NCLEX NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. A client with generalized anxiety disorder presents with restlessness and fatigue. Which additional clinical manifestation would the nurse monitor for?
- A. Hoarding
- B. Panic attacks
- C. Excessive worry
- D. Fear of leaving the house
Correct answer: Excessive worry
Rationale: The nurse would monitor for excessive worry. Generalized anxiety disorder is characterized by physical and cognitive symptoms of chronic or excessive anxiety and worry. Excessive worry is a core feature of generalized anxiety disorder. Hoarding is a symptom of hoarding disorder, not generalized anxiety disorder. Panic attacks are typical of panic disorder, not generalized anxiety disorder. Fear of leaving the house is a characteristic of agoraphobia, which is distinct from generalized anxiety disorder.
2. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
- A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
- B. Administer 15 mL of sterile fluid into the tube prior to suctioning
- C. Suction for no longer than 30 seconds at a time
- D. Wait 30 seconds after suctioning before attempting again
Correct answer: Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.
3. What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct answer: Use a lubricated blunt tip thermometer.
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
4. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct answer: Unequal leg length
Rationale: The correct answer is 'Unequal leg length.' Shortening of a leg is a common sign of developmental dysplasia of the hip. Limited adduction (Choice B) may be present but is less specific to developmental dysplasia of the hip. Diminished femoral pulses (Choice C) are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds (Choice D) are a normal finding and would not be expected in a patient with developmental dysplasia of the hip.
5. What preparation is necessary for a colposcopy procedure?
- A. NPO for 8-12 hours before the procedure.
- B. D/C all hypertension medications for two days prior to the procedure.
- C. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system.
- D. None of the above prep is necessary for this type of procedure.
Correct answer: None of the above prep is necessary for this type of procedure.
Rationale: A colposcopy procedure is performed to examine the vagina and cervix. The only preparation required is washing the external genitals with soap and water on the morning of the procedure. Choices A, B, and C suggest unnecessary preparations that are not relevant to a colposcopy. NPO for 8-12 hours, discontinuing hypertension medications, and using laxatives are not part of the standard preparation for a colposcopy.
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