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Psychosocial Integrity NCLEX REVIEW ScienceMedicineNursing mgiven2capital Save Basic Care and Comfort NCLEX que...44 terms Jessi_Austin7Preview
NCLEX EXAM PREVIEW
110 terms kandykat1012Preview NCLEX Psychosocial Integrity Quest...25 terms laurahomansxo Preview Reduct 19 terms mg An 8 year-old child is admitted to the children's inpatient mental health unit. After the mother's departure, the client cries and refuses to eat dinner. Which of the following nursing actions is most appropriate?Tell the child that privileges will be denied for uncooperative behavior Remind the child of the expectation to eat some or all of the dinner Explain that the parent will be upset if the child does not cooperate Offer to play with the child Offer to play with the child The nurse is assisting a client with substance use disorder (SUD) to deal with issues of guilt. Which response by the nurse would be best for this client?"What have you done that you feel most guilty about? What steps can you begin to take to help you lessen this guilt?" "Don't focus on the guilty feelings. These feelings will only lead to drinking and taking drugs." "You've caused a great deal of pain to your family and close friends. It will take time to undo all the things you've done." "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior." "What have you done that you feel most guilty about? What steps can you begin to take to help you lessen this guilt?" A client tells the nurse, "I have something very important to tell you if you promise not to tell." The nurse should respond with which statement?"I must document and report any information." "I can't make such a promise." "I must report everything to the treatment team." "That depends on what you tell me." "I can't make such a promise."
A client of Hispanic heritage refuses emergency unit treatment until a curandero is called. What should the nurse understand about the practices of a curandero?The client believes in witchcraft A curandero offers spiritual advising A curandero uses holistic healing practices Herbal preparations will be used A curandero uses holistic healing practices A client who is thought to be homeless is brought to the emergency department (ED) by the police. The client is unkempt, has difficulty concentrating, is unable to sit still, and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time?Allow the client to randomly move about the holding area until a hospital room is available Locate a room that features minimal stimulation during the admission process Engage the client in an activity that requires focus and individual effort Isolate the client in a secure room until control is regained by the client Locate a room that features minimal stimulation during the admission process A 15 year-old is admitted with a fracture of the arm and is told that surgery is required. A nurse finds the child crying and unwilling to talk. What is the most appropriate approach by the nurse?Try to distract the child with a hand-held electronic game Tell the child that the surgery will have no problems Make arrangements for the friends to visit as soon as possible Give the child some privacy Give the child some privacy A client diagnosed with a terminal condition is admitted to the nursing unit. What should be the initial action taken by the nurse?Collaborate with the multidisciplinary team members Discuss the options for advanced directives with the client and the family Ensure the client is free from pain, nausea or dyspnea Refer the client's family to the chaplain Refer the client's family to the chaplain A client who is a victim of domestic violence tells the batterer: "I need a little time away." How would the nurse expect that the batterer might respond?With acceptance, perceiving the comment as an indication that the relationship is in trouble With a new commitment and an opportunity to seek counseling With relief, welcoming the separation as a means to have more personal time With fear of rejection, resulting in increased rage toward the client With fear of rejection, resulting in increased rage toward the client
The client reports seeing spiders crawling on the walls, over the bed, and on the food tray, but denies feeling spiders crawling on the skin. The nurse determines that there are no spiders in the room. Which of the following assessments should the nurse use to document these findings?(Select all that apply.) Tactile hallucinations Spiders reported to be crawling on client Spiders not found in the room Spiders reported to be crawling on surfaces Delusional thinking Visual hallucinations Incoherent speech Visual hallucinations Spiders not found in the room Spiders reported to be crawling on surfaces A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?Refer the client to a victim advocate Interview the client privately Ask the client if there are any old injuries Photograph the specific injuries and include with documentation Interview the client privately The nurse assesses the use of coping mechanisms by an adolescent one week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be observed by the nurse?Identification, assimilation, withdrawal Ambivalence, dependence, demanding Denial, projection, regression Intellectualization, rationalization, repression Denial, projection, regression Helplessness and hopelessness may contribute to regressive, dependent behavior, which often occurs at any age with hospitalization. Denial or minimization of the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.At the geriatric day care program, a client who has been diagnosed with a neurocognitive disorder (dementia) is crying and repeatedly saying: "I want to go home. Call my daddy to come for me." The nurse should take which action?Direct the client firmly to the assigned group activity Inform the client that the client must wait until the program ends at 5:00 pm to leave Tell the client you will call someone to come get the client and suggest the client to join an exercise group while waiting Give the client simple information about what the client will be doing that day Tell the client you will call someone to come get the client and suggest the client to join an exercise group while waiting Comfort and distraction are key approaches in validation therapy. They are the kindest and most effective actions for clients who have varying degrees of a neurocognitive disorder (formerly referred to as dementia.) The distressed, disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. However, reorientation is often ineffective when the client is upset. Environmental changes provoke stress and fear, especially in clients diagnosed with any degree of Alzheimer's disease.
Behaviors of alcohol and drug abuse have outcomes of impaired judgment and increased risk-taking behavior. What nursing diagnosis best applies to this data?Risk for knowledge deficit Risk for injury Altered thought process Disturbance in self-esteem Risk for injury The nurse is performing an initial assessment for sports physicals at a college clinic. An 18-year old male client reveals he has legally obtained medical marijuana for his migraine headaches. Which of the following is the priority teaching point?"Marijuana use may decrease the body's ability to resist infections." "Frequent use of marijuana may affect a student's short-term memory." "There is a concern that marijuana impairs the structure of lung tissue." "It is important to avoid driving while under the influence of marijuana." "It is important to avoid driving while under the influence of marijuana." A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting or singing. Which of the following actions by the nurse is an example of cultural awareness?The nurse silently reflects about how her biases regarding Native Americans can influence how she approaches the client's parent.The nurse notifies the nursing supervisor to request that the parent stop chanting or singing because of noise concerns.The nurse contacts social services to perform a home evaluation before the newborn is discharged.The nurse begins a discussion with the client's parent by asking, "Tell me about other traditions that your tribe uses?" The nurse silently reflects about how her biases regarding Native Americans can influence how she approaches the client's parent.A postpartum Hispanic client refuses hospital food because it is "cold." What action should the nurse take initially?Schedule the dietitian to meet with the client as soon as possible Ask the client what foods are acceptable or are unacceptable Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes Encourage the client to eat for healing and strength Ask the client what foods are acceptable or are unacceptable During an interview of a new admission, the nurse notices that the client is shifting positions, wringing the hands, and avoiding eye contact. It is important for the nurse to take which of these approaches?Recognize the behavior as a side effect of medication Refocus the discussion on a less anxiety-provoking topic Ask the client what the client is feeling at this moment Assess the client for auditory hallucinations Ask the client what the client is feeling at this moment A client with a diagnosis of depression has recently been acting suicidal and is now more social and energetic than usual. Smiling, the client tells a nurse, "I've made some decisions about my life." What should be the nurse's initial response?"You need to discuss your decisions with your therapist." "I'm so glad to hear that you've made some decisions." "Have you been thinking about suicide again?" "Are you thinking about killing yourself?" "Are you thinking about killing yourself?"
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