NCLEX-RN
NCLEX Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?
Correct Answer: D
Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly.
Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction.
Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction.
Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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