NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
- A. Provide the client with a list of reliable internet sites that offer information on medications.
- B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
- C. Reassure the client that information about the medication is included in the written instructions.
- D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.
Correct answer: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.
2. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
- A. Self-care deficit
- B. Functional incontinence
- C. Fluid volume deficit
- D. High risk for infection
Correct answer: D
Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.
3. Which approach would the healthcare provider use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?
- A. Creating an anxiety-free environment for the client
- B. Assisting the client with the development of healthy, adaptive coping mechanisms
- C. Avoiding triggers that produce anxiety in the client
- D. Providing reinforcement that the client's anxiety issues can be eliminated
Correct answer: B
Rationale: The healthcare provider would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the healthcare provider to help the client replace the ineffective worrying with effective, healthy coping mechanisms. Creating an anxiety-free environment is not feasible or recommended; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is important, avoiding all triggers that produce anxiety is often impractical. Providing reinforcement that anxiety issues can be eliminated is not appropriate as anxiety is a normal human experience that needs to be managed effectively rather than eliminated completely.
4. 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?
- A. Do not tell your partner unless asked.
- B. This is a decision you alone can make.
- C. You are having difficulty deciding what to say.
- D. Tell your partner that you don't know how you became sick.
Correct answer: C
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.
5. The healthcare provider is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct answer: B
Rationale: The correct answer is taking anticoagulants for the past year. Anticoagulants increase the risk of bleeding during surgery, which can lead to complications. It is crucial for the healthcare provider to be aware of this medication. While clients taking birth control pills (option A) may be more prone to developing blood clots, these issues typically arise after surgery. Clients who recently completed antibiotic therapy (option C) or have taken laxatives PRN for the last 6 months (option D) are at lower risk compared to those taking anticoagulants (option B) during surgery.
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