in assisting an older adult client prepare to take a tub bath which nursing action is most important
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?

Correct answer: A

Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.

2. A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?

Correct answer: B

Rationale: Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.

3. Which communication technique is a part of therapeutic communication?

Correct answer: D

Rationale: The correct answer is providing relevant information to the client. In therapeutic communication, it is essential to provide clients with all pertinent information to help them understand their health status and what to expect. This empowers clients and promotes trust in the nurse-client relationship. Asking for explanations, showing sympathy, and asking personal questions are examples of nontherapeutic communication techniques. Asking personal questions can intrude on the client's privacy and may not be relevant to their care. Showing sympathy, while well-intentioned, may come across as pity rather than true empathy. Asking for explanations can sometimes put clients on the defensive rather than fostering a collaborative dialogue.

4. Which reaction toward the physical symptom would the nurse observe in a client with conversion disorder?

Correct answer: B

Rationale: In conversion disorder, the nurse would observe apathy toward the physical symptom. The development of the symptom serves as an unconscious method of reducing anxiety. The symptom is accepted passively, known as 'la belle indifférence.' There is no anger observed as symptoms are passively accepted. Similarly, there is no direct anxiety related to the physical symptom, as the conflict is resolved through the symptom development. While many individuals might experience agitation and seek to identify the cause of physical symptoms, in conversion disorder, there is an unusual calmness or indifference towards the physical manifestation, indicating apathy rather than other emotional responses.

5. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?

Correct answer: C

Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.

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