NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?
- A. EEG
- B. EKG
- C. Electrolytes
- D. Echocardiogram
Correct answer: C
Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.
2. A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?
- A. Evaluate her willingness to pursue adoption.
- B. Encourage her to focus on her own recovery.
- C. Emphasize that she does have two children already.
- D. Ensure that other treatment options for her are explored.
Correct answer: D
Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.
3. Which characteristic usually results in a behavior being viewed and accepted as normal?
- A. Fits within standards accepted by one's society
- B. Helps the person reduce the need for coping skills
- C. Allows the person to express feelings and thoughts
- D. Facilitates achievement of short-term and long-term goals
Correct answer: A
Rationale: Behaviors that align with the standards accepted by a society are generally viewed as normal. Societal norms and values play a significant role in defining what is considered normal behavior. Choices B, C, and D may be important aspects of an individual's functioning, but they do not solely determine whether a behavior is viewed as normal. Coping skills, expressions of feelings, and goal achievement can vary in their cultural context and societal acceptance, therefore they are not definitive indicators of normalcy.
4. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?
- A. Sitting quietly with the client
- B. Telling the client that crying is not helpful
- C. Suggesting that the client play a board game
- D. Recommending how the client can change this situation
Correct answer: A
Rationale: The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.
5. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
- A. Interview a family member instead.
- B. Wait for the patient to answer the questions.
- C. Remind the patient that you have other patients who need care.
- D. Give the patient an assessment form listing the questions and a pen.
Correct answer: B
Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.
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