NCLEX-RN
NCLEX RN Psychosocial Integrity Questions Questions
Extract:
Question 1 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 2 of 5
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.
Question 3 of 5
A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, 'I'll never be the same now.' Based on this information, which should the nurse identify as the client's primary concern?
Correct Answer: D
Rationale: A client with a renal disorder such as CKD may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience an altered body image. Anxiety is not appropriate because the client is exhibiting anger at this time. The client is not cognitively impaired, eliminating option 2, and is not stating a refusal to undergo therapy, so eliminate option 3.
Question 4 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.
Question 5 of 5
A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
Correct Answer: C
Rationale: Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.