NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
Extract:
Question 1 of 5
The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?
Correct Answer: C
Rationale: Building trust is critical for clients with paranoia, who may be suspicious and guarded. A trusting relationship encourages engagement and cooperation, making it the priority over reassurance, urging disclosure, or socialization.
Question 2 of 5
The nurse is admitting a client who is to undergo ureterolithotomy. Which should the nurse assess in order to determine if the client is ready for surgery?
Correct Answer: B,C,D,E
Rationale: Ureterolithotomy is the removal of a calculus from the ureter using either a flank or abdominal incision. The client should have an understanding of the same items as are required for any surgery, including knowledge of the procedures, the expected outcome, the postoperative routines, and any expected discomfort. The client should also be assessed for any concerns or anxieties before surgery. Because no urinary diversion is created during this procedure, the client has no need for a visit from a member of a support group.
Question 3 of 5
A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, 'I know I need it, but I'm not sure this surgery is a great idea.' Which nursing response should best help the nurse assess the client's preoperative concerns?
Correct Answer: D
Rationale: Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory.
Question 4 of 5
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
Correct Answer: A
Rationale: This statement describes mood swings between mania and depression, characteristic of bipolar disorder.
Question 5 of 5
A 17-year-old female with a self-admitted opioid addiction is seen by the nurse in a mental health clinic. Which intervention would the nurse not consider in establishing a therapeutic relationship?
Correct Answer: B
Rationale: Mandating attendance can undermine trust and autonomy, hindering a therapeutic relationship.