a female adolescent has anorexia nervosa and is malnourished and severely underweight which statement indicates that she is experiencing secondary gai a female adolescent has anorexia nervosa and is malnourished and severely underweight which statement indicates that she is experiencing secondary gai
Logo

Nursing Elites

NCLEX NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

Correct answer: "My mother keeps trying to get me to eat."

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A’s in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

2. A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

Correct answer: How to draw up and administer injections of the medication

Rationale: When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.

3. A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?

Correct answer: Kussmaul respirations

Rationale: Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.

4. Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

Correct answer: Participates in learning perioperative care

Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.

5. Which of the following organs would be described as being located retroperitoneally?

Correct answer: Kidneys

Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.

Similar Questions

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?
A client on lithium has diarrhea and vomiting. What should the nurse do first?
Which response would the nurse provide to a client in labor at 32 weeks’ gestation who tells the nurse that she and her husband are very concerned because the baby will be born 2 months early?
During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'
A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99