NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
Question 2 of 5
A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
Correct Answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.
Question 3 of 5
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
Correct Answer: D
Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option
A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.
Question 4 of 5
A charge nurse observes an unlicensed assistive personnel (UAP) talking in an unusually loud voice to a client with schizophrenia experiencing delirium. Which priority action should the charge nurse take?
Correct Answer: C
Rationale: The nurse must ascertain that the client is safe and then discuss the matter with the UAP in an area away from the hearing of the client. If the client hears the conversation, the client may become more confused or agitated. The remaining options are incorrect actions for this situation.
Question 5 of 5
The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?
Correct Answer: B
Rationale: Respecting the veteran’s need for space by keeping the environment quiet and maintaining distance reduces stimulation and potential escalation, especially during possible PTSD episodes. Approaching or touching may increase agitation, and reassurance is less actionable.