the nurse observes bilateral bruises on the arms of an elderly client in a long term care facility which of the following questions should the nurse

NCLEX-PN

Psychosocial Integrity Nclex PN Questions

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

A. "How did you get those bruises?"?
B. "Did someone grab you by your arms?"?
C. "Do you fall often?"?
D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

2. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?

A. "You will need to lie flat during the exam."?
B. "You need to empty your bladder before the procedure."?
C. "You will be asleep during the procedure."?
D. "The doctor will inject a medication to treat your illness during the procedure."?

Correct answer: B

Rationale: The client scheduled for a pericentesis should be instructed to empty the bladder to prevent the risk of bladder puncture when the needle is inserted. A pericentesis involves removing fluid from the peritoneal cavity. The client is typically positioned sitting up or leaning over a table, making answer A incorrect. During a pericentesis, the client is usually awake, so answer C is incorrect. Medications are not commonly injected into the peritoneal cavity during this procedure, making answer D incorrect. However, it's important to note that the administration of medications during the procedure could vary based on specific circumstances.

3. What is a common characteristic of a batterer?

A. Grew up in a loving, secure home
B. Was an only child
C. Was physically or psychologically abused
D. Admits they have a problem with anger

Correct answer: C

Rationale: The correct answer is that a batterer is typically someone who was physically or psychologically abused. Research shows that many individuals who engage in abusive behavior report a history of being abused themselves. Choices A, B, and D are incorrect. While it is possible for a batterer to have grown up in a loving, secure home, been an only child, or acknowledge their anger issues, the most common factor associated with becoming a batterer is a history of being abused.

4. After talking to the nurse, the charge nurse should:

A. Report the incident to the Board of Nursing
B. File a formal reprimand
C. Terminate the nurse
D. Charge the nurse with a tort

Correct answer: B

Rationale: The appropriate action after discussing the problem with the nurse is to document the incident and file a formal reprimand. Reporting to the Board of Nursing may be necessary if the behavior persists or harm occurs to the client, but it is not the initial step. Termination should be considered if the issue continues despite warnings. Charging the nurse with a tort is not a suitable course of action in this situation as a tort refers to a wrongful act against a client or their belongings, not an appropriate disciplinary measure. Therefore, choices A, C, and D are incorrect.

5. While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?

A. Hemoglobin
B. Creatinine
C. Blood glucose
D. White blood cell count

Correct answer: C

Rationale: When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.