NCLEX-RN
NCLEX Patient Needs Psychosocial Integrity Therapeutic Communications Questions
Extract:
Question 1 of 5
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
Correct Answer: A,E
Rationale: Administering medications (
A) helps manage hallucinations, and asking about harmful voices (E) assesses safety.
Touch (
B) may be misinterpreted, validating hallucinations (
C) is harmful, and distraction in a dayroom (
D) may overwhelm the client.
Question 2 of 5
The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
Correct Answer: C
Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.
Question 3 of 5
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
Correct Answer: A,E
Rationale: Administering medications (
A) helps manage hallucinations, and asking about harmful voices (E) assesses safety.
Touch (
B) may be misinterpreted, validating hallucinations (
C) is harmful, and distraction in a dayroom (
D) may overwhelm the client.
Question 4 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.
Question 5 of 5
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.