the nurse notes bruises on the pregnant clients face and abdomen there are no bruises on her legs and arms further assessment is required to confirm w
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Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?

Correct answer: A

Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.

2. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

Correct answer: B

Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.

3. Which statement regarding an interpreter is correct?

Correct answer: C

Rationale: The correct answer is that interpreting not only the language but also the culture is important. Health care facilities should provide professional interpreters to ensure accurate communication with clients who do not speak English proficiently. It is crucial for interpreters to understand and convey cultural nuances to prevent misunderstandings. Relatives or friends of the client should not serve as interpreters as they may not be impartial or adequately skilled. Providing literal word-for-word translations is not always effective as it may not capture the intended meaning. Interpreters should be available throughout the client's care process, not just during direct communication, to ensure effective and culturally sensitive care.

4. When a client who has had a mastectomy sees her incision for the first time, she exclaims, 'I look horrible! Will it ever look better?' Which response would the nurse provide?

Correct answer: A

Rationale: The correct response, 'You seem shocked by the way you look now,' acknowledges the client's feelings and provides an opportunity for the client to express emotions freely. This reflection of feelings may help promote eventual acceptance of body image changes. Choices B, C, and D provide false reassurance and negate the client's feelings. Saying that the area will heal quickly now that the tumor is gone dismisses the client's concerns. Similarly, stating that others won't know about the surgery or that the client will feel better once the swelling subsides does not address the client's current emotional state and may undermine trust in the nurse-client relationship.

5. During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?

Correct answer: B

Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.

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After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset and crying. Which statement would be a therapeutic response?
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