a female adolescent has anorexia nervosa and is malnourished and severely underweight which statement indicates that she is experiencing secondary gai
Logo

Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

2. The client admitted for uncontrolled diabetes is worried about how to pay bills for the family while hospitalized. Which statement by the nurse is therapeutic?

Correct answer: A

Rationale: The therapeutic communication technique used in this scenario is reflection. By repeating the client's concern, the nurse acknowledges the client's feelings and encourages further exploration of the topic. Choice A is correct as it reflects the client's worry without offering false assurance, advice, or using professional jargon. Choice B dismisses the client's concerns with false reassurance. Choice C introduces professional jargon, which may hinder effective communication. Choice D provides advice, which can limit the client's expression of feelings and concerns.

3. During her shift at the hospital, a nurse receives a stern reprimand from a physician over something over which she had no control. The nurse does not respond. When she returns home that evening, she sees her children's toys all over the floor, gets mad, and begins to yell at them. Which form of defense mechanism is this nurse using?

Correct answer: C

Rationale: Displacement is the process of redirecting feelings or impulses from one person to another. In this scenario, the nurse chose not to respond to the physician, but instead displaced her negative emotions onto her children, who are less threatening and more vulnerable. This defense mechanism allowed her to express her anger in a safer outlet. Symbolization involves representing unconscious feelings or impulses through symbols, not redirecting them. Suppression is the conscious effort to push unwanted thoughts or feelings out of awareness, not displacing them onto others. Projection involves attributing one's thoughts or emotions to someone else, which is not evident in this case.

4. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

Correct answer: C

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

5. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?

Correct answer: D

Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.

Similar Questions

The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
A client asks the nurse, 'Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?' Which is the nurse's most appropriate response?
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?
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses