which steps should the nurse take when administering ear drops to an adult client
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. What step should be taken when administering ear drops to an adult client?

Correct answer: A

Rationale:

2. Which of the following individuals is at the highest risk of suicide?

Correct answer: A

Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.

3. Which clinical findings indicate positive signs and symptoms of schizophrenia?

Correct answer: D

Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.

4. When caring for a patient who speaks a different language and an interpreter is unavailable, which action by the nurse is most appropriate?

Correct answer: D

Rationale: When faced with a language barrier and lacking an interpreter, using simple gestures can help convey meaning to the patient. This approach can assist in basic communication and understanding. Talking slowly may not be effective if the patient does not understand the language, and speaking loudly can be perceived as aggressive or intimidating. Repeating words may not aid comprehension if the patient is unfamiliar with the language. Therefore, using gestures is the most appropriate option in this situation.

5. Which of the following mental health situations is considered a psychiatric emergency?

Correct answer: C

Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.

Similar Questions

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
Which of the following actions is most appropriate when working with a client who is extremely angry?
An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A client is being treated for anxiety and desires to be free from anxious feelings and despair. According to Maslow's hierarchy of needs, which level does this client need to meet?
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?

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