NCLEX-RN
NCLEX Psychosocial Questions Questions
Extract:
Question 1 of 5
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
Correct Answer: B
Rationale: The correct answer is to explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool. Changing client care assignments (
Choice
A) is not necessary as the child's behavior is developmentally appropriate. Discussing the appropriate use of 'time-out' (
Choice
C) is not relevant in this situation as the child is displaying normal attachment behavior, not misbehavior. Explaining that the child needs extra attention (
Choice
D) may not be necessary as the child is likely seeking comfort from the familiar presence of the mother, which is a typical response in a stressful situation like being in a hospital environment.
Question 2 of 5
A female nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the nurse to intervene if she takes which action?
Correct Answer: C
Rationale: In some Arab cultures, it is not considered appropriate for a male to be alone with a female who is not his spouse.
Therefore, it is important for the nurse to respect the patient's cultural beliefs and privacy by ensuring that a female nurse is not alone with the male patient. Sitting down at the bedside and closing the privacy curtain could potentially lead to a situation where the nurse is alone with the patient, which goes against the patient's cultural norms. The other actions, such as explaining the pain scale, asking about the onset of headaches, and requesting a male nurse to bring a hospital gown, are all appropriate and do not conflict with the patient's cultural beliefs.
Question 3 of 5
A client who is at 28 weeks' gestation and in active labor is crying. She says, 'I just know that this baby is going to die. What's the use of doing all this to save it?' Which explanation would interpret the client's statements?
Correct Answer: B
Rationale: The client's statement indicates anticipatory grief, where she is preparing for a potential loss. This grief is not necessarily about the literal death of the baby but about the loss of the anticipated healthy full-term baby. The client may not be ready to bond with the reality of a preterm baby. Providing gentle, positive support is essential to help her cope with her feelings, as firm support may come across as dismissive. Sedation is not appropriate as it could hinder the client's emotional processing. Allowing the client to express her emotions and work through anticipatory grieving is crucial. The use of the word 'it' reflects the client's emotional struggle and is not the primary issue at hand.
Question 4 of 5
A college athlete sustained a complete transection of the spinal cord while practicing on a trampoline. The health care provider explained that return of function to the lower extremities is not likely. Two weeks later, the client verbalizes the need to practice for an upcoming tournament. Which conclusion would the nurse make about the client's statement?
Correct Answer: A
Rationale: The correct answer is 'Exhibiting denial.' Denial is a common defense mechanism when facing a serious health issue. The individual rejects the existence of the problem due to the overwhelming anxiety and emotional distress it causes. In this case, the athlete's desire to practice for an upcoming tournament despite being informed about the unlikely return of lower extremity function indicates denial of the severity of their condition.
Choice B, 'Verbalizing a fantasy,' is incorrect as a fantasy involves creating imagined events to fulfill unconscious wishes, which is not evident here.
Choice C, 'No longer able to adapt,' is incorrect because the client is actually demonstrating a maladaptive coping mechanism by denying the reality of their situation.
Choice D, 'Motivated to recover mobility,' is incorrect as the client's goal of practicing for a tournament does not align with the realistic expectation of recovering mobility after a complete spinal cord transection.
Question 5 of 5
The nurse is performing an admission assessment for a non-English speaking patient who is from China. Which actions could the nurse take to enhance communication (select one that does not apply)?
Correct Answer: D
Rationale: Electronic translation applications, telephone-based medical interpreters, and agency interpreters are all appropriate tools to enhance communication with non-English-speaking patients. However, asking the patient's teenage daughter to interpret is not recommended due to potential misinterpretation of crucial information during the admission assessment. While family members may be considered in the absence of a professional interpreter, there is a risk of misunderstanding or lack of sharing essential details. It is important to rely on trained interpreters to ensure accurate communication and avoid miscommunication or misinterpretation of critical information. Using gestures can be helpful, but over-exaggeration of gestures is unnecessary and may lead to confusion.