a client asks the nurse should i tell my partner that i just found out im human immunodeficiency virus hiv positive which is the nurses most appropria a client asks the nurse should i tell my partner that i just found out im human immunodeficiency virus hiv positive which is the nurses most appropria
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Nursing Elites

NCLEX NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. A client asks the nurse, 'Should I tell my partner that I just found out I’m human immunodeficiency virus (HIV) positive?' Which is the nurse’s most appropriate response?

Correct answer: You are having difficulty deciding what to say.

Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.

2. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?

Correct answer: Provide research-based information about therapeutic hypothermia

Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.

3. When caring for an asthmatic patient with an early-phase reaction, which of the following is indicative of an early-phase reaction?

Correct answer: Rapid bronchospasms

Rationale: Rapid bronchospasms are a symptom of an early-phase reaction in an asthmatic patient. During the early phase, bronchospasms occur due to immediate hypersensitivity reactions. Inflammatory epithelial lesions, increased secretions, and increased mucosal edema are typically seen in late-phase reactions as part of the inflammatory response that occurs later. Therefore, rapid bronchospasms are most indicative of an early-phase reaction.

4. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

Correct answer: A: Establish trust

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

5. A patient is being visited at home by a healthcare professional. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the healthcare professional needs to contact the physician?

Correct answer: I have ringing in my ears.

Rationale: The correct answer is 'I have ringing in my ears.' Ringing in the ears is a severe adverse effect of Naproxen, indicating potential toxicity. This symptom warrants immediate medical attention. Choices A, B, and C are less concerning and do not directly indicate a severe adverse effect or toxicity related to Naproxen. Upset stomach, mild back pain, and occasional headaches are common side effects that may not require immediate physician contact.

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