NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
- A. Ask the client to remain quiet so the procedure can be performed safely.
- B. Concentrate on completing the insertion as efficiently as possible.
- C. Calmly reassure the client that the discomfort will be temporary.
- D. Tell the client a joke as a means of distraction from the procedure.
Correct answer: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
2. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
3. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct answer: A
Rationale: The correct answer is 'Daily black, sticky stool.' Black sticky stool (melena) is indicative of gastrointestinal bleeding, a serious condition that requires immediate attention from the healthcare provider. Options B and D, 'Daily dark brown stool' and 'Soft light brown stool twice a day,' respectively, represent variations of normal stool characteristics and do not raise immediate concerns about the client's health. Option C, 'Firm brown stool every other day,' suggests constipation, which is of lesser concern and can be managed with interventions.
4. When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
5. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
- A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
- B. Instruct the UAP not to wake the client under any circumstances during the night.
- C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
- D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Correct answer: A
Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.
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