NCLEX-RN
NCLEX Psychosocial Questions Questions
Extract:
Question 1 of 5
When performing a cultural assessment with a patient from a different culture, what action should the nurse take first?
Correct Answer: B
Rationale: When conducting a cultural assessment, the first step is to inquire if the patient has any affiliation with a specific cultural group. This helps the nurse understand the patient's background and beliefs. Requesting an interpreter before interviewing the patient may be necessary if language barriers exist. Waiting for a family member to assist with the assessment may delay the process and compromise patient confidentiality. Telling the patient what the nurse knows about their culture assumes knowledge and may lead to misunderstandings or inaccuracies.
Question 2 of 5
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
Correct Answer: B
Rationale: The correct answer is to explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool. Changing client care assignments (
Choice
A) is not necessary as the child's behavior is developmentally appropriate. Discussing the appropriate use of 'time-out' (
Choice
C) is not relevant in this situation as the child is displaying normal attachment behavior, not misbehavior. Explaining that the child needs extra attention (
Choice
D) may not be necessary as the child is likely seeking comfort from the familiar presence of the mother, which is a typical response in a stressful situation like being in a hospital environment.
Question 3 of 5
A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing?
Correct Answer: C
Rationale: The client is experiencing disenfranchised grief. Disenfranchised grief refers to grief over a loss that is not socially recognized or acknowledged. In this case, grief after an abortion falls into this category. It can lead to prolonged emotional distress as the loss may not be openly acknowledged or supported by others. Complex bereavement is characterized by dysfunctional grieving that extends beyond 12 months. Anticipatory grief occurs when the loss is expected or predictable, allowing individuals to start the grieving process before the actual loss. Complicated grief is marked by an inability to progress through the grief stages, leading to intense feelings of depression, anger, and emptiness, often coupled with a preoccupation with the deceased.
Question 4 of 5
When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.
Question 5 of 5
A college athlete sustained a complete transection of the spinal cord while practicing on a trampoline. The health care provider explained that return of function to the lower extremities is not likely. Two weeks later, the client verbalizes the need to practice for an upcoming tournament. Which conclusion would the nurse make about the client's statement?
Correct Answer: A
Rationale: The correct answer is 'Exhibiting denial.' Denial is a common defense mechanism when facing a serious health issue. The individual rejects the existence of the problem due to the overwhelming anxiety and emotional distress it causes. In this case, the athlete's desire to practice for an upcoming tournament despite being informed about the unlikely return of lower extremity function indicates denial of the severity of their condition.
Choice B, 'Verbalizing a fantasy,' is incorrect as a fantasy involves creating imagined events to fulfill unconscious wishes, which is not evident here.
Choice C, 'No longer able to adapt,' is incorrect because the client is actually demonstrating a maladaptive coping mechanism by denying the reality of their situation.
Choice D, 'Motivated to recover mobility,' is incorrect as the client's goal of practicing for a tournament does not align with the realistic expectation of recovering mobility after a complete spinal cord transection.