which benefit accompanies mild apprehension

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. Which benefit accompanies mild apprehension?

A. Physiological functions are slowed.
B. There is an increased alertness.
C. Behavioral responses become automatic.
D. Ego defense mechanisms are mobilized.

Correct answer: B

Rationale: A mild level of anxiety can be beneficial because it increases alertness and focuses attention. Physiological functions are actually amplified initially, not slowed, due to mild apprehension; however, prolonged anxiety can lead to decreased function due to exhaustion. Automatic behavioral responses and ego defense mechanisms may hinder an individual's awareness rather than enhancing it, making them less beneficial compared to increased alertness.

2. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?

A. Suggest that the client requesting attention speak with another staff member.
B. Leave the new client, saying, 'I'll talk with the other client until things calm down.'
C. Introduce the two clients and suggest that the client join them on a tour of the facility.
D. Say to the interrupting client, 'I'll be back to talk with you after I orient this new client.'

Correct answer: D

Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.

3. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

4. A client who has multiple sclerosis is admitted to the hospital with increasingly frequent and severe exacerbations. One day, the client's partner confides to the nurse, 'Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home.' After listening to the partner's concerns, which response would the nurse make?

A. 'Joining a support group of people who are coping with this situation may be helpful.'
B. 'You may be able to decrease your feelings of guilt by seeking counseling.'
C. 'It would be helpful if you became involved in volunteer work at this time.'
D. 'I recognize it's hard to deal with, but try to remember that this, too, shall pass.'

Correct answer: A

Rationale: Joining a support group of individuals facing similar circumstances can provide valuable support and the opportunity to share experiences, making it the most appropriate response. The response suggesting counseling to decrease feelings of guilt is premature because the partner did not directly express guilt and it may not be the most immediate need. Suggesting involvement in volunteer work at this time fails to address the partner's current emotional distress and may come across as dismissive. Offering false reassurance by stating 'this, too, shall pass' does not validate the partner's feelings and minimizes the seriousness of their concerns.

5. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
B. Instruct the UAP not to wake the client under any circumstances during the night.
C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Correct answer: A

Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.