NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern.
Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
Question 2 of 5
The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
Correct Answer: B
Rationale: Psychosocial assessment includes client data related to psychological and social issues. The CVC can create socially awkward situations and impair the client's security in her body image. The client data presented do not support assessing the client for poor self-care. Although pain and neck range of motion are valid issues for this client, options 3 and 4 are physiological issues and do not relate to the concerns of the client.
Question 3 of 5
A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation?
Correct Answer: D
Rationale: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.
Question 4 of 5
A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?
Correct Answer: A
Rationale: The mother of an LGA infant with facial bruising may be reluctant to interact with the infant because of concern about causing additional pain to the infant.
Touching the infant gently with the fingertips should be encouraged. The bruising is temporary. Option 2 does not address the mother's verbalized concerns. The LGA infant may have polycythemia, which can contribute to bruising, but the bruising is not actually caused by the polycythemia. Option 4 advises the mother not to touch the baby's face because the bruising is painful, but touch is an important component of the attachment process.
Question 5 of 5
During the nursing assessment, the client states, 'My surgeon just told me that my cancer has spread, and I have less than 6 months to live.' Which nursing response would be the most therapeutic?
Correct Answer: A
Rationale: The client has received very distressing news and is most likely still experiencing shock and denial. In option 1, the nurse invites the client to ventilate feelings. Option 2 is social and expresses the nurse's feelings rather than the client's feelings. Option 3 is patronizing and stereotypical. Option 4 provides social communication and false hope.