NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?
- A. Dietary practices
- B. Concept of space
- C. Immigration status
- D. Role within the family
Correct answer: D
Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.
2. A client states that she is angry and feels rejected by her boyfriend. Which action would the nurse encourage?
- A. Call the boyfriend to work things out.
- B. Avoid confronting the boyfriend.
- C. Date new people whenever possible.
- D. Learn to constructively vent anger.
Correct answer: D
Rationale: The correct answer is to encourage the client to learn to constructively vent anger. Coping mechanisms, such as venting anger, can help the client address feelings of rejection. Calling the boyfriend to work things out is offering unsolicited advice and may not be effective in managing emotions. Avoiding confronting the boyfriend may reduce anxiety temporarily but will not assist in resolving the underlying issues. Encouraging the client to date new people whenever possible is not appropriate at this stage, as it is essential for the client to work through the current crisis before considering new relationships.
3. 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.
4. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?
- A. Brightening the lights in the room
- B. Encouraging the mother to talk to her baby
- C. Wrapping and then turning the infant to the side
- D. Beginning physical and behavioral assessments
Correct answer: B
Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.
5. When performing a cultural assessment with a patient from a different culture, what action should the nurse take first?
- A. Request an interpreter before interviewing the patient
- B. Wait until a family member is available to help with the assessment
- C. Ask the patient about any affiliation with a particular cultural group
- D. Tell the patient what the nurse already knows about the patient's culture
Correct answer: B
Rationale: When conducting a cultural assessment, the first step is to inquire if the patient has any affiliation with a specific cultural group. This helps the nurse understand the patient's background and beliefs. Requesting an interpreter before interviewing the patient may be necessary if language barriers exist. Waiting for a family member to assist with the assessment may delay the process and compromise patient confidentiality. Telling the patient what the nurse knows about their culture assumes knowledge and may lead to misunderstandings or inaccuracies.
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