which behavior best indicates to the nurse that the client has received adequate preparation for the scheduled diagnostic studies which behavior best indicates to the nurse that the client has received adequate preparation for the scheduled diagnostic studies
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NCLEX Psychosocial Questions

1. Which behavior best indicates that the client has received adequate preparation for the scheduled diagnostic studies?

Correct answer: Arrives early and waits quietly to be called for the tests

Rationale: The correct answer is arriving early and waiting quietly to be called for the tests. This behavior indicates that the client is prepared, as early arrival suggests an expected degree of anxiety and the quiet waiting indicates a lower level of anxiety and adequate preparation. Asking for the tests to be explained again may signal inadequate explanation, nervousness, or poor memory. Checking the appointment card repeatedly or pacing up and down the hallway indicate a high level of anxiety, which could be associated with inadequate teaching. Nurses providing preprocedural teaching should assess for anxiety related to procedures, coping mechanisms, and retention of information post-teaching. If issues are identified, strategies such as paraphrasing information, having a support person present, seeking advice from someone who has undergone the procedure, or visiting the test center beforehand can be utilized.

2. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

Correct answer: Administer the feeding as ordered

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

3. Which therapeutic approach would indicate the client is receiving desensitization therapy?

Correct answer: Imagery

Rationale: The correct answer is 'Imagery.' Imagery is a therapeutic approach used in desensitization therapy. It helps in facilitating positive self-talk and involves the client initiating and controlling mental pictures to correct faulty cognitions. Modeling, role-playing, and assertiveness training are effective general behavioral approaches but are not specific to desensitization therapy.

4. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?

Correct answer: Set up oxygen and suction equipment.

Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (Choice A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (Choice C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (Choice D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.

5. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

Correct answer: Determine if there are safety issues.

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

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