Page 2603 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal injury
Priority Concepts: Mobility; Tissue Integrity
Reference: Lewis et al. (2017), pp. 1470-1471.

908. Answer: 1

Rationale: A psychosocial assessment of a client who is immobilized would most
appropriately include the need for sensory stimulation. This assessment should also
include such factors as body image, past and present coping skills, and coping
methods used during the period of immobilization. Although home care support,
the ability to perform activities of daily living, and transportation are components of
an assessment, they are not as specifically related to psychosocial adjustment as is
the need for sensory stimulation.
Test-Taking Strategy: Focus on the strategic words, most appropriate, and note the
subject, psychosocial adjustment. Option 3 can be eliminated first because it relates
to physiological integrity rather than psychosocial integrity. Next, eliminate options
2 and 4 because they are most closely related to physical supports, rather than
psychosocial needs of the client.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal Injury
Priority Concepts: Mobility; Sensory Perception
Reference: Lewis et al. (2017), pp. 1430, 1477.

909. Answer: 3

Rationale: Complex scientific or medical terminology should be avoided when
counseling an Amish client (or any client). When counseling a female Amish client,
most often the husband and wife will want to discuss health care options together.
Standing close and speaking loudly is inappropriate in most counseling situations.
Test-Taking Strategy: Use knowledge of the Amish society and therapeutic
communication techniques to answer this question. Options 2 and 4 can be
eliminated first because option 4 is inappropriate and option 2 is not a therapeutic
intervention. In addition, note that options 2 and 3 are opposite, which may indicate
that one of these options is correct. Option 1 can be eliminated because of Amish
cultural habits.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Culture and Spirituality
Content Area: Foundations of Care: Spirituality, Culture, and Ethnicity
Health Problem: N/A
Priority Concepts: Communication; Culture

2603