NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which behavior would the nurse recognize as developmentally atypical in preschoolers?
- A. Thumb sucking during stress
- B. Feeling guilty for behaving inappropriately
- C. Feeling happy if there is a newborn in the family
- D. Curiosity about their surroundings
Correct answer: C
Rationale: The correct answer is feeling happy if there is a newborn in the family. Preschoolers are more likely to exhibit feelings of stress and jealousy rather than happiness with the arrival of a new baby in the family. Thumb sucking and bed-wetting are common behaviors displayed by preschoolers during times of stress. Guilt typically arises in children when they perceive that they have not behaved appropriately. Preschoolers are known to be naturally curious about their surroundings, showing an interest in exploring and learning about the environment around them. Therefore, feeling happy with the birth of a new baby is developmentally atypical for preschoolers.
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. What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
- A. Removing the child's undergarments
- B. Placing the child's toys on the bedside table
- C. Allowing the child to climb onto the stretcher
- D. Having the parents accompany the child to the operating suite
Correct answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
4. What is the best intervention for a client with borderline personality disorder?
- A. Establishing clear boundaries
- B. Exploring vocational possibilities
- C. Discussing feelings of victimization
- D. Spending 1 to 2 hours per day with the client
Correct answer: A
Rationale: The best intervention for a client with borderline personality disorder is to establish clear boundaries. Individuals with this disorder struggle with impulsivity and have difficulty recognizing and respecting boundaries in their relationships. By establishing clear boundaries, it helps provide structure and consistency to the client, aiding in their treatment and management of the disorder. Exploring vocational possibilities may be important at some point, but it is not the priority intervention for managing borderline personality disorder. Discussing feelings of victimization, while common, may not be as effective initially due to the client's lack of insight and resistance. Spending 1 to 2 hours per day with the client may not be as productive as shorter, more focused interactions that are geared towards boundary reinforcement.
5. Before discharging an anxious client, which information about anxiety would the nurse teach the family?
- A. Anxiety is a totally unique feeling and experience.
- B. Apprehension is generalized to the total environment.
- C. Fears result from conscious actions, thoughts, and wishes.
- D. Anxiety is a pattern of emotional and behavioral responses to stress.
Correct answer: D
Rationale: Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. It is a pattern of emotional and behavioral responses to stress. Anxiety is a common experience for many individuals. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.
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