NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (
B), providing reassurance (
C), and ensuring a private setting (
D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
Question 2 of 5
A client diagnosed with catatonic schizophrenia demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. Which intervention by the nurse is most appropriate to increase interpersonal communication?
Correct Answer: C
Rationale: Clients who are withdrawn may be immobile and mute, and they require consistent, repeated approaches. Intervention includes the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. Asking this client direct questions is not therapeutic. The client is not to be left alone. This client is not capable of interaction in the dayroom.
Question 3 of 5
A client is admitted to the psychiatric unit with a diagnosis of schizophrenia. The client verbalizes to the nurse, 'Someone wants to kill me tonight.' Which response by the nurse is best?
Correct Answer: D
Rationale: Acknowledging the client’s fear validates their emotions and builds trust without reinforcing delusions. Denying the belief, questioning, or reassuring about safety may escalate agitation or distrust in a client with schizophrenia.
Question 4 of 5
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.
Question 5 of 5
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.