the nurse is obtaining a lie sit stand blood pressure reading on a client which action is most important for the nurse to implement

NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

A. Stay with the client while the client is standing.
B. Record the findings on the graphic sheet in the chart.
C. Keep the blood pressure cuff on the same arm.
D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

2. After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset and crying. Which statement would be a therapeutic response?

A. 'I'll be here if you want to talk.''
B. 'Try to relax"?it'll speed up the healing process.''
C. 'With any luck, you'll get pregnant again soon.''
D. 'It's best that this happened early rather than having the baby die after it was born.''

Correct answer: A

Rationale: A therapeutic response in this situation is to offer support and empathy. Saying, 'I'll be here if you want to talk' gives the client and her partner the opportunity to express their emotions and seek comfort. It acknowledges their distress and assures them of the nurse's availability. Choice B, advising to relax to speed up the healing process, dismisses their current emotions and may hinder open communication. Choice C, suggesting getting pregnant again soon, minimizes their grief over the loss and may not be what the couple needs to hear at that moment. Choice D, stating it's best that the miscarriage happened early, is insensitive as it invalidates the couple's feelings of loss and grief. Grieving is a natural process, and the timing of the loss does not diminish its significance.

3. Which statement regarding an interpreter is correct?

A. Relatives or friends of the client cannot serve as interpreters.
B. The interpreter should aim to convey meaning rather than provide literal translations.
C. Interpreting not only the language but also the culture is important.
D. The interpreter should be available only during client-provider communication.

Correct answer: C

Rationale: The correct answer is that interpreting not only the language but also the culture is important. Health care facilities should provide professional interpreters to ensure accurate communication with clients who do not speak English proficiently. It is crucial for interpreters to understand and convey cultural nuances to prevent misunderstandings. Relatives or friends of the client should not serve as interpreters as they may not be impartial or adequately skilled. Providing literal word-for-word translations is not always effective as it may not capture the intended meaning. Interpreters should be available throughout the client's care process, not just during direct communication, to ensure effective and culturally sensitive care.

4. What behavior is expected of members of Alcoholics Anonymous (AA)?

A. Speaking at and participating in weekly meetings
B. Promising to attend at least 12 meetings yearly
C. Maintaining controlled drinking after 6 months
D. Acknowledging an inability to control the drinking

Correct answer: D

Rationale: A fundamental aspect of Alcoholics Anonymous (AA) is the acceptance of one's inability to control their drinking behavior. This acknowledgment is crucial for individuals seeking recovery from alcohol abuse issues. While speaking at and participating in meetings is encouraged, it is not a strict requirement for AA members. Similarly, there is no specific mandate on the number of meetings to attend yearly, as long as the individual finds the support they need. Maintaining controlled drinking after 6 months is not aligned with AA principles, as the group emphasizes complete abstinence from alcohol to support long-term sobriety.

5. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?

A. I'm sorry to hear that.'
B. 'Oh, you have a lot of good years left.'
C. 'You are concerned about your sex life?'
D. 'Have you asked your primary health care provider about that?'

Correct answer: C

Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.