a 20 year old female client with a noticeable body odor has refused to shower for the last 3 days she states i have been told that it is harmful to b

NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation to the client.

Correct answer: D

Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.

2. A newly diagnosed client with human immunodeficiency virus (HIV) comments to the nurse, 'There are so many rotten people around. Why couldn't one of them get HIV instead of me?' Which statement is the nurse's best response?

A. 'I can understand why you are afraid of dying.'
B. 'It seems unfair that you contracted this disorder.'
C. 'Do you really wish this disorder on someone else?'
D. 'Have you thought of speaking with your religious adviser?'

Correct answer: B

Rationale: The client is expressing feelings of unfairness and questioning why they have HIV. The nurse's best response is to acknowledge the client's emotions. Choice B, 'It seems unfair that you contracted this disorder,' reflects empathy and validates the client's feelings, which can help them move towards acceptance. Choice A, 'I can understand why you are afraid of dying,' introduces the topic of death, which may not be the primary concern at this stage. Choice C, 'Do you really wish this disorder on someone else?' is judgmental and could induce guilt in the client. Choice D, 'Have you thought of speaking with your religious adviser?' deflects the conversation and does not address the client's current emotional needs.

3. Which intervention would the nurse implement to develop a caring relationship with the client's family?

A. Deciding health care options for the client
B. Identifying the client's family members and their roles
C. Declining to inform the client's family after performing a procedure
D. Refraining from discussing the client's health with the family

Correct answer: B

Rationale: To establish a caring relationship with the client's family, the nurse should start by identifying the family members and understanding their roles in the client's life. This step is crucial in determining how they can contribute to the client's healthcare and support. Deciding healthcare options for the client (Choice A) is not the nurse's role; it should be a collaborative decision with the client and family. Declining to inform the client's family after a procedure (Choice C) goes against transparency and collaboration in care. Refraining from discussing the client's health with the family (Choice D) can hinder effective communication and support, which are essential in developing a caring relationship with the family.

4. Which of the following individuals is at the highest risk of suicide?

A. An 80-year-old man who lost his wife last year
B. A 36-year-old woman whose former neighbor committed suicide
C. A 40-year-old married businessman
D. A 46-year-old former alcoholic who has been sober for 12 years

Correct answer: A

Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.

5. Which is a true statement regarding stress related disorders?

A. Stress related disorders are only caused by stress
B. Symptoms of stress related disorders would not exist if the client was not experiencing stress
C. Stress related disorders are also called psycho-physiologic disorders
D. None of the above

Correct answer: C

Rationale: The correct answer is that stress related disorders are also called psycho-physiologic disorders. These disorders have a physiologic basis for their development, but stress can exacerbate the symptoms. While stress plays a significant role in these disorders, they are not solely caused by stress. Choice A is incorrect as stress is a contributing factor rather than the sole cause. Choice B is incorrect because symptoms of stress related disorders can persist even when the individual is not actively experiencing stress. Choice D is incorrect as there is a true statement among the choices, which is that stress related disorders are also known as psycho-physiologic disorders.