NCLEX-RN
NCLEX Patient Needs Psychosocial Integrity Therapeutic Communications Questions
Extract:
Question 1 of 5
The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse?
Correct Answer: C
Rationale: Clients and families are often fearful about the activation of the ICD. Their fears are about the device itself and also about the occurrence of life-threatening dysrhythmias that trigger its function. Family members need reassurance that, even if the device activates while they are touching the client, the level of the charge is not high enough to harm the family member, although it will be felt. The ICD emits a warning beep when the client is near magnetic fields, which could possibly deactivate it, but it does not beep before countershock.
Question 2 of 5
A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism should the nurse assess the client is using?
Correct Answer: B
Rationale: Distancing is an unwillingness or inability to discuss events. The behaviors described are not associated with any of the other options.
Question 3 of 5
The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?
Correct Answer: D
Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.
Question 4 of 5
The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?
Correct Answer: C
Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.
Question 5 of 5
Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nurse?
Correct Answer: B
Rationale: The anatomical location of a hernia frequently causes more psychological concern to the parents than does the actual condition or treatment. The remaining options all indicate accurate understanding associated with the surgery. The correct option is an incorrect comment requiring follow-up.