the nurse is assessing an elder who the nurse suspects is being physically abused the most important question for nurse to ask is
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Nursing Elites

NCLEX-PN

Psychosocial Integrity Nclex PN Questions

1. The nurse is assessing an elder whom the nurse suspects is being physically abused. The most important question for the nurse to ask is:

Correct answer: B

Rationale: The most important question for the nurse to ask when suspecting elder abuse is 'Who provides your physical care?' This question is crucial as the primary caregiver, who is often the abuser in cases of elder abuse, lives with the client. Research has shown that spouses and adult children are the most common abusers. By inquiring about the provider of physical care, the nurse can assess the potential abuser's proximity to the elder. Choices A, C, and D are less pertinent to identifying the primary caregiver, who is more likely to be the abuser.

2. Which of the following coping mechanisms protects an individual from anxiety?

Correct answer: A

Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.

3. What can the nurse instruct the mother of a teething 9-month-old infant to relieve discomfort?

Correct answer: D

Rationale: Teething in infants can cause discomfort, but it is a normal process. Symptoms may include nighttime awakening, daytime restlessness, excess drooling, and temporary loss of appetite. The recommended approach to relieve teething discomfort includes providing cool liquids, a Popsicle, or hard foods like dry toast for chewing. These items can help soothe the infant's gums. Rubbing the gums with baby aspirin dissolved in water is not recommended as it can be harmful. OTC topical medications are unnecessary for teething discomfort. Scheduling a dental evaluation is not required solely for teething. It's important to avoid home remedies like baby aspirin and opt for safer options like cool liquids. If necessary, acetaminophen (Tylenol) can be used under healthcare provider guidance to alleviate discomfort.

4. Which laboratory test would be the least effective in diagnosing a myocardial infarction?

Correct answer: A

Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.

5. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

Correct answer: A

Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.

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