NCLEX-RN
NCLEX RN Psychosocial Integrity Questions
Extract:
Question 1 of 5
While assisting with bathing, the client who has sustained a spinal cord injury states, 'I can't do this. I wish I were dead.' Which therapeutic response should the nurse make to encourage communication?
Correct Answer: B
Rationale: Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking 'why' in option 1, the nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. The remaining options are nontherapeutic statements that block communication.
Question 2 of 5
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.
Question 3 of 5
The nurse is caring for a client who presented to the ED with a blood alcohol level of 208 mg/dL. The client states that his last drink was about 8 hours ago. He exhibits coarse tremors of the hands, anxiety, and elevated blood pressure. Which of the following would the nurse expect if his condition progresses to withdrawal delirium? Select all that apply.
Correct Answer: A,E,F
Rationale: Withdrawal delirium typically includes fever, disorientation, and fluctuating consciousness, with onset 48-72 hours after the last drink. Increased appetite or excessive sleeping are not typical.
Question 4 of 5
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (
A) Singing or talking to provide comfort and reduce anxiety; (
B) Exposing only one area to maintain dignity and prevent chilling; (
D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (
C) may increase agitation and is not appropriate.
Question 5 of 5
A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?
Correct Answer: B
Rationale: The nurse should recognize that a mother will go through the grief process after giving birth to a child with a birth defect. After the grief process, the mother can begin to focus on bonding with the infant. The remaining options are incorrect because they are each only one component of the grief process.