NCLEX NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. A 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. A few hours later the mother tells the nurse, 'I have to leave now, but whenever I try to go, my child gets upset, and then I start to cry.' Which is the best action by the nurse?
- A. Walking the mother to the elevator
- B. Encouraging the mother to spend the night
- C. Staying with the child while the mother leaves
- D. Telling the mother to wait until the child falls asleep
Correct answer: Staying with the child while the mother leaves
Rationale: The best action for the nurse in this situation is to stay with the child while the mother leaves. By doing so, the nurse can provide comfort and reassurance to both the child and the mother. This approach acknowledges the mother's need to leave while ensuring the child is not left alone and is supported during the separation. Walking the mother to the elevator does not address the child's emotional needs and may not provide adequate support. Encouraging the mother to spend the night is not necessary and may not be feasible for her. Telling the mother to wait until the child falls asleep is not recommended as it may create a sense of dishonesty and uncertainty for the child, who should be aware of the mother's departure and reassured that she will return.
2. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?
- A. Assess for clotting in fistula tubing
- B. Apply a dressing over the fistula site
- C. Assess for a bruit or thrill at the site of the fistula
- D. Assess circulation proximal to the fistula site
Correct answer: Assess for a bruit or thrill at the site of the fistula
Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.
3. The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?
- A. “You need to regain your strength before attempting such exertion.”
- B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
- C. “Have a glass of wine to relax you, then you can try to have sex.”
- D. “If you can maintain an active walking program, you will have less risk.”
Correct answer: “When you can climb 2 flights of stairs without problems, it is generally safe.”
Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.
4. Which client is most likely to be at risk for spiritual distress?
- A. Roman Catholic woman considering an abortion
- B. Jewish man considering hospice care for his wife
- C. Seventh-Day Adventist who needs a blood transfusion
- D. Muslim man who needs a total knee replacement
Correct answer: Roman Catholic woman considering an abortion
Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.
5. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode.
- B. Administer stool softeners daily as prescribed.
- C. Administer antidysrhythmics prn as ordered.
- D. Maintain the client on strict bed rest.
Correct answer: Administer stool softeners daily as prescribed.
Rationale: Administering stool softeners daily is crucial to prevent straining during defecation, which can lead to the Valsalva maneuver. Straining can increase intrathoracic pressure, decrease venous return to the heart, and reduce cardiac output, potentially worsening the client's condition. If constipation occurs, the use of laxatives may be necessary to avoid straining. Administering antidysrhythmics on an as-needed basis is not indicated for preventing the Valsalva maneuver; they are used to manage dysrhythmias. Strict bed rest is not necessary and may lead to complications such as deconditioning, DVT, and respiratory issues in the absence of specific medical indications.
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