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
Logo

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. Narrow therapeutic index medications:

Correct answer: C

Rationale: The therapeutic index is the ratio between the median lethal dose and median effective dose of a drug, indicating the safety margin. Narrow therapeutic index medications have a small difference between minimum toxic levels and minimum effective concentration in the blood, making them high-risk drugs that require close monitoring to avoid toxicity. Choice A is incorrect because pharmacokinetics refer to drug absorption, distribution, metabolism, and elimination, not the therapeutic index. Choice B is incorrect because narrow therapeutic index drugs necessitate monitoring due to their narrow margin of safety. Choice D is incorrect because narrow therapeutic index drugs do not necessarily have limited potency but are characterized by a small window between efficacy and toxicity.

3. In a brief treatment program, what is a realistic short-term goal for a client who was raped?

Correct answer: D

Rationale: A realistic short-term goal for a client who was raped and is receiving a brief treatment program is for the client to verbalize feelings about the event. This goal focuses on helping the client express their emotions, which can be a crucial step in the healing process. Options A and C are incorrect because a brief treatment program is not typically aimed at identifying or resolving all psychosocial problems or deep-rooted trauma and fear. Option B is also incorrect as the goal is to support the client in processing their feelings rather than focusing on behaviors.

4. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct answer: D

Rationale: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade fever; thus, answers A and B are incorrect. Chest congestion, as mentioned in answer C, is not typical of tonsillectomy complications, making it an incorrect choice.

5. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?

Correct answer: A

Rationale: The client with Alzheimer's disease is the most stable among the clients listed and can be appropriately assigned to the nursing assistant. Nursing assistants are capable of providing care such as feeding and assisting with activities of daily living for individuals with Alzheimer's disease. Clients with pneumonia, appendicitis, and thrombophlebitis are less stable and necessitate the expertise of a registered nurse for accurate assessment and interventions. Therefore, the nursing assistant can effectively care for the client with Alzheimer's disease while ensuring that the other clients receive the necessary level of care from a registered nurse.

Similar Questions

A twenty-one-year-old man suffered a concussion, and the MD ordered an MRI. The patient asks, 'Will they allow me to sit up during the MRI?' The correct response by the nurse should be:
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
Which of the following factors can impact an individual's ability to give informed consent?
While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on:
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses