the nurse notes bruises on the pregnant clients face and abdomen there are no bruises on her legs and arms further assessment is required to confirm w
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Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?

Correct answer: A

Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.

2. Which factor is most critical for a single mother of 2 children who recently lost her job and does not know what to do?

Correct answer: B

Rationale: In a crisis intervention, the priority is to identify available situational supports, such as family, friends, community resources, and social services, that can help the single mother and her children during this difficult time. Understanding the developmental history of the children may be important to assess their needs, but it is not the most critical factor in this immediate crisis. Exploring underlying unconscious conflicts is more suited for long-term therapy rather than crisis intervention. While the willingness to restructure lifestyle may eventually be necessary, the immediate focus should be on finding support systems to address the current crisis.

3. The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Correct answer: C

Rationale: Allowing the mother time to verbalize her feelings and providing support when she sees her newborn with birth defects for the first time is crucial. Staying with her allows for immediate emotional support, acceptance, and understanding, which can help ease her stress. Bringing the infant as requested without proper emotional support may overwhelm the mother. Describing the infant's appearance before she sees the baby might not be accurate and could add to her distress. Showing pictures of the birth defects before the mother sees her baby may not be helpful and could increase her anxiety. Engaging in discussions about treatment at this point may be premature and overwhelming for the mother.

4. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

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

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.

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Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?

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