when performing sterile wound care in the acute care setting the nurse obtains a bottle of normal saline from the bedside table that is labeled opened
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

Correct answer: A

Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination. Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.

2. Which term refers to a comprehensive set of thoughts or images of oneself?

Correct answer: A

Rationale: The term 'Global self' specifically refers to a comprehensive set of thoughts or images about oneself. It encompasses a person's overall perception of themselves, including their beliefs, values, and self-image. 'Core self-concept' is more focused on the fundamental beliefs individuals hold about themselves, 'Personal identity' relates to the characteristics and qualities that distinguish a person from others, and 'Ideal self' represents the person an individual aspires to be rather than their current self-perception. Therefore, 'Global self' is the most appropriate term for the description provided in the question.

3. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?

Correct answer: A

Rationale: The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.

4. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

5. A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?

Correct answer: A

Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.

Similar Questions

A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, 'You think that it looks repulsive.' The nurse identifies that the client is using which defense mechanism?
When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in?
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?
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?

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