NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
When developing Jerry's plan of care, which of the following would NOT be helpful to include?
Correct Answer: A
Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.
Question 2 of 5
The nurse implements which de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior?
Correct Answer: A,B,D,E
Rationale: When the client is angry and exhibits increasingly agitated behavior, the nurse should employ de-escalation techniques to prevent client violence and assaultive behaviors. These techniques include assessing the situation, using a calm and clear tone of voice when communicating with the client, remaining calm, avoiding verbal struggles, presenting clear options to the client, and maintaining the client's self-esteem and dignity. The nurse should establish what the client considers to be her or his need and maintain a large personal space (touching the client could increase agitation).
Question 3 of 5
A client with schizophrenia is admitted to the inpatient mental health unit. When asked her name, she responds, 'I am Elizabeth, the Queen of England.' Which should the nurse recognize this client's statement is indicating?
Correct Answer: C
Rationale: A delusion is an important personal belief that is almost certainly not true and that resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. Loose association is thinking that is characterized by speech in which ideas that are unrelated shift from one subject to another. A hallucination is a false perception.
Question 4 of 5
Which dysfunction of the reproductive system is associated with anorexia nervosa in females?
Correct Answer: C
Rationale: Amenorrhea (cessation of menses) is associated with anorexia nervosa in females due to endocrine imbalances resulting from depleted fat stores. Galactorrhea is a milky discharge from the nipples unrelated to normal breast milk production. Gynecomastia is swelling of breast tissue in males. Premenstrual dysphoric disorder occurs about 1 week before menses and includes mood swings, depression, fatigue, bloating, overeating, and difficulty focusing, resolving when menstruation starts. In the context of anorexia nervosa, the primary concern is the disruption of the menstrual cycle due to low body weight, leading to amenorrhea.
Question 5 of 5
A charge nurse is supervising a new nurse who is providing care to a client diagnosed with end-stage heart failure. The client is withdrawn and reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement, if made by the new nurse to the client, indicates that the new nurse has a need for further teaching regarding the use of therapeutic communication techniques?
Correct Answer: B
Rationale: When the nurse asks a 'why' question of the client, the nurse is requesting an explanation for feelings and behaviors when the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the nurse is encouraging the verbalization of emotions or feelings, which is a therapeutic communication technique. In option 3, the nurse is using the therapeutic communication technique of exploring, which involves asking the client to describe something in more detail or to discuss it more fully. In option 4, the nurse is using the therapeutic communication technique of giving information. Identifying the common fear of death among clients with end-stage heart failure may encourage the client to voice concerns.