during the first meeting of a therapy group members exhibit frequent periods of silence tense laughter and nervous movements which conclusion would th
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Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. 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?

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.

2. What is the primary purpose served when an individual takes action to reduce anxiety?

Correct answer: A

Rationale: The primary purpose of taking action to reduce anxiety is to alleviate emotional tension and prevent the exacerbation of anxiety symptoms. By reducing tension, anxiety levels decrease, leading to a sense of comfort, safety, and security. Denial of the situation is not the goal when addressing anxiety; rather, acknowledging and managing it is crucial. While physical discomfort may accompany anxiety, the focus is on alleviating the emotional aspect to mitigate physical manifestations. Although mild anxiety can sometimes improve decision-making skills, higher levels of anxiety typically impede cognitive functions, making resolution in decision-making less likely.

3. A client says, 'I hear a man speaking from the corner of the room. Do you hear him, too?' Which response is best?

Correct answer: D

Rationale: The best response is D: 'No, I don't hear him, but that must be upsetting for you.' This response acknowledges the client's experience without validating the hallucination. The nurse expresses empathy by acknowledging the client's feelings ('that must be upsetting for you'), showing understanding and support. Choice A focuses on the content of the hallucination, which may inadvertently reinforce the delusion. Choice B validates the hallucination by agreeing that the nurse also hears the man. Choice C denies the client's experience and can lead to further distress by invalidating their perception.

4. 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?

Correct answer: A

Rationale: The correct answer is 'Daily black, sticky stool.' Black sticky stool (melena) is indicative of gastrointestinal bleeding, a serious condition that requires immediate attention from the healthcare provider. Options B and D, 'Daily dark brown stool' and 'Soft light brown stool twice a day,' respectively, represent variations of normal stool characteristics and do not raise immediate concerns about the client's health. Option C, 'Firm brown stool every other day,' suggests constipation, which is of lesser concern and can be managed with interventions.

5. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

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