NCLEX-PN
Psychosocial Integrity Nclex PN Questions Questions
Question 1 of 5
A client reports hearing voices. What should the nurse do next?
Correct Answer: C
Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.
Question 2 of 5
A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with
Correct Answer: B
Rationale: The correct answer is 'the child being shaken.' Children who are shaken are frequently grasped by both upper arms, leading to bruises in that area. The presentation of a difficult-to-awaken child with bruises on the upper arms is highly concerning for non-accidental trauma, such as abusive shaking. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely because the combination of a child being difficult to awaken and bruises on both upper arms is highly suggestive of non-accidental trauma rather than benign causes like ill-fitting clothing, falling while learning to walk, or parents trying to awaken the child.
Question 3 of 5
Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens's concerns is likely to predominate?
Correct Answer: C
Rationale: The most prominent concern for Mrs. Owens is likely what will happen to her son, Jonathan, after she passes away. While retirement fund sustainability is important, it is not likely to be her primary concern. Funeral arrangements, although significant, are secondary to the welfare of her son with schizophrenia. The question of how to communicate with Jonathan's physician is less likely to be a predominant concern since Mrs. Owens has likely already addressed this issue over the 38 years of managing her son's care.
Question 4 of 5
When assisting a client in gaining insight into anxiety, what should the nurse do?
Correct Answer: B
Rationale: To assist a client in gaining insight into anxiety, it is crucial to identify triggers or events that lead to increased anxiety. This approach helps the client recognize causal factors contributing to their anxiety, promoting self-awareness and understanding. Choice A is incorrect because it should focus on triggers rather than specific behaviors. Choice C is incorrect as it emphasizes managing anxiety through relaxation techniques rather than understanding its roots. Choice D is incorrect as it addresses resistive behavior rather than exploring the causes of anxiety.
Question 5 of 5
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
Correct Answer: C
Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.