NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. A client at a local university claims to be the president of the university. Which type of delusion is the client displaying?
- A. Somatic
- B. Grandiose
- C. Erotomanic
- D. Persecutory
Correct answer: B
Rationale: The correct answer is 'Grandiose.' This type of delusion involves an exaggerated sense of self-importance, where the individual believes they are a prominent figure or possess special abilities. In this scenario, the client claiming to be the president of the university is displaying grandiose delusions. Somatic delusions relate to bodily functions or sensations, which are not present in this case. Erotomanic delusions involve the fixed belief that another person is in love with the individual, which is not applicable here. Persecutory delusions involve the belief that one is being targeted or conspired against, which is also not demonstrated in the given situation.
2. Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.
- A. Emotional: room coldness
- B. Environmental: boredom
- C. Physical: pain
- D. Communication: silence
Correct answer: C
Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.
3. After undergoing dilation and curettage following an early miscarriage, a client is crying. Which response would the nurse give?
- A. ''This must be a very difficult experience for you to deal with.''
- B. 'You'll have other children to take the place of the child you lost.''
- C. 'Of course you're sad now, but at least you know you can get pregnant.''
- D. 'I know how you feel, but when a woman miscarries, it's usually for the best.''
Correct answer: A
Rationale: The correct response acknowledges the client's grief without judgment and provides validation. Choice B is inappropriate as it suggests replacing the lost child with other children, which is insensitive and dismissive of the client's current loss. Choice C minimizes the client's feelings by focusing on the ability to get pregnant rather than addressing the emotional impact of the miscarriage. Choice D is dismissive and patronizing, suggesting that the miscarriage was for the best, which can be hurtful and diminish the client's grief.
4. A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
- A. Orange juice has vitamin C that deters bacterial growth.
- B. Apple juice is the most useful in acidifying the urine.
- C. Cranberry juice stops pathogens' adherence to the bladder.
- D. Grapefruit juice increases absorption of most antibiotics.
Correct answer: C
Rationale: The correct answer is 'Cranberry juice stops pathogens' adherence to the bladder.' Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. This helps prevent UTIs. Options A, B, and D are incorrect because orange juice with vitamin C, apple juice for urine acidification, and grapefruit juice for antibiotic absorption do not have the same proven effectiveness in preventing UTIs as cranberry juice does.
5. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
- A. Remind the child to clean his genital area.
- B. Defer perineal care because of the child's age.
- C. Retract the foreskin gently to cleanse the penis
- D. Ask the parents why the child is not circumcised
Correct answer: C
Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.
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