NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
2. Which source of stress would the nurse anticipate in a 5-year-old client?
- A. Jealousy
- B. Stubbornness
- C. Procrastination
- D. Companionship
Correct answer: C
Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.
3. While receiving a preoperative enema, a client starts to cry and says, 'I'm sorry you have to do this messy thing for me.' Which is the nurse's best response?
- A. I don't mind it.'
- B. 'You seem upset.'
- C. 'This is part of my job.'
- D. 'Nurses get used to this.'
Correct answer: B
Rationale: The nurse's best response in this situation is to acknowledge the client's emotional state, as it shows empathy and encourages further expression of feelings. Choice A, 'I don't mind it,' dismisses the client's emotions and does not address the underlying issue. Choice C, 'This is part of my job,' focuses on the task rather than the client's emotional needs. Choice D, 'Nurses get used to this,' minimizes the client's feelings and lacks empathy. By selecting choice B, 'You seem upset,' the nurse acknowledges the client's distress and opens the door for further communication and support.
4. A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.
5. A daughter of a Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter's behavior reflect?
- A. Prejudice
- B. Stereotyping
- C. Assimilation
- D. Ethnocentrism
Correct answer: C
Rationale: The correct answer is assimilation. Assimilation involves incorporating the behaviors of a dominant culture. In this scenario, maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike, which is not demonstrated by the daughter's behavior. Ethnocentrism is the perception that one's beliefs are superior to those of others, which is not evident in this situation.
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