NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?
Correct Answer: A
Rationale: One of the most important nursing roles is providing emotional support to the client and family during the counseling process. Option 2, like option 4, is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if this is not requested, the nurse is abandoning the client in a time of need. Option 4 overwhelms the client with information while she is trying to cope with the news of the disease.
Question 2 of 5
A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client? Select all that apply.
Correct Answer: B,D,E
Rationale: A lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known pathology. Using a commode behind a curtain may inhibit voiding for some individuals, especially with a roommate present. The use of a bathroom is preferable, and this may be supplemented with the use of running water or pouring water over the perineum, as needed. Catheterization is not a nursing intervention and presents a risk of infection. If noninvasive techniques do not work, then the primary health care provider may prescribe that the client be catheterized.
Question 3 of 5
An older client is brought to the emergency department by a family member with whom the client lives. The nurse observes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. Based on the nurse's assessment data, the client is suspected of which form of victimization?
Correct Answer: B
Rationale: Victimization in a family can take many forms. When analyzing a specific client situation, it is important to understand which form of abuse is being considered. Physical abuse can take the form of battering (hitting, slapping, striking), or it can be more subtle, such as neglect (the failure to meet basic needs). Sexual abuse can involve unwanted sexual remarks, sexual advances, and physical sexual acts. Emotional and psychological abuse can involve inflicting verbal statements that cause mental anguish or alienation of the victim.
Question 4 of 5
A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse?
Correct Answer: A
Rationale: The home care nurse must determine what is causing the client's frustration. The issue needs to be addressed by the nurse before involving the provider. Administering the insulin provides only a short-term solution. Continuing to teach may only further block the learning process.
Question 5 of 5
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.