NCLEX NCLEX-PN
Psychosocial Integrity Nclex PN Questions
1. A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
- A. wearing clothing that is too small for the child.
- B. the child being shaken.
- C. falling while learning to walk.
- D. parents trying to awaken the child.
Correct answer: the child being shaken.
Rationale: The correct answer is 'the child being shaken.' In cases of suspected child abuse, bruises on both upper arms can be indicative of a child being shaken, as children who are shaken are frequently grasped by both upper arms. The presentation of a 10-month-old child being difficult to awaken, along with bruises on the upper arms, raises concern for inflicted injury. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely in this scenario as they do not align with the concerning signs of suspected abuse indicated by the bruises and the child's altered level of consciousness.
2. A nurse assisting with data collection regarding the client’s eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?
- A. Myopia
- B. Hyperopia
- C. Photophobia
- D. Accommodation
Correct answer: Accommodation
Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light. Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'
3. A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?
- A. Anasarca
- B. Ecchymosis
- C. Unilateral edema
- D. Increased vascularity of the skin tissue
Correct answer: Anasarca
Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.
4. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct answer: C: severe.
Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.
5. When testing the function of the oculomotor, trochlear, and abducens nerves, which parameter does a nurse check to determine their function?
- A. Tongue symmetry
- B. Eye movements
- C. Facial symmetry
- D. Corneal reflex
Correct answer: B
Rationale: The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).
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