NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Question 1 of 5
The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?
Correct Answer: C
Rationale: Allowing time to acclimate helps the client adjust to the new environment, reducing stress and supporting engagement, especially given their cognitive and social challenges. Scheduling activities or encouraging choices may be premature, and rest alone does not address isolation.
Question 2 of 5
A client who is receiving total parenteral nutrition (TPN) tells the nurse, 'I'm not sure that I want to receive an infusion of lipids because it could make me obese.' Which initial action should the nurse take?
Correct Answer: A
Rationale: A client who receives TPN is at risk for developing an essential fatty acid deficiency; however, this client's comment requires more than a simple informational response initially. Thus, the nurse responds with option 1 to assist the client with self-expression and to deal with aspects of illness and treatment. Option 2 delays client self-expression and devalues the client's feelings. Options 3 and 4 provide information only.
Question 3 of 5
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, 'The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?' Which is the most appropriate therapeutic response the nurse should make to the client?
Correct Answer: B
Rationale: Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no problems are associated with this procedure; this is closed-ended and is incorrect. Although option 4 contains accurate information, the word immediately can increase the client's anxiety.
Question 4 of 5
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.
Question 5 of 5
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.