NCLEX-RN
Psychosocial Integrity NCLEX Questions Quizlet
1. 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.
2. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?
- A. Discard the saline solution and obtain a new unopened bottle.
- B. Obtain a new sterile syringe to draw up the labeled saline solution.
- C. Use the saline solution and then relabel the bottle with the current date.
- D. Use the normal saline solution once more and then discard.
Correct answer: A
Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination. Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.
3. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?
- A. 'You may not have enough energy before long to hold a big party.'
- B. 'Do you mean to say that you want to plan your funeral and wake?'
- C. 'Planning a party and thinking about all your friends sounds like fun.'
- D. 'You should be thinking about spending your last days with your family.'
Correct answer: C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.
4. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.
5. Which of the following is an example of neurofeedback used with a child diagnosed with reactive attachment disorder (RAD)?
- A. A child's brain waves are monitored through electrodes placed on the scalp
- B. Parents give their child a sticker when he behaves appropriately
- C. A child uses a sand tray to draw shapes and release stress while talking with a nurse
- D. Parents or a nurse hold a child close during play until he becomes angry enough to unleash his rage
Correct answer: A
Rationale: Neurofeedback is a form of treatment that may be used for children diagnosed with reactive attachment disorder (RAD). Neurofeedback involves attaching electrodes to the scalp in a method similar to an EEG. The child's brainwaves are then monitored while being exposed to positive images or games to produce positive brain patterns. Choice A is the correct answer as it describes the process of neurofeedback, which is a common therapeutic approach for managing RAD. Choices B, C, and D are incorrect because they do not directly involve monitoring brain waves through electrodes to provide feedback for brain pattern adjustments, which is the core concept of neurofeedback therapy.
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