which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

2. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

3. After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?

Correct answer: A

Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.

4. What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?

Correct answer: C

Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.

5. Jerry is a 55-year-old veteran who has been admitted after a motor vehicle accident with multiple injuries. His friend reported that he had been using synthetic marijuana prior to the accident, and that he also sees a psychiatrist at the VA hospital for an unknown diagnosis. He stated that Jerry sometimes gets "hyper"? for no reason, starts "ranting"? and becomes violent. Of the following, which general psychiatric disorder is characterized by a pattern of aggression or violence that includes irritability, agitation, and violent behavior during manic or psychotic episodes?

Correct answer: C

Rationale: Bipolar disorder is characterized by a pattern of aggression or violence that includes irritability, agitation, and violent behavior during manic or psychotic episodes. This disorder is highly co-morbid with substance use, which can worsen the prognosis. While schizophrenia may involve aggression, it is not typically associated with mood episodes like mania that characterize bipolar disorder. Post-traumatic stress disorder (PTSD) is primarily characterized by re-experiencing traumatic events, avoidance behaviors, and hyperarousal, but not the distinct mood episodes seen in bipolar disorder. Delusional disorder is characterized by fixed false beliefs without the mood changes seen in bipolar disorder. Therefore, the correct answer is Bipolar disorder.

Similar Questions

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