NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet Questions
Extract:
Question 1 of 5
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
Correct Answer: A
Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is relevant but is not a high-priority intervention compared to addressing the immediate grief support needs of the client. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. While antidepressant medication might be necessary based on further assessment, grief counseling is a more appropriate initial action as grief is a typical response to the loss of a loved one.
Question 2 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.
Question 3 of 5
Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:
Correct Answer: B
Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (
Choice
A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (
Choice
C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (
Choice
D) can introduce bias and may not lead to an objective evaluation.
Question 4 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 5 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.