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NCLEX Psychosocial Integrity Questions
1. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?
- A. Projection
- B. Sublimation
- C. Compensation
- D. Rationalization
Correct answer: Rationalization
Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.
2. The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?
- A. ''I will use a short nipple on the bottle.''
- B. ''I should avoid using straws for drinking.''
- C. ''I can give my child the pacifier in 2 weeks.''
- D. ''I may give my baby food mixed with water.''
Correct answer: ''I should avoid using straws for drinking.''
Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.
3. After taking the vital signs for your patient and finding them to be normal, what should you do next?
- A. Report the vital signs to the doctor
- B. Write the vital signs on a scrap paper
- C. Call the family members
- D. Document them on the graphic VS form
Correct answer: Document them on the graphic VS form
Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.
4. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure?
- A. 200/92
- B. 200/100
- C. 100/200/92
- D. 200/100/92
Correct answer: 200/92
Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
5. The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?
- A. You should use an orthodontic nipple on the child's bottle.
- B. You need to use a plastic spoon to feed the child.
- C. You can allow the child to use a pacifier but only for 30 minutes at a time.
- D. You need to monitor the child's temperature for signs of infection using an oral thermometer.
Correct answer: You should use an orthodontic nipple on the child's bottle.
Rationale: After a cleft palate repair, it is crucial to use an orthodontic nipple on the child's bottle to feed them appropriately. The mother should be instructed to give the child baby food or baby food mixed with water. It is important to avoid introducing straws, pacifiers, spoons, or fingers into the child's mouth for 7 to 10 days post-surgery to prevent complications. The use of a pacifier should be avoided for at least 2 weeks following the surgical repair to promote proper healing. Additionally, taking oral temperatures should be avoided, and alternative temperature monitoring methods should be utilized to reduce the risk of infection. Therefore, options B, C, and D are incorrect because they could potentially lead to complications or hinder the child's recovery after cleft palate repair.
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