NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in the plan of care before seclusion?
Correct Answer: D
Rationale: Seclusion is a process in which a client is placed alone in a specially designed room for protection and close supervision. This client is removed to a nonstimulating environment as a result of her behavior. Options 1, 2, and 3 are nontherapeutic actions. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
Question 2 of 5
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.
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
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
Question 5 of 5
The nurse is leading a crisis intervention group comprising high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of the suicide. Which should be the initial therapeutic action by the nurse?
Correct Answer: C
Rationale: It is essential to determine the students' views. Inquiring about the students' perception of the suicide will specifically identify the appraisal of the suicide and the meaning of the perception. Although option 1 is exploratory, it does not address the 'here-and-now' appraisal in terms of the classmate's suicide. Although the nurse is interested in how students have coped in the past, this inquiry should not be the most immediate assessment. Options 2 and 4 are attempts to foster students' self-esteem. Such an approach is premature at this point.