select the best outcome for a patient with the nursing diagnosis impaired social interaction related to sociocultural dissonance as evidenced by stati

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well?"? The patient will:

A. demonstrate improved social skills
B. express a desire to interact with others
C. become more independent in decision-making
D. select and participate in one group activity per day

Correct answer: D

Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.

2. After performing the appropriate client assessment, which of the following inferences would the nurse make?

A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work

Correct answer: A

Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.

3. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

4. Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

Correct answer: A

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.

5. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

A. Assessing the patient for jaundice
B. Providing oral hygiene after a meal
C. Palpating the abdomen for distention
D. Assisting the patient to choose the diet

Correct answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.