NCLEX NCLEX-RN
Psychosocial Integrity NCLEX PN Questions
1. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother–infant bonding?
- A. Asking the mother to change her baby’s diaper
- B. Assuring the mother that her baby is receiving excellent care
- C. Encouraging the mother to touch her baby whenever possible
- D. Keeping the mother informed about the care the nursing staff is providing her baby
Correct answer: Encouraging the mother to touch her baby whenever possible
Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother–infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother–infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby’s diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.
2. The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item?
- A. Babinski reflex
- B. DNA synthesis
- C. Urinary function
- D. Chromosomal analysis
Correct answer: Urinary function
Rationale: Cryptorchidism, also known as undescended testes, may be caused by hormonal deficiency, intrinsic testicular abnormality, or a structural problem. Diagnostic studies for cryptorchidism typically involve assessing urinary function because the kidneys and testes originate from the same embryonic tissue. The Babinski reflex is a test for neurological function and is not relevant to evaluating cryptorchidism. DNA synthesis and chromosomal analysis are not commonly used diagnostic tests for cryptorchidism, as they are unrelated to the disorder's etiology or presentation.
3. In which order should the nurse take the following actions for an older patient with new onset confusion who is normally alert and oriented?
- A. Obtain the oxygen saturation, Check the patient's pulse rate, Notify the health care provider, Document the change in status
- B. Obtain the oxygen saturation, Check the patient's pulse rate, Document the change in status, Notify the health care provider
- C. Document the change in status, Notify the health care provider, Check the patient's pulse rate, Obtain the oxygen saturation
- D. Document the change in status, Check the patient's pulse rate, Obtain the oxygen saturation, Notify the health care provider
Correct answer: B
Rationale: The correct order of actions for the nurse in this scenario is to first obtain the oxygen saturation to assess the patient's airway and oxygenation status. Next, checking the patient's pulse rate helps in evaluating circulation. Subsequently, documenting the change in the patient's status is important for maintaining an accurate record of care. Finally, notifying the health care provider is crucial to ensure timely intervention and further management. Choices A, C, and D are incorrect because assessing oxygen saturation should precede checking the pulse rate to address potential physiological causes of confusion. Additionally, documentation should follow patient assessment and notification of the healthcare provider for appropriate record-keeping and communication.
4. The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
- A. Provide smaller, more frequent feedings.
- B. Burp the infant frequently during feedings.
- C. Thin the feedings by adding water to the formula.
- D. Thicken the feedings by adding rice cereal to the formula.
Correct answer: D: Thicken the feedings by adding rice cereal to the formula.
Rationale: Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.
5. While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. Which stage of the transtheoretical model of change would the nurse correlate the client’s behavior with?
- A. Action
- B. Preparation
- C. Maintenance
- D. Contemplation
Correct answer: D: Contemplation
Rationale: The transtheoretical model of change defines changing patterns in individuals across five stages based on their readiness to change. The stages are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client acknowledges the benefits of change and considers making the change within the next 6 months. This aligns with the client's realization of the harmful effects of alcohol consumption and intent to stop drinking within 6 months. The action stage involves actively making changes, the preparation stage includes goal-setting with an intention to change within 60 days, and the maintenance stage focuses on sustaining changed behavior for at least 6 months and taking preventive measures to avoid relapse. Therefore, in this scenario, the client's behavior aligns with the contemplation stage of the transtheoretical model of change.
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