NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
A client having premature ventricular contractions states to the nurse, 'I'm so afraid that something bad will happen.' Which action by the nurse provides the most immediate help to the client?
Correct Answer: C
Rationale: When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance.
Question 2 of 5
The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?
Correct Answer: C
Rationale: Building trust is critical for clients with paranoia, who may be suspicious and guarded. A trusting relationship encourages engagement and cooperation, making it the priority over reassurance, urging disclosure, or socialization.
Question 3 of 5
A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, 'Do I have to worry about this diabetes anymore?' Which is the most appropriate response by the nurse?
Correct Answer: C
Rationale: The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care, it may not develop.
Question 4 of 5
A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse?
Correct Answer: A
Rationale: The home care nurse must determine what is causing the client's frustration. The issue needs to be addressed by the nurse before involving the provider. Administering the insulin provides only a short-term solution. Continuing to teach may only further block the learning process.
Question 5 of 5
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.