NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
2. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?
- A. "I know you're busy, but it's lunchtime."
- B. "Are the voices bothering you again?"
- C. "Get going; you don't want to miss lunchtime."
- D. "It's lunchtime; I'll walk with you to the dining room."
Correct answer: D
Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.
3. Which is an example of an intentional tort?
- A. Negligence
- B. Malpractice
- C. Breach of duty
- D. False imprisonment
Correct answer: D
Rationale: False imprisonment is a clear example of an intentional tort where one person deliberately confines another without lawful justification. It involves intentional, wrongful restraint of a person's freedom of movement. Negligence, on the other hand, is an unintentional tort that occurs when someone fails to exercise reasonable care, resulting in harm to others. Malpractice, which involves professional negligence, is also classified as an unintentional tort as it is a failure to meet the standard of care expected in a particular profession. Breach of duty, while a legal concept, is not an example of an intentional tort. It refers to a failure to fulfill a legal obligation or duty owed to another party, often leading to legal consequences, but it is not categorized as an intentional tort.
4. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?
- A. "I don't remember anything about what happened to me."
- B. "I'd rather not talk about it right now."
- C. "It's the other guy's fault! He was going too fast."
- D. "My mother is heartbroken about this."
Correct answer: A
Rationale: The correct answer is "I don't remember anything about what happened to me." This statement indicates the use of suppression, which is the willful act of putting an unacceptable thought or feeling out of one's mind. In this case, the client is deliberately excluding memories of the traumatic event to protect their self-esteem. The other choices do not reflect suppression: Choice B shows avoidance or deflection, Choice C demonstrates blame shifting, and Choice D indicates empathy towards another individual.
5. A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
- A. Pulse characteristics
- B. Open airway
- C. Entrance and exit wounds
- D. Cervical spine injury
Correct answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.
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