NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
The nurse is preparing a plan of care for a client demonstrating mania. Which interventions should be included in the plan of care?
Correct Answer: C,D,E,F
Rationale: A client with mania will be extremely restless, disorganized, and chaotic. Grandiose plans are extremely out of touch with reality, and judgment is poor. Interventions for the client in acute mania include using a firm and calm approach to provide structure and control, using short and concise explanations or statements because of the client's short attention span, remaining neutral and avoiding power struggles and value judgments, being consistent in approach and expectations and having frequent staff meetings to plan consistent approaches and to set agreed-on limits to avoid manipulation by the client, hearing and acting on legitimate client complaints, and redirecting energy into more appropriate and constructive channels.
Question 2 of 5
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
Question 3 of 5
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.
Question 4 of 5
A client who received an implanted port for intermittent chemotherapy says, 'I'm not sure if I can handle having a tube coming out of me. What will my friends think?' Which action should the nurse implement first?
Correct Answer: C
Rationale: An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when an intravenous line is connected, and the port is accessed for therapy. The remaining options do not correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring about the client's friends is a reasonable response, but it can also provide false hope that the friends will be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be beneficial because the client will not be using them; in addition, this can heighten client anxiety and concerns.
Question 5 of 5
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve being easily bored, shallow relationships, attention-seeking (
C), and impulsivity, mood shifts, and manipulative behavior (
D). Options A and E describe Cluster A, and B describes Cluster C.