a client is crying after undergoing dilation and curettage after an early miscarriage spontaneous abortion which response would the nurse give
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions

1. After undergoing dilation and curettage following an early miscarriage, a client is crying. Which response would the nurse give?

Correct answer: A

Rationale: The correct response acknowledges the client's grief without judgment and provides validation. Choice B is inappropriate as it suggests replacing the lost child with other children, which is insensitive and dismissive of the client's current loss. Choice C minimizes the client's feelings by focusing on the ability to get pregnant rather than addressing the emotional impact of the miscarriage. Choice D is dismissive and patronizing, suggesting that the miscarriage was for the best, which can be hurtful and diminish the client's grief.

2. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

Correct answer: D

Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.

3. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.

4. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

Correct answer: A

Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.

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

Correct answer: A

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.

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