NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.
Question 2 of 5
The nurse is planning care for a client who is experiencing anxiety after a myocardial infarction. Which priority nursing intervention should be included in the plan of care?
Correct Answer: A
Rationale: Accurate information reduces fear, strengthens the nurse-client relationship, and assists the client with dealing realistically with the situation. Providing detailed information may increase the client's anxiety. Information should be provided simply and clearly. Encouraging family involvement may or may not be helpful. Medication should not be used unless necessary.
Question 3 of 5
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.
Question 4 of 5
A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client? Select all that apply.
Correct Answer: B,D,E
Rationale: A lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known pathology. Using a commode behind a curtain may inhibit voiding for some individuals, especially with a roommate present. The use of a bathroom is preferable, and this may be supplemented with the use of running water or pouring water over the perineum, as needed. Catheterization is not a nursing intervention and presents a risk of infection. If noninvasive techniques do not work, then the primary health care provider may prescribe that the client be catheterized.
Question 5 of 5
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.