NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. A 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. A few hours later the mother tells the nurse, 'I have to leave now, but whenever I try to go, my child gets upset, and then I start to cry.' Which is the best action by the nurse?
- A. Walking the mother to the elevator
- B. Encouraging the mother to spend the night
- C. Staying with the child while the mother leaves
- D. Telling the mother to wait until the child falls asleep
Correct answer: C
Rationale: The best action for the nurse in this situation is to stay with the child while the mother leaves. By doing so, the nurse can provide comfort and reassurance to both the child and the mother. This approach acknowledges the mother's need to leave while ensuring the child is not left alone and is supported during the separation. Walking the mother to the elevator does not address the child's emotional needs and may not provide adequate support. Encouraging the mother to spend the night is not necessary and may not be feasible for her. Telling the mother to wait until the child falls asleep is not recommended as it may create a sense of dishonesty and uncertainty for the child, who should be aware of the mother's departure and reassured that she will return.
2. Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?
- A. 'Getting angry is not appropriate; let's address this calmly.''
- B. ''Yelling is not acceptable and won't help us resolve this issue.''
- C. 'You must eat the first tray of food, and then I'll get another tray for you.''
- D. 'It must be frustrating to get the wrong tray. I'll order another tray for you.''
Correct answer: D
Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.
3. A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?
- A. Revising the client's will and planning a visit to a friend
- B. Alternating between crying and talking openly about death
- C. Seeking second, third, and fourth medical opinions
- D. Refusing to follow treatments and stating they won't help anyway
Correct answer: A
Rationale: Revising the will and planning a visit to a friend are indicative of emotional acceptance of impending death as they demonstrate realistic, productive, and constructive ways of using the remaining time. Alternating between crying and talking openly about death may suggest depression rather than acceptance. Seeking multiple medical opinions shows disbelief, denial, or desperation rather than acceptance. Refusing treatments and stating they won't help reflects anger and hopelessness, not acceptance.
4. A client admitted with a diagnosis of cervical cancer tells the nurse, 'I haven't had a Papanicolaou (Pap) smear for more than 8 years. I probably wouldn't be in the hospital today if I'd had those tests more often.' Which response would the nurse provide?
- A. ''Please tell me why you waited so long.''
- B. 'You feel as though you've neglected your health.''
- C. 'It's never too late to start taking care of yourself.''
- D. 'Most women hate to have Pap smears done, but they're really important.''
Correct answer: B
Rationale: The correct response, ''You feel as though you've neglected your health,'' is appropriate as it indicates recognition of expressed feelings, encouraging verbalization. This response is nondirective and reflective. Choice A, asking the client why she waited so long, ignores the client's current emotional needs and may cut off communication. Choice C, stating that it is never too late to start taking care of her health, is judgmental as it implies that the client has been negligent. Choice D, although acknowledging the importance of Pap smears, fails to address the client's current emotional state and needs.
5. 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.
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