which factor is most critical for a single mother of 2 children who recently lost her job and does not know what to do

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. Which factor is most critical for a single mother of 2 children who recently lost her job and does not know what to do?

A. Developmental history of children
B. Available situational supports
C. Underlying unconscious conflict
D. Willingness to restructure lifestyle

Correct answer: B

Rationale: In a crisis intervention, the priority is to identify available situational supports, such as family, friends, community resources, and social services, that can help the single mother and her children during this difficult time. Understanding the developmental history of the children may be important to assess their needs, but it is not the most critical factor in this immediate crisis. Exploring underlying unconscious conflicts is more suited for long-term therapy rather than crisis intervention. While the willingness to restructure lifestyle may eventually be necessary, the immediate focus should be on finding support systems to address the current crisis.

2. Which of the following is a true statement about palliative care?

A. The goal of palliative care is to provide end-of-life care for a client as they transition toward death.
B. Palliative care provides comfort and support for those who may have a terminal illness.
C. Palliative care provides resources for funeral arrangements after death.
D. Palliative care is a support network for family and friends after the death of a loved one.

Correct answer: B

Rationale: Palliative care is a type of care that focuses on providing support and comfort to individuals who may have a terminal illness or severe symptoms. It aims to improve the quality of life for both the individual receiving care and their family. While it can be provided in various settings, including hospitals, homes, or specialized facilities, the primary focus is on symptom management and addressing the physical, emotional, and spiritual needs of the individual. Choice A is incorrect because palliative care is not solely limited to end-of-life care but also includes managing symptoms and improving quality of life. Choice C is incorrect as palliative care is focused on providing care and support during the individual's life, not on funeral arrangements after death. Choice D is incorrect as palliative care is primarily directed towards the individual receiving care, although it may also provide support to their family and friends during the care process.

3. The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
B. Sit quietly in the client's room until the client leaves the bathroom.
C. Allow the client to cry alone and leave the client in the bathroom.
D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.

4. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?

A. Nursing will help contract the uterus and reduce your risk of bleeding.
B. Breastfeeding twins will take too much energy after the hemorrhage.
C. The blood transfusion may increase the risks to you and the babies.
D. Lactation should be delayed until the 'real milk' is secreted.

Correct answer: A

Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage. Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions. Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies. Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.

5. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

A. Record the amount on the client's fluid output record.
B. Encourage the client to increase oral fluid intake.
C. Notify the healthcare provider of the findings.
D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.