NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
Question 2 of 5
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (
A) Singing or talking to provide comfort and reduce anxiety; (
B) Exposing only one area to maintain dignity and prevent chilling; (
D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (
C) may increase agitation and is not appropriate.
Question 3 of 5
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
Question 4 of 5
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.
Question 5 of 5
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.