NCLEX-PN
Psychosocial Integrity NCLEX PN Questions Questions
Extract:
Question 1 of 5
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, 'No woman will ever want to marry me now.' Which of the following responses by the nurse is most therapeutic?
Correct Answer: D
Rationale: This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic.
Question 2 of 5
A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
Correct Answer: A
Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants.
Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.
Question 3 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.
Question 4 of 5
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, 'No woman will ever want to marry me now.' Which of the following responses by the nurse is most therapeutic?
Correct Answer: D
Rationale: This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic.
Question 5 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.