NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
Question 2 of 5
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.
Question 3 of 5
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (
A) Singing or talking to provide comfort and reduce anxiety; (
B) Exposing only one area to maintain dignity and prevent chilling; (
D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (
C) may increase agitation and is not appropriate.
Question 4 of 5
A client who is in halo traction states to the visiting nurse, 'I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is.' Which therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.
Question 5 of 5
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.