NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
Correct Answer: A,B,F
Rationale: Alcohol/drug use, poverty, and unplanned pregnancy are established risk factors for spousal abuse. Age, education, and social circles are not specific risk factors.
Question 2 of 5
The nurse plans care for a client diagnosed with anorexia nervosa. Which goal will the nurse make a priority for this client?
Correct Answer: A
Rationale: Gradual weight gain (0.25 lb/week) is the priority goal for anorexia, addressing malnutrition and physical health risks. Electrolyte balance and meal consumption are important but secondary, and identifying normal weight is a long-term cognitive goal.
Question 3 of 5
A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
Question 4 of 5
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
Correct Answer: D
Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate).
Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload.
Therefore, determining the role of pain in tachypnea is crucial for appropriate management.
Question 5 of 5
Which of the following mental health situations is considered a psychiatric emergency?
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SA
D) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.