NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
Correct Answer: A
Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.
Question 2 of 5
For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?
Correct Answer: A
Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.
Question 3 of 5
A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, 'I'm no good to anyone. I might as well be dead.' Which most therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.
Question 4 of 5
A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
Correct Answer: A
Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.
Question 5 of 5
The nurse observes that a client is restless, tense, and reports feeling empty. The nurse notes the client has a history of threatening self-mutilation. Which nursing action is appropriate?
Correct Answer: D
Rationale: Taking inventory of the client’s room ensures safety by identifying and removing potential tools for self-harm, given the history of threatened self-mutilation. Other actions do not directly address the immediate risk.