NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take?
- A. Complete an incident report.
- B. Select another sterile needle.
- C. Disinfect the needle with an alcohol swab.
- D. Notify the supervisor of the department immediately.
Correct answer: B
Rationale: After a needle stick, the needle is considered contaminated and should be discarded. The nurse should select another sterile needle to use. Completing an incident report is not necessary in this situation because the needle was sterile when the nurse was stuck and not in contact with any other person's body fluids. Notifying the supervisor immediately is not required as the situation can be managed by selecting a new needle. Disinfecting the needle with an alcohol swab is not recommended as it does not meet the standards of safe practice and infection control.
2. A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?
- A. Evaluate her willingness to pursue adoption.
- B. Encourage her to focus on her own recovery.
- C. Emphasize that she does have two children already.
- D. Ensure that other treatment options for her are explored.
Correct answer: D
Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.
3. A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
- A. Administer anti-anxiety medications as prescribed by the healthcare provider
- B. Engage in a conversation with the client regarding methods to enhance rest and sleep
- C. Escort the client to a private room and stay with them
- D. Review the client's medical history to determine previous treatment for these issues
Correct answer: C
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
4. Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
5. A child is undergoing chemotherapy to treat a neuroblastoma, stage IV, and had his first chemotherapy session last week. He arrives with his mother for this week's session. How would the nurse greet the child?
- A. How did you feel after your last treatment?
- B. What are your thoughts on the treatment so far?
- C. Did you experience any side effects after the last session?
- D. Are you ready for the next round of treatment?
Correct answer: A
Rationale: The most appropriate way for the nurse to greet the child is by asking, 'How did you feel after your last treatment?' This question allows the child to share their experience voluntarily, empowering them to feel in control of the conversation. It also demonstrates empathy and a caring attitude. Option B, 'What are your thoughts on the treatment so far?' is broad and may not address the child's immediate feelings after the last session. Option C, 'Did you experience any side effects after the last session?' focuses solely on side effects and may predispose the child to think negatively. Option D, 'Are you ready for the next round of treatment?' does not address the child's current well-being or feelings, missing an opportunity for emotional support and connection.
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