NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse implements which de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior?
Correct Answer: A,B,D,E
Rationale: When the client is angry and exhibits increasingly agitated behavior, the nurse should employ de-escalation techniques to prevent client violence and assaultive behaviors. These techniques include assessing the situation, using a calm and clear tone of voice when communicating with the client, remaining calm, avoiding verbal struggles, presenting clear options to the client, and maintaining the client's self-esteem and dignity. The nurse should establish what the client considers to be her or his need and maintain a large personal space (touching the client could increase agitation).
Question 2 of 5
Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment?
Correct Answer: B
Rationale: In the early phase of treatment for a client with schizophrenia, the nurse needs to address the client's suspicious feelings to establish trust and create a therapeutic environment. Suspicious feelings can hinder the development of a positive nurse-client relationship. Continual pacing, while a symptom, can be managed by the nurse and does not directly impact the therapeutic relationship. Inability to socialize with others and a disturbed relationship with the family are important factors but are of lesser concern in the early treatment phase as compared to addressing suspicious feelings to build trust and rapport.
Question 3 of 5
What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?
Correct Answer: D
Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client.
Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries.
Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.
Question 4 of 5
The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, 'I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings.' Which action by the nurse is most appropriate?
Correct Answer: A
Rationale: Encouraging the client to share promotes engagement and allows the group to support them, addressing their restlessness therapeutically. Removing them isolates, labeling as manipulative is judgmental, and ignoring dismisses their needs.
Question 5 of 5
A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?
Correct Answer: D
Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.