NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet
1. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?
- A. 'You may not have enough energy before long to hold a big party.'
- B. 'Do you mean to say that you want to plan your funeral and wake?'
- C. 'Planning a party and thinking about all your friends sounds like fun.'
- D. 'You should be thinking about spending your last days with your family.'
Correct answer: C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.
2. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.
3. A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:
- A. Reinforcement
- B. Presenting reality
- C. Role playing
- D. Summarizing
Correct answer: C
Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.
4. 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?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
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.
5. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?
- A. Discard the saline solution and obtain a new unopened bottle.
- B. Obtain a new sterile syringe to draw up the labeled saline solution.
- C. Use the saline solution and then relabel the bottle with the current date.
- D. Use the normal saline solution once more and then discard.
Correct answer: A
Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination. Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.
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