NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet Questions
Extract:
Question 1 of 5
Which client is most likely to be at risk for spiritual distress?
Correct Answer: A
Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.
Question 2 of 5
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?
Correct Answer: C
Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option
A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option
B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option
D) as the catheter could be inserted easily.
Question 3 of 5
A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
Correct Answer: C
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
Question 4 of 5
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.
Question 5 of 5
An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
Correct Answer: B
Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.