NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
Correct Answer: B
Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option
A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option
C) does not provide focused support to the weak side. Standing slightly in front and to the right (option
D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.
Question 2 of 5
A client is to have arterial blood gases drawn. While the nurse is performing Allen's test, the client states to the nurse, 'What are you doing? No one else has done that!' Which response the nurse makes to the client is most therapeutic?
Correct Answer: D
Rationale: Allen's test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response provides information to the client. Option 1 is defensive and nontherapeutic in that it offers false reassurance. Option 2 identifies client advocacy, but it is overly controlling and aggressive, and undermines treatment. Option 3 is aggressive, controlling, and nontherapeutic in its disapproving stance.
Question 3 of 5
Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
Correct Answer: D
Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery.
Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified.
Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase.
Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.
Question 4 of 5
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
Correct Answer: C
Rationale: The correct answer is 'Cranberry juice stops pathogens' adherence to the bladder.' Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. This helps prevent UTIs. Options A, B, and D are incorrect because orange juice with vitamin C, apple juice for urine acidification, and grapefruit juice for antibiotic absorption do not have the same proven effectiveness in preventing UTIs as cranberry juice does.
Question 5 of 5
An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.