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Psychosocial Integrity NCLEX PN Questions
1. The client believes that the illness is a punishment for sins. Which cultural health belief is the client communicating?
- A. Yin/Yang balance
- B. Biomedical belief
- C. Determinism belief
- D. Magicoreligious belief
Correct answer: Magicoreligious belief
Rationale: The client is communicating a magicoreligious belief by attributing the illness to punishment for sins. In this belief system, illness is seen as caused by supernatural forces or hexes, often related to spiritual or religious beliefs. The yin/yang balance belief system does not view illness as punishment but rather as an imbalance of opposing forces. Biomedical belief focuses on physical and biochemical processes as the cause of health and illness. Determinism belief revolves around outcomes being preordained and unchangeable, not related to punishment for sins.
2. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- A. The patient will be admitted to the medicine unit for observation and medication.
- B. The patient will be admitted to the day surgery unit for sclerotherapy.
- C. The patient will be admitted to the surgical unit and resection will be scheduled.
- D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct answer: The patient will be admitted to the surgical unit and resection will be scheduled.
Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.
3. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
- A. Decrease intake of fluids after the evening meal.
- B. Drink a glass of cranberry juice every day.
- C. Drink a glass of warm decaffeinated beverage at bedtime.
- D. Consult the healthcare provider about a sleeping pill.
Correct answer: Decrease intake of fluids after the evening meal.
Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.
4. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
- A. Blood pressure guidelines for children are based on age.
- B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
- C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
- D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Correct answer: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.
5. A nurse and client are discussing the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
- A. Pre-interaction
- B. Orientation
- C. Working
- D. Termination
Correct answer: Working
Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.
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