NCLEX-RN
NCLEX Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?
Correct Answer: B
Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client.
Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (
Choice
A), therapy focus (
Choice
C), or delving into the client's depression (
Choice
D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.
Question 2 of 5
What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
Correct Answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
Question 3 of 5
Which of these is a one-on-one communication between the nurse and another person?
Correct Answer: C
Rationale: Interpersonal communication is a one-on-one interaction between a nurse and another person that often occurs face-to-face. It involves direct communication between two individuals. Small-group communication involves interaction among a small number of people, not just one-on-one. Intrapersonal communication is internal communication that occurs within an individual's mind. Transpersonal communication involves interactions within a person's spiritual domain, which is beyond individual one-on-one communication.
Question 4 of 5
A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, 'Am I going to die?' Which response would the nurse make?
Correct Answer: C
Rationale: The most appropriate response to the client's question regarding their prognosis is to acknowledge the variable nature of multiple sclerosis by stating that 'The prognosis varies, as most individuals have remissions and exacerbations.' This response provides realistic information while offering some hope.
Choice A ('Most individuals with your disease live a normal life span.') gives false reassurance as repeated exacerbations may affect life span.
Choice B ('Is your family here? I would like to explain your disease to all of you.') does not directly address the client's question and involves the family unnecessarily.
Choice D ('Why don't you speak with your health care provider to get more details?') deflects the responsibility and does not address the client's immediate concerns about their prognosis.
Question 5 of 5
The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
Correct Answer: A
Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.