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 priorit

NCLEX-RN

Psychosocial Integrity NCLEX PN Questions

1. 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?

A. Assess for feelings of loneliness and isolation.
B. Determine if the client has unresolved grief.
C. Determine if there are safety issues.
D. Ask about the availability of support systems.

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.

2. A mother complains to the nurse that her 3-year-old child refuses to go to preschool. The child rarely interacts and avoids playing with other children. Which statement would the nurse provide?

A. Do not be concerned because all toddlers behave this way.
B. Ask the teacher to push the child to speak up and open up to the other kids.
C. Set boundaries and supervise the child closely.
D. Give your child time to get acquainted and warm up to the new environment.

Correct answer: D

Rationale: According to the mother's description, the child is a slow-to-warm-up child. These children are uneasy in new situations or with unfamiliar people. The nurse would educate the mother to give the child time to be more familiar with the new environment. All toddlers do not behave in the same manner. A slow-to-warm-up child should not be pressured to do anything against his or her wishes. Setting boundaries and closely supervising the child is not the best approach for a child who needs time to adapt. Asking the teacher to push the child to open up can create more anxiety and stress for the child, which is not recommended.

3. Which type of environment would be most suitable for a confused client?

A. Familiar
B. Variable
C. Challenging
D. Stimulating

Correct answer: A

Rationale: The most appropriate environment for a confused client is a familiar one. A familiar environment provides security and safety, reducing stress for the confused client. Confused individuals struggle to adapt to constant changes, making a variable environment unsuitable. A challenging environment would likely increase anxiety and frustration in a confused client. Similarly, a stimulating environment could overwhelm the confused client, exacerbating their confusion.

4. During the first meeting of a therapy group, members exhibit frequent periods of silence, tense laughter, and nervous movements. Which conclusion would the nurse make?

A. The group requires an active leader who will intervene to relieve signs of obvious stress.
B. The group process is unhealthy and there is unwillingness to openly relate.
C. The members are displaying expected behaviors because relationships are not yet established.
D. The behaviors should be immediately addressed so members will not become too uncomfortable.

Correct answer: C

Rationale: During the initial stages of a therapy group, it is common for members to exhibit behaviors such as silence, tense laughter, and nervous movements. These behaviors indicate anxiety and insecurity due to the lack of established relationships and trust among the group members. This is a normal part of group development, and it does not necessarily mean that the group process is unhealthy. Intervening or addressing these behaviors immediately is not required as they are expected in the early stages of group interaction. As the group progresses and relationships are built, these behaviors are likely to diminish naturally without the need for active leader intervention. Therefore, the correct conclusion is that the members are displaying expected behaviors because relationships are not yet established. Choices A, B, and D are incorrect because active leader intervention is not necessary, the group process is not unhealthy, and addressing the behaviors immediately is not required as they are part of the early group dynamics and are expected to subside as relationships develop.

5. What behavior is expected of members of Alcoholics Anonymous (AA)?

A. Speaking at and participating in weekly meetings
B. Promising to attend at least 12 meetings yearly
C. Maintaining controlled drinking after 6 months
D. Acknowledging an inability to control the drinking

Correct answer: D

Rationale: A fundamental aspect of Alcoholics Anonymous (AA) is the acceptance of one's inability to control their drinking behavior. This acknowledgment is crucial for individuals seeking recovery from alcohol abuse issues. While speaking at and participating in meetings is encouraged, it is not a strict requirement for AA members. Similarly, there is no specific mandate on the number of meetings to attend yearly, as long as the individual finds the support they need. Maintaining controlled drinking after 6 months is not aligned with AA principles, as the group emphasizes complete abstinence from alcohol to support long-term sobriety.