NCLEX NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet
1. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour
- D. Drink approximately 4 ounces of water every hour
Correct answer: Dorsiflex and plantarflex the feet 10 times each hour
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.
2. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?
- A. Now I know my baby will need a cesarean section.
- B. My baby will need two shots soon after birth.
- C. I will not be able to breastfeed.
- D. My baby's father does not need testing; I know I am the one with hepatitis.
Correct answer: My baby will need two shots soon after birth.
Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.
3. Which feeling would be difficult for a client with major depression to express?
- A. Need for comforting
- B. Anger toward others
- C. Remorse for past behaviors
- D. Feelings of low self-esteem
Correct answer: Anger toward others
Rationale: Clients with major depression often have difficulty expressing anger toward others as their anger is typically directed inwards. Expressing the need for comforting is common among clients with major depression. They can also articulate remorse for past behaviors to an excessive degree. Furthermore, feelings of low self-esteem can be openly expressed by clients with major depression. Therefore, the difficulty in expressing anger toward others is the most appropriate choice as clients with major depression tend to internalize their anger.
4. Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage?
- A. Choosing creative ways to promote social participation
- B. Providing information to the client about the treatment plan
- C. Encouraging the client to participate actively in treatment procedures
- D. Involving the client’s partners or family members in the caring process
Correct answer: Providing information to the client about the treatment plan
Rationale: During the identity versus role confusion stage, which occurs during adolescence or puberty, it is essential for the nurse to empower hospitalized adolescents by providing them with sufficient information about their treatment plan. This approach enables the clients to actively participate in decision-making regarding their care. Choosing creative ways to promote social participation is more aligned with assisting clients during the generativity versus self-absorption and stagnation stage, where fostering social engagement can contribute to a sense of fulfillment. Involving the client’s partners or family members in the caring process is typically beneficial during the intimacy versus isolation stage to create a strong support system for the client. Encouraging active participation in treatment procedures is more relevant to the industry versus inferiority stage, ensuring that the hospitalized client engages effectively in their care.
5. Which behavior best indicates that the client has received adequate preparation for the scheduled diagnostic studies?
- A. Asks for the tests to be explained again
- B. Checks the appointment card multiple times
- C. Arrives early and waits quietly to be called for the tests
- D. Paces back and forth in the hallway on the morning of the tests
Correct answer: Arrives early and waits quietly to be called for the tests
Rationale: The correct answer is arriving early and waiting quietly to be called for the tests. This behavior indicates that the client is prepared, as early arrival suggests an expected degree of anxiety and the quiet waiting indicates a lower level of anxiety and adequate preparation. Asking for the tests to be explained again may signal inadequate explanation, nervousness, or poor memory. Checking the appointment card repeatedly or pacing up and down the hallway indicate a high level of anxiety, which could be associated with inadequate teaching. Nurses providing preprocedural teaching should assess for anxiety related to procedures, coping mechanisms, and retention of information post-teaching. If issues are identified, strategies such as paraphrasing information, having a support person present, seeking advice from someone who has undergone the procedure, or visiting the test center beforehand can be utilized.
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