a client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy which has caused hair loss the client states i feel li

NCLEX-RN

Psychosocial Integrity NCLEX Questions

1. A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, 'I feel like I've lost my sense of power.' Which response would the nurse give?

A. 'Hair does not empower a person.'
B. 'Losing power seems important to you.'
C. Knowledge is power; I'll give you some pamphlets to read.'
D. 'Hair loss is common; it will grow back, so you should not worry.'

Correct answer: B

Rationale: The correct response is, 'Losing power seems important to you.' This response acknowledges the client's feelings and provides an opportunity for further discussion. Choice A is confrontational and dismissive, potentially shutting down communication. Choice C offers pamphlets, which may be seen as dismissing the client's concerns and avoiding engaging in a conversation. Choice D minimizes the client's feelings and may discourage further expression of emotions. By choosing option B, the nurse shows empathy and encourages the client to explore their emotions in a supportive environment.

2. Which statement best describes the pathophysiology of dementia of the Alzheimer type?

A. There is a genetic predisposition and dysregulation of neurotransmitters.
B. The dementia is transient and secondary to a physical imbalance or disorder.
C. Hypoxia and decreased perfusion of select areas of the brain cause tissue damage.
D. The presence of amyloid plaques is associated with brain tissue destruction.

Correct answer: D

Rationale: In Alzheimer's disease, the accumulation of amyloid plaques in the brain is a hallmark feature. These plaques are associated with the destruction of brain tissue, contributing to the cognitive decline seen in dementia. Genetic predisposition and dysregulation of neurotransmitters are factors linked to the development of Alzheimer's disease, but the primary pathology lies in the amyloid plaques. Transient dementia is not characteristic of Alzheimer's disease, which is a progressive neurodegenerative disorder. Hypoxia and decreased perfusion are more typical of vascular dementia, where blood flow to the brain is compromised.

3. Which client is most likely to be at risk for spiritual distress?

A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-Day Adventist who needs a blood transfusion
D. Muslim man who needs a total knee replacement

Correct answer: A

Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.

4. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?

A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime so the pill can help him sleep.
C. Attend to the acutely ill client's needs first because this client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.

5. Which of the following individuals is at the highest risk of suicide?

A. An 80-year-old man who lost his wife last year
B. A 36-year-old woman whose former neighbor committed suicide
C. A 40-year-old married businessman
D. A 46-year-old former alcoholic who has been sober for 12 years

Correct answer: A

Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.