NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
The nurse is caring for a client who presented to the ED with a blood alcohol level of 208 mg/dL. The client states that his last drink was about 8 hours ago. He exhibits coarse tremors of the hands, anxiety, and elevated blood pressure. Which of the following would the nurse expect if his condition progresses to withdrawal delirium? Select all that apply.
Correct Answer: A,E,F
Rationale: Withdrawal delirium typically includes fever, disorientation, and fluctuating consciousness, with onset 48-72 hours after the last drink. Increased appetite or excessive sleeping are not typical.
Question 2 of 5
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.
Question 3 of 5
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
Question 4 of 5
A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse should make which interpretation about this behavior?
Correct Answer: A
Rationale: Depression is a common problem related to clients who have long-term and debilitating illnesses. None of the remaining options are related to the symptoms present in the question and therefore are not appropriate interpretations.
Question 5 of 5
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.