NCLEX-RN
RN Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.
Question 2 of 5
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
Question 3 of 5
A client diagnosed with acute kidney injury is having trouble remembering information and instructions as a result of altered laboratory values. Which actions should the nurse take when communicating with this client? Select all that apply.
Correct Answer: A,B,C,D
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simple, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language. Thorough and complete explanations may be confusing and will not be understandable for the client.
Question 4 of 5
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
Question 5 of 5
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.