NCLEX-RN
NCLEX Patient Needs Psychosocial Integrity Therapeutic Communications Questions
Extract:
Question 1 of 5
The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, 'You won't have to worry about me much longer.' Which meaning should the nurse interpret from this statement?
Correct Answer: A
Rationale: A client who is at risk for suicide who says, 'You won't have to worry about me much longer,' is making an expression of a suicidal intent. Although depression, self-mutilation, and hopelessness may relate to violence to oneself, the statement that he or she will not be around is a direct comment about the act of suicide.
Question 2 of 5
A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, 'Maybe I shouldn't bother going. I wonder if I should just take more medication instead.' Which therapeutic response should the nurse make to the client?
Correct Answer: A
Rationale: Anxiety and fear are often present before stress testing. The nurse should explore a client's feelings if concerns are expressed. Option 1 is open-ended and is the only choice that is phrased to engender trust and the sharing of concerns by the client. Eliminate options that are inappropriate statements and limit communication.
Question 3 of 5
The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse?
Correct Answer: C
Rationale: Clients and families are often fearful about the activation of the ICD. Their fears are about the device itself and also about the occurrence of life-threatening dysrhythmias that trigger its function. Family members need reassurance that, even if the device activates while they are touching the client, the level of the charge is not high enough to harm the family member, although it will be felt. The ICD emits a warning beep when the client is near magnetic fields, which could possibly deactivate it, but it does not beep before countershock.
Question 4 of 5
A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, 'If my doctor tells me to do it, I will. Otherwise, I won't.' Which behavior should the nurse determine that the client is displaying?
Correct Answer: D
Rationale: Clients may experience numerous emotional and behavioral responses after an MI. Dependency is one response that may be manifested by the client's refusal to perform any tasks or activities unless specifically approved by the primary health care provider. Although the client's statement may express anger to some degree, it most specifically addresses dependency. There are no data in the question to support denial or depression.
Question 5 of 5
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.