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Psychosocial Integrity NCLEX Questions Quizlet
1. Before assessing a new patient, a nurse is told by another healthcare worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” The nurse’s responsibility is to:
- A. document the other worker’s assessment of the patient.
- B. assess the patient based on data collected from all sources.
- C. validate the worker’s impression by contacting the patient’s significant other.
- D. discuss the worker’s impression with the patient during the assessment interview
Correct answer: assess the patient based on data collected from all sources.
Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.
2. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
- A. Offer psychological support for depression.
- B. Offer high-calorie, high-protein dietary choices.
- C. Administer prescribed opioids to relieve pain as needed.
- D. Teach about the need to avoid scratching any pruritic areas.
Correct answer: Administer prescribed opioids to relieve pain as needed
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
3. The healthcare provider is examining a patient who is reporting “feeling cold.” Which is a mechanism of heat loss in the body?
- A. Exercise
- B. Radiation
- C. Metabolism
- D. Food digestion
Correct answer: Radiation
Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.
4. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
- A. Perform nursing activities throughout the entire shift
- B. Assess for signs of increased muscle tone
- C. Minimize environmental noise
- D. Teach clients to perform the Valsalva maneuver
Correct answer: C: Minimize environmental noise
Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
5. Which desired outcome written by the nurse is correctly written and measurable?
- A. Client will have a normal bowel pattern by April 2
- B. The client will lose 4 lbs. within the next 2 weeks
- C. The nurse will provide skin care at least 3 times each day
- D. The client will breathe better after resting for 10 minutes
Correct answer: The client will lose 4 lbs. within the next 2 weeks
Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.
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