NCLEX NCLEX-RN
Psychosocial Integrity NCLEX PN Questions
1. Which signs and symptoms would the nurse observe in a client with schizophrenia?
- A. Traumatic flashbacks and hypervigilance
- B. Depression and psychomotor retardation
- C. Loosened associations and hallucinations
- D. Ritualistic behavior and obsessive thinking
Correct answer: Loosened associations and hallucinations
Rationale: In clients with schizophrenia, the nurse would observe loosened associations and hallucinations. Loosened associations refer to disorganized thinking where thoughts are not logically connected. Hallucinations involve perceiving things that are not based in reality. Traumatic flashbacks and hypervigilance are more indicative of post-traumatic stress disorder. Depression and psychomotor retardation are common in depression, not schizophrenia. Ritualistic behavior and obsessive thinking are typically seen in obsessive-compulsive disorders, not schizophrenia.
2. Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?
- A. Flush the central line with heparin at least every four hours
- B. Administer narcotic analgesics as needed
- C. Remove the urinary catheter as soon as the client is ambulatory
- D. Order a high-protein diet for the client
Correct answer: Remove the urinary catheter as soon as the client is ambulatory
Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.
3. Which of the following is the most likely cause of constipation in a client?
- A. Postponing bowel movement when the urge to defecate occurs
- B. Intestinal infection
- C. Antibiotic use
- D. Food allergies
Correct answer: Postponing bowel movement when the urge to defecate occurs
Rationale: The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.
4. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?
- A. Catheterizing the infant using the smallest available Foley catheter
- B. Attaching a urinary collection device to the infant's perineum for collection
- C. Obtaining the specimen from the diaper by squeezing the diaper after the infant voids
- D. Noting the time of the next expected voiding and then preparing a specimen cup for the urine
Correct answer: Attaching a urinary collection device to the infant's perineum for collection
Rationale: The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.
5. Where is the pulse point located on the top of the foot?
- A. the dorsalis pedis
- B. This is the pulse point checked in patients with peripheral vascular problems.
- C. This pulse point may be absent in some patients due to a congenital anomaly.
- D. All of the above.
Correct answer: All of the above
Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.
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