NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
Question 2 of 5
The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
Correct Answer: D
Rationale:
To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
Question 3 of 5
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
Correct Answer: B
Rationale: Joining a social activity like a bridge club indicates improved mood and engagement, a sign that the antidepressant is effective.
Question 4 of 5
The nurse implements which de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior?
Correct Answer: A,B,D,E
Rationale: When the client is angry and exhibits increasingly agitated behavior, the nurse should employ de-escalation techniques to prevent client violence and assaultive behaviors. These techniques include assessing the situation, using a calm and clear tone of voice when communicating with the client, remaining calm, avoiding verbal struggles, presenting clear options to the client, and maintaining the client's self-esteem and dignity. The nurse should establish what the client considers to be her or his need and maintain a large personal space (touching the client could increase agitation).
Question 5 of 5
The nurse notes that a toddler has numerous bruises, a possible fractured left humerus, and several lacerations. Which action will the nurse take first?
Correct Answer: A
Rationale: Suspected child abuse, indicated by multiple bruises, a possible fracture, and lacerations, requires immediate reporting to Child Protective Services as mandated by law to ensure the child's safety. This takes precedence over other actions to initiate protective measures promptly.