NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 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.
Question 2 of 5
A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, 'I'm no good to anyone. I might as well be dead.' Which most therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.
Question 3 of 5
The nurse admits a client diagnosed with Alzheimer disease. The client is mildly anxious and very confused. Which action does the nurse take?
Correct Answer: D
Rationale: Orienting the client to self, day, time, place, and situation addresses confusion and anxiety, providing a calming and grounding effect. Explaining the environment is helpful but less structured, and rules or consent forms are inappropriate given the client’s confusion.
Question 4 of 5
Which parameter would be assessed to determine the degree of anxiety being experienced by the client?
Correct Answer: C
Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.
Question 5 of 5
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
Correct Answer: B
Rationale: Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical.