NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
When administering medications through a nasogastric tube connected to low intermittent suction, which action should the nurse do first?
Correct Answer: D
Rationale: When administering medications through a nasogastric tube connected to low intermittent suction, the nurse should first turn off the intermittent suction device. This step is crucial to prevent the medications from being immediately suctioned out before they can be absorbed. Clamping the nasogastric tube is not the initial action because it may cause pressure buildup and lead to complications. Confirming the placement of the tube is important but should not be the first step in this scenario. Using a syringe to instill the medications comes after ensuring the suction is turned off to enable proper administration and absorption of the medications.
Question 2 of 5
Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?
Correct Answer: D
Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.
Question 3 of 5
A 16-year-old client with Crohn's disease is hospitalized. Which statement by the client would alert the nurse to a potential developmental problem?
Correct Answer: C
Rationale: Adolescents who withdraw from peers into isolation struggle with developing identity, so option 3 should cause the nurse to be concerned. It is appropriate for the client to ask for hygiene measures to be attended to before the peer group arrives. Option 2 indicates that the client is eager for companionship. Adolescents often develop special interests within their groups that may help them maximize certain skills, such as with computers.
Question 4 of 5
The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
Question 5 of 5
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
Correct Answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.