NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
- A. The occurrence of any episodes of sleep apnea
- B. The child's blood pressure, pulse, and respirations
- C. Length of rapid eye movement (REM) sleep that the child is experiencing
- D. Description of the family's home environment
Correct answer: D
Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.
2. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
- A. Only refer to the client by gender
- B. Identify the client only by age
- C. Avoid using the client's name
- D. Discuss the client another time
Correct answer: D
Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.
3. The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to their daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine they are currently following.
Correct answer: D
Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.
4. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?
- A. Maintain standard precautions.
- B. Initiate contact isolation measures.
- C. Insert an indwelling urinary catheter.
- D. Instruct the client in the use of adult diapers.
Correct answer: A
Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.
5. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
- A. Take a vitamin supplement tablet once a day.
- B. Change positions in the chair at least every hour.
- C. Increase daily intake of water or other oral fluids.
- D. Purchase a newer model wheelchair.
Correct answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.
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