NCLEX-PN
Psychosocial Integrity Nclex PN Questions
1. A primary belief of psychiatric mental health nursing is:
- A. Most people have the potential to change and grow.
- B. Every person is worthy of dignity and respect.
- C. Human needs are individual to each person.
- D. Some behaviors have no meaning and cannot be understood.
Correct answer: B
Rationale: The correct answer is that every person is worthy of dignity and respect. This is a fundamental principle in psychiatric mental health nursing, emphasizing the importance of treating individuals with dignity and respect regardless of their condition. This belief forms the basis of establishing a therapeutic nurse-client relationship. Choice A is a positive belief, but the primary focus in psychiatric mental health nursing is on respecting the worth and dignity of each individual. Choice C is related to understanding individual human needs but does not encompass the core value of dignity and respect. Choice D is incorrect as psychiatric nursing emphasizes the importance of interpreting and understanding all behaviors as meaningful expressions of the client's experience.
2. To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?
- A. Tell the client to stop using the defense mechanism of denial
- B. Positively reinforce each expression of feelings
- C. Instruct the client to express feelings
- D. Challenge the client each time denial is used
Correct answer: B
Rationale: The most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.
3. A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. packed red blood cells
- B. platelets
- C. plasma
- D. granulocytes
Correct answer: A
Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.
4. When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
- A. Constantly observing the client to prevent self-harm.
- B. Enlisting the client in defining and describing harmful behaviors.
- C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
- D. Removing all items from the environment that the client could use to harm themselves.
Correct answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.
5. The nurse is assessing an elder whom the nurse suspects is being physically abused. The most important question for the nurse to ask is:
- A. "How much money do you keep around the house?"?
- B. "Who provides your physical care?"?
- C. "How close does your nearest relative live?"?
- D. "What form of transportation do you use?"?
Correct answer: B
Rationale: The most important question for the nurse to ask when suspecting elder abuse is 'Who provides your physical care?' This question is crucial as the primary caregiver, who is often the abuser in cases of elder abuse, lives with the client. Research has shown that spouses and adult children are the most common abusers. By inquiring about the provider of physical care, the nurse can assess the potential abuser's proximity to the elder. Choices A, C, and D are less pertinent to identifying the primary caregiver, who is more likely to be the abuser.
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