NCLEX-RN
NCLEX Psychosocial Integrity Questions Questions
Extract:
Question 1 of 5
Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?
Correct Answer: D
Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.
Question 2 of 5
Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?
Correct Answer: D
Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.
Question 3 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 4 of 5
Which benefit accompanies mild apprehension?
Correct Answer: B
Rationale: A mild level of anxiety can be beneficial because it increases alertness and focuses attention. Physiological functions are actually amplified initially, not slowed, due to mild apprehension; however, prolonged anxiety can lead to decreased function due to exhaustion. Automatic behavioral responses and ego defense mechanisms may hinder an individual's awareness rather than enhancing it, making them less beneficial compared to increased alertness.
Question 5 of 5
Which action often triggers an episode of violence or aggression in a patient with a psychiatric diagnosis involving violent behavior?
Correct Answer: C
Rationale: Enforcing rules is often a trigger for patients with psychiatric diagnoses involving violent behavior. Limit-setting or denying patient demands can be perceived as control and intimidation, leading to aggressive responses. Nursing staff must respond calmly and professionally to prevent escalation. Avoiding such patients or matching their emotions can worsen the situation.
Therefore, enforcing rules can provoke violent episodes in these patients.