NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to implement suicide precautions for an acutely suicidal client. Which nursing interventions are included with regard to these precautions?
Correct Answer: A,B,C,D,E
Rationale: Suicide precautions involve constant observation of the client by the nursing staff. This intense attention from the nurse provides for safety and also allows for constant reassessment of risk. Suicide precautions include maintaining arm's length distance with the client at all times; ensuring that meal trays contain no glass or metal silverware; carefully watching the client swallow each dose of medication; conducting one-on-one nursing observation and interaction 24 hours a day and explaining to the client the procedures involved with suicide precautions; and documenting client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. During observation when the client is sleeping, the client's hands should always be in view and not under the bedcovers.
Question 2 of 5
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
Correct Answer: D
Rationale:
To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (
Choice
A) may lead to unreliable information, and a drug reference book (
Choice
B) may not address individualized questions. While the written instructions may contain information (
Choice
C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.
Question 3 of 5
A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?
Correct Answer: A
Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.
Question 4 of 5
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building.
Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
Question 5 of 5
The nurse on the psychiatric unit notices that a client diagnosed with depression does not eat meals. Which response by the nurse is appropriate?
Correct Answer: B
Rationale: Asking the client to identify favorite foods engages them in their care and may increase appetite by incorporating preferences, addressing the underlying issue of poor intake. Other options may not address motivation or may impose goals without client input.