which initial response would the nurse make to a 67 year old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have

NCLEX-RN

Psychosocial Integrity NCLEX Questions

1. Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?

A. 'At your age, sex isn't that important.''
B. ''That is a natural occurrence at your age.''
C. ''You sound upset about not being able to have an erection.''
D. 'Maybe it's time for you to speak to your primary health care provider about this.''

Correct answer: C

Rationale: The correct response is, 'You sound upset about not being able to have an erection.' When a client discloses personal information, the nurse should respond in a non-judgmental manner to encourage further communication and gather more details. This response demonstrates empathy and understanding, opening the door for the patient to express his feelings and concerns. Choice A, 'At your age, sex isn't that important,' is dismissive and fails to address the client's emotions or concerns, potentially hindering open communication. Choice B, 'That is a natural occurrence at your age,' provides inaccurate information as the inability to have an erection is not considered a normal part of aging. Choice D, 'Maybe it's time for you to speak to your primary health care provider about this,' while important eventually, should not be the initial response as the nurse should first explore the client's feelings and concerns before discussing potential referrals or interventions.

2. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

A. Do not worry. Epilepsy can be treated with medications.
B. The seizure may or may not mean your child has epilepsy.
C. Since this was the first convulsion, it may not happen again.
D. Long-term treatment will prevent future seizures.

Correct answer: B

Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.

3. Under what patient conditions or situations are restraints sometimes used?

A. As punishment when the patient is uncontrollable
B. To prevent the patient from pulling their IV out
C. When a patient is a danger to self and others
D. Both B and C

Correct answer: D

Rationale: Restraints are sometimes used to prevent a patient from pulling out their IV or another life-saving tube and when the person poses a serious danger to themselves and/or others. Restraints are never used as a form of punishment. Choice A is incorrect because restraints are not utilized for punishment but for patient safety and care. Choice B and C are correct because they reflect the appropriate and necessary situations where restraints may be used in healthcare settings.

4. For which condition would electroconvulsive therapy (ECT) be used?

A. Severe clinical depression
B. Substance abuse disorders
C. Antisocial personality disorder
D. Psychosis occurring in schizophrenia

Correct answer: A

Rationale: Electroconvulsive therapy (ECT) is indicated for severe clinical depression, especially in cases where clients do not respond well to psychotropic medications or require immediate intervention due to the severity of their depression. ECT is not typically used as a primary treatment for substance abuse disorders, antisocial personality disorder, or psychosis occurring in schizophrenia. While ECT is an effective intervention for severe depression, it is important to consider individual client needs and response to other treatment options before resorting to ECT.

5. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

A. The occurrence of any episodes of sleep apnea
B. The child's blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family's home environment

Correct answer: D

Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.