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Psychosocial Integrity NCLEX PN Questions
1. A client is receiving treatment for delusional behavior. He believes that his neighbor is purposefully poisoning his water system in an attempt to make him sick. Which of the following responses of the nurse is most appropriate?
- A. Did you have the water tested to be sure?
- B. Why do you feel like your neighbor is trying to poison you?
- C. Let's just sit here and watch this television program.
- D. Don't be silly; your neighbor would do no such thing.
Correct answer: Why do you feel like your neighbor is trying to poison you?
Rationale: When a client presents with delusional beliefs, the nurse should avoid arguing with the client and should accept the client's initial need to hold onto the delusions. By asking the client 'Why do you feel like your neighbor is trying to poison you?' the nurse encourages the client to express his beliefs further. This open-ended question allows the client to elaborate on his delusions without feeling judged. It helps build trust between the nurse and the client, which is crucial for therapeutic communication. This approach may eventually lead to the client being more receptive to exploring and addressing his delusions. Choices A, C, and D are incorrect. Choice A may come off as dismissive and does not address the client's underlying beliefs. Choice C is a distraction and does not address the client's concerns. Choice D is confrontational and dismissive of the client's beliefs, which can damage the therapeutic relationship.
2. A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:
- A. Disconnect the current infusion
- B. Clean the cap with alcohol and attach a 5 cc syringe
- C. Draw 5 cc of a blood sample to discard
- D. Flush with saline after the sample
Correct answer: Clean the cap with alcohol and attach a 5 cc syringe
Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.
3. During her shift at the hospital, a nurse receives a stern reprimand from a physician over something over which she had no control. The nurse does not respond. When she returns home that evening, she sees her children's toys all over the floor, gets mad, and begins to yell at them. Which form of defense mechanism is this nurse using?
- A. Symbolization
- B. Suppression
- C. Displacement
- D. Projection
Correct answer: C: Displacement
Rationale: Displacement is the process of redirecting feelings or impulses from one person to another. In this scenario, the nurse chose not to respond to the physician, but instead displaced her negative emotions onto her children, who are less threatening and more vulnerable. This defense mechanism allowed her to express her anger in a safer outlet. Symbolization involves representing unconscious feelings or impulses through symbols, not redirecting them. Suppression is the conscious effort to push unwanted thoughts or feelings out of awareness, not displacing them onto others. Projection involves attributing one's thoughts or emotions to someone else, which is not evident in this case.
4. Plantar flexion can be prevented with ________________.
- A. foot soaks
- B. foot boards
- C. toenail care
- D. proper shoes
Correct answer: foot boards
Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.
5. Which signs and symptoms would the nurse observe in a client with schizophrenia?
- A. Traumatic flashbacks and hypervigilance
- B. Depression and psychomotor retardation
- C. Loosened associations and hallucinations
- D. Ritualistic behavior and obsessive thinking
Correct answer: Loosened associations and hallucinations
Rationale: In clients with schizophrenia, the nurse would observe loosened associations and hallucinations. Loosened associations refer to disorganized thinking where thoughts are not logically connected. Hallucinations involve perceiving things that are not based in reality. Traumatic flashbacks and hypervigilance are more indicative of post-traumatic stress disorder. Depression and psychomotor retardation are common in depression, not schizophrenia. Ritualistic behavior and obsessive thinking are typically seen in obsessive-compulsive disorders, not schizophrenia.
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