NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A mother brings her previously continent 6-year-old son to the pediatric clinic because he has resumed bedwetting. The nurse assesses the home environment and discovers that there is a new baby at home. Which explanation by the nurse best describes for the mother the defense mechanism the son is using?
Correct Answer: A
Rationale: The defense mechanism of regression is characterized by returning to an earlier form of expressing an impulse. Option 2 is characterized by blocking a wish or desire from conscious expression. Option 3 occurs when a person models behavior after someone else. Option 4 occurs when a person unconsciously falsifies an experience by giving a 'rational' explanation.
Question 2 of 5
The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which statement should the nurse make to the client to most encourage therapeutic communication?
Correct Answer: C
Rationale: Option 3 encourages the client to discuss his or her feelings. Options 1 and 4 show disapproval, and option 2 provides false reassurance; these are nontherapeutic techniques.
Question 3 of 5
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option
A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option
B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option
C) is not appropriate as it goes against unit rules and does not address the client's concerns.
Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.
Question 4 of 5
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
Correct Answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.
Question 5 of 5
The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
Correct Answer: D
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.