NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.
Question 2 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 3 of 5
The nurse obtains an electrocardiogram (ECG) rhythm strip for an adult client who is anxious about the results. The ECG shows that the heart rate is 90 beats per minute. Which statement should the nurse make to the client to relieve anxiety?
Correct Answer: A
Rationale: A normal adult resting pulse rate ranges between 60 and 100 beats per minute; therefore, the rate is normal. The nurse would not tell a client not to worry. Options 3 and 4 indicate that the ECG is abnormal.
Question 4 of 5
A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, 'I'm not having surgery. You must have the wrong person! My test results were negative. I'll be going home tomorrow.' The nurse recognizes the client's statement as indicative of which defense mechanism?
Correct Answer: A
Rationale: By definition, ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Denial is the defense mechanism that blocks out painful or anxiety-inducing events or feelings. In this case, the client cannot deal with the upcoming surgery for cancer and therefore denies the illness. Psychosis and delusions are not defense mechanisms. Displacement is the discharging of pent-up feelings on people who are less dangerous than those who initially aroused the feelings.
Question 5 of 5
A client suffering from visual hallucinations calls the nurse to her room and says, 'You need to hurry up and kill all these bugs on the wall before they get on me.' Which response by the nurse is most appropriate?
Correct Answer: D
Rationale: This response acknowledges the client's perception without reinforcing the hallucination, promoting trust and reality orientation.