which response would the nurse make when a client moans softly oh no im next they couldnt protect him and they cant protect me after learning a recent
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX PN Questions

1. Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?

Correct answer: B

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you're here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There's no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

2. A term used to describe members of the same group based on physiological characteristics, such as skin color or body structure, is known as:

Correct answer: C

Rationale: The correct term used to describe members of the same group based on physiological characteristics, such as skin color or body structure, is 'Race.' Race categorizes people based on physical traits like skin color. Ethnicity refers to shared cultural characteristics, traditions, language, and heritage, not physical attributes. Culture encompasses the values, beliefs, behaviors, and practices shared by a group. 'Minority' refers to a smaller number or part compared to the whole, not specifically based on physiological characteristics.

3. Which behavioral characteristic describes the domestic abuser?

Correct answer: D

Rationale: The correct answer is 'Low self-esteem.' Domestic abusers often exhibit behaviors stemming from their own experiences of abuse, leading to a cycle of violence. They commonly have low self-esteem, which drives their need to exert control and power over their partners. Choice A, 'Alcoholic,' is not a defining behavioral characteristic of domestic abusers. Choice B, 'Overconfident,' is not typically associated with abusers who often exhibit insecurity and control issues. Choice C, 'High tolerance for frustrations,' is not a primary characteristic of domestic abusers; rather, they often have a low tolerance for situations that challenge their need for control.

4. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

5. Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?

Correct answer: B

Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.

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