NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
The nurse provides care for a client diagnosed with substance abuse. The nurse recognizes the client is using projection as a defense mechanism when the client makes which statement?
Correct Answer: B
Rationale: Projection involves attributing one's own undesirable behaviors to others. The client blaming their spouse for excessive medication use reflects projection by deflecting their own substance abuse issues onto another person.
Question 2 of 5
The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement?
Correct Answer: A
Rationale: Keeping the room organized and clean minimizes sensory overload and confusion, promoting a calming environment for a client with delirium. High noise, dim lights, or restraints can worsen agitation and are not appropriate unless safety is imminently threatened.
Question 3 of 5
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
Question 4 of 5
The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
Correct Answer: B
Rationale: Psychosocial assessment includes client data related to psychological and social issues. The CVC can create socially awkward situations and impair the client's security in her body image. The client data presented do not support assessing the client for poor self-care. Although pain and neck range of motion are valid issues for this client, options 3 and 4 are physiological issues and do not relate to the concerns of the client.
Question 5 of 5
While in the dining area, an adult client at the retirement center yells, 'This turkey is dry and cold! I can't stand the food here!' Which is the best response by the nurse to the client's behavior?
Correct Answer: C
Rationale: Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening with the client. Agency procedure should be followed regarding those who are allowed access to the facility kitchen. Option 1 is angry, aggressive, and nontherapeutic. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.