NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)
Correct Answer: A,C,E,F
Rationale: Appropriate interventions include: (
A) Remaining with the client for support; (
C) Administering lorazepam to reduce anxiety; (E) Providing privacy to create a safe space; (F) Writing down information to aid communication. Police interviews (
B) or describing the incident (
D) may increase distress and are not immediate priorities.
Question 2 of 5
Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?
Correct Answer: D
Rationale: The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child's association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child's trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.
Question 3 of 5
What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?
Correct Answer: D
Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client.
Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries.
Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.
Question 4 of 5
Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment?
Correct Answer: B
Rationale: In the early phase of treatment for a client with schizophrenia, the nurse needs to address the client's suspicious feelings to establish trust and create a therapeutic environment. Suspicious feelings can hinder the development of a positive nurse-client relationship. Continual pacing, while a symptom, can be managed by the nurse and does not directly impact the therapeutic relationship. Inability to socialize with others and a disturbed relationship with the family are important factors but are of lesser concern in the early treatment phase as compared to addressing suspicious feelings to build trust and rapport.
Question 5 of 5
Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage?
Correct Answer: B
Rationale: During the identity versus role confusion stage, which occurs during adolescence or puberty, it is essential for the nurse to empower hospitalized adolescents by providing them with sufficient information about their treatment plan. This approach enables the clients to actively participate in decision-making regarding their care. Choosing creative ways to promote social participation is more aligned with assisting clients during the generativity versus self-absorption and stagnation stage, where fostering social engagement can contribute to a sense of fulfillment. Involving the client's partners or family members in the caring process is typically beneficial during the intimacy versus isolation stage to create a strong support system for the client. Encouraging active participation in treatment procedures is more relevant to the industry versus inferiority stage, ensuring that the hospitalized client engages effectively in their care.