the nurse identifies a potential for infection in a client with partial thickness second degree and full thickness third degree burns what intervent
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?

Correct answer: B

Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.

2. What behavior is expected of members of Alcoholics Anonymous (AA)?

Correct answer: D

Rationale: A fundamental aspect of Alcoholics Anonymous (AA) is the acceptance of one's inability to control their drinking behavior. This acknowledgment is crucial for individuals seeking recovery from alcohol abuse issues. While speaking at and participating in meetings is encouraged, it is not a strict requirement for AA members. Similarly, there is no specific mandate on the number of meetings to attend yearly, as long as the individual finds the support they need. Maintaining controlled drinking after 6 months is not aligned with AA principles, as the group emphasizes complete abstinence from alcohol to support long-term sobriety.

3. What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?

Correct answer: C

Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.

4. A client who exhibits blurred and double vision and muscular weakness is informed of the diagnosis of multiple sclerosis (MS). The client becomes visibly upset. Which response would the nurse make?

Correct answer: A

Rationale: The response 'That must have shocked you. Tell me what the health care provider told you about it' acknowledges the effect of the diagnosis on the client and explores what is known. This response shows empathy and encourages the client to share their understanding. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary at this initial stage. The statement 'Don't worry; early treatment often alleviates symptoms of the disease' provides false reassurance as the course of MS varies for each individual and may not always respond well to treatment. The statement 'You should be glad we caught it early so it can be cured' does not address the client's current emotional state and is inaccurate; MS is a chronic autoimmune disease that currently has no cure.

5. Based on Maslow's hierarchy of needs, which client is demonstrating characteristics of self-actualization?

Correct answer: D

Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level where individuals strive to reach their full potential and achieve personal growth. A self-actualized person, as per Maslow, has an accurate perception of reality and is accepting of themselves and others. This individual is characterized by traits such as fairness, independence, spontaneity, and creativity. While choices A, B, and C represent important aspects of human needs fulfillment, they align more closely with lower levels in Maslow's hierarchy. Choice A refers to meeting self-esteem needs, choice B relates to love and belonging needs, and choice C addresses safety needs, all of which are below self-actualization in the hierarchy of needs.

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