NCLEX-PN
Psychosocial Integrity Nclex PN Questions Questions
Extract:
Question 1 of 5
Implementing counseling by the nurse specialist for the raped victim represents:
Correct Answer: B
Rationale:
Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (
Choice
C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (
Choice
A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (
Choice
D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.
Question 2 of 5
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
Correct Answer: A
Rationale: The correct answer is denial. In this scenario, the client's statement indicates denial, which is a common reaction in Kübler-Ross's Stages of Grieving. Denial involves the refusal to accept or believe that a loss, such as a terminal illness diagnosis, is happening.
Choices B, C, and D are incorrect: Anger involves feelings of resentment or frustration; Bargaining is an attempt to negotiate or make deals to avoid the situation; Acceptance is the final stage where the individual comes to terms with the reality of the situation.
Question 3 of 5
Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
Correct Answer: C
Rationale: CPK-MB is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients who have brain damage, and CPK-MM is elevated in clients who have skeletal muscle damage. CPK-MI does not exist.
Question 4 of 5
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
Correct Answer: D
Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease.
Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.
Question 5 of 5
A client has sustained a hyphema. What intervention should the nurse take?
Correct Answer: B
Rationale: Initial care of the client involves preventing further damage and rebleeding. Clients are kept at bed rest if possible, usually with the head of the bed raised. TV watching is permitted but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse should not administer a pharmacologic agent or thermal therapy without a physician's order.