NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, 'What's the use? I'll never remember all of this, and I'll probably die anyway!' The nurse determines that the client's statement is most likely due to which psychosocial concern?
Correct Answer: D
Rationale: Anxiety and fear often develop after heart failure, and they can further tax the failing heart. The client's statement is made in the middle of receiving self-care instructions. There is no evidence in the question to support option 1, 2, or 3.
Question 2 of 5
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, 'I'm not sure I can take any more of this treatment.' Which therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client's frame of reference are important components of the nurse-client relationship. This assists clients with expressing and exploring feelings, which can lead to problem-solving. The other options are examples of barriers to effective communication, including option 1, which is stereotyping; option 2, which is defensiveness; and option 4, which is showing disapproval.
Question 3 of 5
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
Question 4 of 5
The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse?
Correct Answer: C
Rationale: Clients with advanced Parkinson disease are at higher risk for abuse due to increased dependency, physical limitations, and potential cognitive impairments, making them vulnerable to neglect or mistreatment. Other conditions listed are less likely to increase vulnerability to the same extent.
Question 5 of 5
The nurse is admitting a client who is to undergo ureterolithotomy. Which should the nurse assess in order to determine if the client is ready for surgery?
Correct Answer: B,C,D,E
Rationale: Ureterolithotomy is the removal of a calculus from the ureter using either a flank or abdominal incision. The client should have an understanding of the same items as are required for any surgery, including knowledge of the procedures, the expected outcome, the postoperative routines, and any expected discomfort. The client should also be assessed for any concerns or anxieties before surgery. Because no urinary diversion is created during this procedure, the client has no need for a visit from a member of a support group.