NCLEX-PN
Psychosocial Integrity NCLEX PN Questions Questions
Extract:
Question 1 of 5
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
Correct Answer: A
Rationale: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional.
Question 2 of 5
A central venous pressure reading of 11 cm/H(2)0 of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable:
Correct Answer: C
Rationale: >10 cm/H(2)0 may indicate a condition of pericarditis.
Question 3 of 5
A mother has just given birth to a baby who died soon after. The mother has been crying and states, 'I can't believe this has happened to me. I did everything right during this pregnancy.' How should the nurse respond to this mother?
Correct Answer: D
Rationale: Perinatal loss is a great tragedy for the parents. A bereaved mother must resolve the crisis of perinatal loss in addition to the crisis of pregnancy. Such a loss is described as losing part of one's self-loss of self-worth. The perinatal grief response must involve attachment and detachment as a part of the mourning process.
Question 4 of 5
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
Correct Answer: D
Rationale: In this scenario, the client's recent weight loss and subsequent pregnancy could lead to concerns about weight regain and body image. The most appropriate nursing diagnosis is 'Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).' This diagnosis reflects the client's potential emotional response to the fear of losing the progress achieved through weight loss and dealing with changes in body image due to pregnancy. Options A and C imply that low self-esteem is already present, which is not supported by the information given. Option B is not as suitable as the client's self-esteem issues are more related to the fear of weight regain and pregnancy, making option D the best choice.
Question 5 of 5
A teenage client is admitted to the hospital because of an acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
Correct Answer: B
Rationale: Acetaminophen is extensively metabolized in the liver. An acetaminophen overdose can lead to severe liver damage and even liver failure, which can be life-threatening.
Choices A, C, and D are incorrect. Acetaminophen overdose does not typically cause life-threatening problems in the lungs, kidneys, or adrenal glands. While prolonged acetaminophen use may increase the risk of renal dysfunction, a single overdose primarily affects the liver.