NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
A client is demonstrating confusion as a result of bed rest and a prolonged length of hospital stay. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
Correct Answer: C
Rationale: The cause of the client's confusion is bed rest and decreased sensory stimulation from a prolonged length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory stimulation. Hopefully the stimulation can help decrease the confusion. Options 1 and 2 do not address the client's need for sensory stimulation. The nurse performs option 4 in preparation for ambulation while the client is on bed rest.
Question 2 of 5
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.
Question 3 of 5
The client angrily tells the nurse that the primary health care provider (HCP) purposefully provided incorrect information. Which responses by the nurse to the client support therapeutic communication?
Correct Answer: B,C,D
Rationale: Options 2 and 3 attempt to clarify the information to which the client is referring. Option 4 attempts to explore whether the client is comfortable talking to the HCP about this issue and encourages direct confrontation. Options 1 and 5 hinder communication by disagreeing with the client and referring the client to the Internet instead of his HCP for clarification. This technique could make the client defensive and block further communication.
Question 4 of 5
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.
Question 5 of 5
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (
B), providing reassurance (
C), and ensuring a private setting (
D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.