NCLEX-RN
Psychosocial Integrity NCLEX Questions
1. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct answer: D
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.
2. A client is receiving treatment for delusional behavior. He believes that his neighbor is purposefully poisoning his water system in an attempt to make him sick. Which of the following responses of the nurse is most appropriate?
- A. Did you have the water tested to be sure?
- B. Why do you feel like your neighbor is trying to poison you?
- C. Let's just sit here and watch this television program.
- D. Don't be silly; your neighbor would do no such thing.
Correct answer: B
Rationale: When a client presents with delusional beliefs, the nurse should avoid arguing with the client and should accept the client's initial need to hold onto the delusions. By asking the client 'Why do you feel like your neighbor is trying to poison you?' the nurse encourages the client to express his beliefs further. This open-ended question allows the client to elaborate on his delusions without feeling judged. It helps build trust between the nurse and the client, which is crucial for therapeutic communication. This approach may eventually lead to the client being more receptive to exploring and addressing his delusions. Choices A, C, and D are incorrect. Choice A may come off as dismissive and does not address the client's underlying beliefs. Choice C is a distraction and does not address the client's concerns. Choice D is confrontational and dismissive of the client's beliefs, which can damage the therapeutic relationship.
3. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
- A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
- B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
- C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
- D. Compare the current reading with the client's previously documented blood pressure readings.
Correct answer: D
Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.
4. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
- A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
- B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
- C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
- D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.
Correct answer: B
Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.
5. A client has been diagnosed with a form of terminal cancer and has started receiving hospice care. The nurse notes that both the client and his family avoid talking about the diagnosis. All attempts at discussion result in changing the subject. The nurse recognizes that this family is exhibiting:
- A. Closed awareness
- B. Mutual pretense
- C. Open awareness
- D. Powerless assessment
Correct answer: B
Rationale: The correct answer is 'Mutual pretense.' Mutual pretense is a form of awareness as a response to death or dying in which those involved avoid discussing the situation. In this scenario, both the client and the family are aware of the terminal cancer diagnosis, but they choose not to talk about it openly. This behavior can stem from various reasons, such as trying to shield loved ones from grief, fear of the future, or discomfort with discussing emotions. 'Closed awareness' (Choice A) refers to a lack of awareness of the impending death, which is not the case here. 'Open awareness' (Choice C) involves open acknowledgment and discussion of the terminal illness, which is contrary to the behavior described. 'Powerless assessment' (Choice D) does not relate to the situation of avoiding discussing the diagnosis in the context of terminal cancer and hospice care.
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