the nurse is caring for a client who is dying while assessing the client for signs of impending death the nurse observes the client for
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Nursing Elites

NCLEX-PN

Psychosocial Integrity Nclex PN Questions

1. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

2. Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?

Correct answer: A

Rationale: The correct statement is that fat emulsions have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories, respectively, for each milliliter. In comparison, a milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices B, C, and D are incorrect. Choice B is false because fat emulsions are essentially pH neutral and isotonic, not hypertonic. Choice C is incorrect because fat emulsions are not basic solutions; they are essentially pH neutral. Choice D is incorrect as fat emulsions are not alkaline; they are pH neutral, making them compatible with most medications.

3. During the work phase of the nurse-client relationship, the client says to her primary nurse, "You think that I could walk if I wanted to, don't you?"? What is the best response by the nurse?

Correct answer: D

Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client's self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client's anxiety by suggesting unresolved psychological conflicts related to walking.

4. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?

Correct answer: B

Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.

5. A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?

Correct answer: B

Rationale: Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.

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