NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.
Question 2 of 5
While assisting with bathing, the client who has sustained a spinal cord injury states, 'I can't do this. I wish I were dead.' Which therapeutic response should the nurse make to encourage communication?
Correct Answer: B
Rationale: Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking 'why' in option 1, the nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. The remaining options are nontherapeutic statements that block communication.
Question 3 of 5
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
Question 4 of 5
The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern?
Correct Answer: D
Rationale: A client with COPD may suffer physical or psychological alterations that impair communication.
To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options.
Question 5 of 5
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.