NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client? Select all that apply.
Correct Answer: B,D,E
Rationale: A lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known pathology. Using a commode behind a curtain may inhibit voiding for some individuals, especially with a roommate present. The use of a bathroom is preferable, and this may be supplemented with the use of running water or pouring water over the perineum, as needed. Catheterization is not a nursing intervention and presents a risk of infection. If noninvasive techniques do not work, then the primary health care provider may prescribe that the client be catheterized.
Question 2 of 5
The nurse provides care for an older adult client who is disoriented to person, place, and time. The client has an incontinence episode. Which statement by the nurse is most appropriate?
Correct Answer: D
Rationale: Offering to clean up and provide dry clothes is compassionate, maintains dignity, and addresses the immediate need without judgment. Catheters are invasive, blaming the client is inappropriate, and simply offering clothes does not address hygiene.
Question 3 of 5
A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client?
Correct Answer: B
Rationale: Fears about having only one functioning kidney are common among clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs as long as it has normal function. This information supports that the remaining options are inaccurate.
Question 4 of 5
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
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.