NCLEX-RN
NCLEX Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?
Correct Answer: B
Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (
Choice
A) can inadvertently validate the hallucinations. Offering false reassurance (
Choice
B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (
Choice
D) is nontherapeutic as it disregards the client's experience and may increase anxiety.
Question 2 of 5
Which behavior would the nurse recognize as developmentally atypical in preschoolers?
Correct Answer: C
Rationale: The correct answer is feeling happy if there is a newborn in the family. Preschoolers are more likely to exhibit feelings of stress and jealousy rather than happiness with the arrival of a new baby in the family. Thumb sucking and bed-wetting are common behaviors displayed by preschoolers during times of stress. Guilt typically arises in children when they perceive that they have not behaved appropriately. Preschoolers are known to be naturally curious about their surroundings, showing an interest in exploring and learning about the environment around them.
Therefore, feeling happy with the birth of a new baby is developmentally atypical for preschoolers.
Question 3 of 5
Which defense mechanism is considered a conscious measure used to cope with anxiety?
Correct Answer: C
Rationale: The correct answer is Suppression. Suppression is a conscious defense mechanism in which an individual intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. It is a way to cope with anxiety by actively pushing aside unwanted thoughts or emotions. Undoing, on the other hand, is an unconscious defense mechanism where one uses words or behaviors to symbolically make amends for unacceptable thoughts or actions. Projection is also an unconscious defense mechanism involving falsely attributing one's own unacceptable impulses to others. Intellectualization, another unconscious defense mechanism, involves using intellect or thinking to avoid dealing with emotionally charged feelings.
Question 4 of 5
Which behavior by the client exhibits denial after a recent diagnosis?
Correct Answer: A
Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.
Question 5 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.