NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet Questions
Extract:
Question 1 of 5
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Correct Answer: C
Rationale:
To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.
Question 2 of 5
Which of the following individuals is at the highest risk of experiencing intimate partner violence?
Correct Answer: C
Rationale: Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (
A), unemployment (
B), and schizophrenia diagnosis (
D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.
Question 3 of 5
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
Correct Answer: C
Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option
A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option
B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option
D) is not relevant to the immediate care required during bathing.
Question 4 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 5 of 5
What step should be taken when administering ear drops to an adult client?
Correct Answer: A
Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (
A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (½ inch) above the ear canal (
B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (
C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (
D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.