NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
Correct Answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
Question 2 of 5
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
Correct Answer: D
Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option
A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.
Question 3 of 5
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
Correct Answer: D
Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.
Question 4 of 5
A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.
Question 5 of 5
The nurse is caring for a client who is a victim of domestic violence. Which of the following would the nurse expect to find in the client's social history? Select all that apply.
Correct Answer: C,D
Rationale: History of child abuse and past abusive relationships are risk factors for domestic violence. Age, charity involvement, or profession are not specific risk factors.