which response would the nurse make to a client who says the voices say ill be safe only if i stay in this room wear these clothes and avoid stepping
Logo

Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

2. What initial treatment would the nurse expect for a preschool-aged child experiencing severe fear of the dark?

Correct answer: D

Rationale: Repetition of brave statements is an effective initial treatment for preschool-aged children with severe fear of the dark. This technique involves encouraging the child to repeat positive and reassuring statements to themselves to build confidence and reduce fear. Prescription medication is not typically the first-line approach for this type of fear in children due to potential side effects and safety concerns. Mental health counseling and cognitive behavioral therapy may be considered if the fear persists or is severe, but they are usually not the initial treatments for preschool-aged children with fear of the dark.

3. At a senior citizens meeting, a healthcare professional talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

Correct answer: B

Rationale: The correct answer is when the client states, ''Sometimes when I put my shoes on, I don't know where my toes are.'' This statement indicates peripheral neuropathy, which can lead to a lack of sensation in the lower extremities. When clients are unable to feel pressure or pain in their feet, they are at a high risk for skin impairment, such as cuts, wounds, or ulcers. Option A is not directly related to impaired skin integrity, as self-administering insulin in the thighs does not pose a direct risk to skin integrity. Option C shows good glucose monitoring, which is important but does not directly indicate impaired skin integrity. Option D suggests dry skin due to infrequent bathing, which is more related to general skin care and not as predictive of impaired skin integrity as the statement in Option B.

4. Which of the following is an example of neurofeedback used with a child diagnosed with reactive attachment disorder (RAD)?

Correct answer: A

Rationale: Neurofeedback is a form of treatment that may be used for children diagnosed with reactive attachment disorder (RAD). Neurofeedback involves attaching electrodes to the scalp in a method similar to an EEG. The child's brainwaves are then monitored while being exposed to positive images or games to produce positive brain patterns. Choice A is the correct answer as it describes the process of neurofeedback, which is a common therapeutic approach for managing RAD. Choices B, C, and D are incorrect because they do not directly involve monitoring brain waves through electrodes to provide feedback for brain pattern adjustments, which is the core concept of neurofeedback therapy.

5. A client who is to undergo dilation and curettage and conization of the cervix for cancer appears tense and anxious. Which approach would the nurse use to support the client emotionally?

Correct answer: B

Rationale: The correct approach for the nurse to support the client emotionally is to ask whether something is troubling the client and if she would like to talk about it. This approach acknowledges the client's anxiety and encourages communication without dismissing her feelings. Option A, explaining that the procedures are minor surgery, may invalidate the client's emotions. Option C assumes the client is worried about something specific, which may not be the case, leading to miscommunication. Option D provides false reassurance and may hinder open communication by dismissing the client's feelings as unwarranted.

Similar Questions

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
During her shift at the hospital, a nurse receives a stern reprimand from a physician over something over which she had no control. The nurse does not respond. When she returns home that evening, she sees her children's toys all over the floor, gets mad, and begins to yell at them. Which form of defense mechanism is this nurse using?
Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?
Which consideration is the most accurate when applying the principles of mental health?
A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate's mother to visit the infant?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses