NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet Questions
Extract:
Question 1 of 5
To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
Correct Answer: D
Rationale:
To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis.
Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
Question 2 of 5
To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
Correct Answer: D
Rationale:
To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis.
Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
Question 3 of 5
The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
Correct Answer: B
Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.
Question 4 of 5
A client has been diagnosed with a form of terminal cancer and has started receiving hospice care. The nurse notes that both the client and his family avoid talking about the diagnosis. All attempts at discussion result in changing the subject. The nurse recognizes that this family is exhibiting:
Correct Answer: B
Rationale: The correct answer is 'Mutual pretense.' Mutual pretense is a form of awareness as a response to death or dying in which those involved avoid discussing the situation. In this scenario, both the client and the family are aware of the terminal cancer diagnosis, but they choose not to talk about it openly. This behavior can stem from various reasons, such as trying to shield loved ones from grief, fear of the future, or discomfort with discussing emotions. 'Closed awareness' (
Choice
A) refers to a lack of awareness of the impending death, which is not the case here. 'Open awareness' (
Choice
C) involves open acknowledgment and discussion of the terminal illness, which is contrary to the behavior described. 'Powerless assessment' (
Choice
D) does not relate to the situation of avoiding discussing the diagnosis in the context of terminal cancer and hospice care.
Question 5 of 5
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?
Correct Answer: A
Rationale: The correct answer is "I don't remember anything about what happened to me." This statement indicates the use of suppression, which is the willful act of putting an unacceptable thought or feeling out of one's mind. In this case, the client is deliberately excluding memories of the traumatic event to protect their self-esteem. The other choices do not reflect suppression:
Choice B shows avoidance or deflection,
Choice C demonstrates blame shifting, and
Choice D indicates empathy towards another individual.