which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

Correct answer: D

Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.

2. Which behavior indicates that the client has learned the most effective method to cope with anger?

Correct answer: B

Rationale: The correct answer is 'Talks about the anger.' This response indicates that the client has learned a positive coping method, as discussing angry feelings is a healthier way of dealing with anger. Talking about anger allows for expression and communication, leading to a better understanding of the emotions involved. Going for a long jog or screaming outside may provide temporary relief, but they do not address the root cause or help in processing the emotions effectively. Focusing solely on the cause of anger without expressing feelings may lead to increased frustration and escalation of anger, rather than promoting constructive coping mechanisms.

3. Which of the following interventions is essential when working with a client who has antisocial personality disorder?

Correct answer: B

Rationale: When working with a client diagnosed with antisocial personality disorder, it is crucial to set strict limits on their behavior. This disorder is characterized by manipulative behavior, impulsivity, and deceitfulness. By setting strict limits, the nurse can establish boundaries to prevent the client from manipulating others or engaging in disruptive behaviors. Monitoring intake and output (Choice A) is not directly related to managing antisocial personality disorder. Providing diversion (Choice C) or limiting visits from family or friends (Choice D) may not address the core issues associated with this disorder, such as manipulation and boundary violations.

4. How is the secondary use of data from the 2000 census classification system utilized to address disparities in mental health care along racial-ethnic lines?

Correct answer: D

Rationale: The census classification system categorizes individuals based on racial and ethnic descriptions. Utilizing this data helps in identifying health disparities and assessing how the health care needs of ethnic populations are being addressed. Option A is incorrect because the primary focus is on analyzing healthcare needs met, not providing care. Option B is incorrect as the census does not encompass every single racial and ethnic group in the United States. Option C is incorrect as the census is not designed to investigate the reasons behind disparities, but rather to quantify and analyze them.

5. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

Correct answer: C

Rationale: Encouraging the adolescent client to talk about her view of herself is the first action the nurse should take. Body image is crucial for adolescents, especially after pregnancy. By addressing the client's concerns about her weight and discussing her self-perception, the nurse can provide emotional support and open a dialogue for further assessment and teaching. Choice A, 'Review the client's weight pattern over the year,' is not the priority at this time as the client's immediate concern is her post-pregnancy weight. Choice B, 'Ask the mother to record her diet for the last 24 hours,' focuses on dietary habits rather than addressing the client's emotional concerns. Choice D, 'Give her several pamphlets on postpartum nutrition,' may be helpful but should come after addressing the client's emotional needs and concerns.

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The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
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