NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
Question 2 of 5
The nurse prepares a client for a left total hip replacement. Which statement by the client indicates to the nurse that the client exhibits an emotional readiness for surgery?
Correct Answer: C
Rationale: Expressing enthusiasm for post-surgical exercises indicates optimism and readiness to engage in recovery, reflecting emotional preparedness. Other statements suggest distrust, uncertainty, or anxiety, which do not indicate readiness.
Question 3 of 5
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
Question 4 of 5
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
Question 5 of 5
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry.
Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.