NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. 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.
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. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?
- A. Establish trust
- B. Increase feelings of self-worth
- C. Solidify sense of identity
- D. Improve ability to socialize
Correct answer: A
Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.
4. Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?
- A. Dietary practices
- B. Concept of space
- C. Immigration status
- D. Role within the family
Correct answer: D
Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.
5. Which nursing action promotes psychosocial development for a newborn?
- A. Washing hands before holding the newborn
- B. Measuring the newborn using an approved length board
- C. Weighing the newborn on the same scale during hospitalization
- D. Placing the newborn in the mother's arms during the first hour of life
Correct answer: D
Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being. Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.
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