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Psychosocial Integrity NCLEX PN Questions
1. What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?
- A. “I see that you're worried. We're using medication to ease your wife's discomfort.”
- B. “This is expected. I suggest that you go home because there's nothing you can do to help.”
- C. “If you’re afraid that she will die, I assure you, very few alcoholics die during detoxification.”
- D. “If you are concerned that she is uncomfortable, I'm sure that she's not in pain.”
Correct answer: “I see that you're worried. We're using medication to ease your wife's discomfort.”
Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.
2. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?
- A. Place a tourniquet at the level of the elbow
- B. Apply direct pressure to the injury
- C. Administer a bolus of 0.9% Normal Saline
- D. Elevate the injured extremity on a pillow
Correct answer: Apply direct pressure to the injury
Rationale: The correct first action for the nurse in this scenario is to apply direct pressure to the injury. When a client presents with traumatic hand amputation causing excessive bleeding, the immediate goal is to control the bleeding. Applying direct pressure with a sterile dressing helps to stem the flow of blood and stabilize the patient. Placing a tourniquet at the level of the elbow should be avoided initially as it may lead to further complications such as tissue damage. Administering a bolus of 0.9% Normal Saline is not the priority in this situation where hemorrhage control is crucial. Elevating the injured extremity on a pillow does not address the primary concern of controlling the bleeding and stabilizing the patient.
3. Which example best describes the concept of beneficence?
- A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
- B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
- C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
- D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented
Correct answer: A nurse provides pain medication for a client in the recovery room who is experiencing pain
Rationale: Beneficence is the ethical principle of doing good and acting in the best interest of the client. Providing pain relief to a client in the recovery room who is experiencing pain aligns with beneficence as it promotes the client's well-being and comfort. Choice B is related to autonomy, where the client's wishes regarding treatment are respected. Choice C involves confidentiality and the client's right to privacy. Choice D represents nonmaleficence, as withholding pain medication from a client in pain could cause harm and goes against the principle of doing no harm.
4. The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
- A. Place the patient under contact precautions
- B. Use strict aseptic technique when caring for the wound
- C. Place another dressing to reinforce the first one
- D. Elevate the patient's leg to prevent more drainage
Correct answer: Place the patient under contact precautions
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.
5. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?
- A. Interpret that the patient is eager and interested in participating in the interview.
- B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
- C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
- D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Correct answer: Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Rationale: Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.
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