness is present when the client believes that personal actions will not affect an outcome in any significant way. Because nephrotic syndrome is progressive, the client may feel that personal actions may not affect the disease process. Anxiety is appropriate when the client has a feeling of unease with a vague or undefined source. Difficulty coping occurs when the client has impaired adaptive abilities or behaviors with regard to meeting expected demands or roles. Negative self-image is when there is an alteration in the way that the client perceives his or her body image.