NCLEX-RN
NCLEX Psychosocial Integrity Questions Questions
Question 1 of 5
Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?
Correct Answer: D
Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.
Question 2 of 5
A client admitted with a diagnosis of cervical cancer tells the nurse, 'I haven't had a Papanicolaou (Pap) smear for more than 8 years. I probably wouldn't be in the hospital today if I'd had those tests more often.' Which response would the nurse provide?
Correct Answer: B
Rationale: The correct response, ''You feel as though you've neglected your health,'' is appropriate as it indicates recognition of expressed feelings, encouraging verbalization. This response is nondirective and reflective. Choice A, asking the client why she waited so long, ignores the client's current emotional needs and may cut off communication. Choice C, stating that it is never too late to start taking care of her health, is judgmental as it implies that the client has been negligent. Choice D, although acknowledging the importance of Pap smears, fails to address the client's current emotional state and needs.
Question 3 of 5
What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
Correct Answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
Question 4 of 5
A client asks the nurse, 'Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?' Which is the nurse's most appropriate response?
Correct Answer: C
Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.
Question 5 of 5
After giving birth to her third child, a client tearfully says to the nurse, 'How much more can I give of myself?' Which principle would the nurse consider in the care of any new mother?
Correct Answer: C
Rationale: A parent's feeling of being overwhelmed by multiple children is a normal response. It is vital to help parents realize this as a means of easing feelings of guilt and shame. The first child causes the greatest amount of adjustment in one's life. It is common for parents to feel anger and resentment toward their children at times due to the challenges of parenting. Stating that parents usually have inborn feelings of love and acceptance of their children is a false generalization and may not hold true for everyone. Therefore, the most appropriate principle for the nurse to consider in this situation is that some parents may experience feelings of being overwhelmed by multiple children.