a female adolescent has anorexia nervosa and is malnourished and severely underweight which statement indicates that she is experiencing secondary gai
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NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

2. What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?

Correct answer: C

Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.

3. The client has a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?

Correct answer: B

Rationale: The most crucial client outcome for successful adjustment to a new colostomy is the readiness to accept an altered body function. Acceptance of changes in body image and function is essential to facilitate mastery of colostomy care techniques and optimal utilization of community resources. Without readiness to accept the altered body function, the client may not be open to learning and adopting necessary changes, hindering the achievement of long-term goals. Understanding dietary modifications, while important, is secondary to the fundamental acceptance of the altered body function in the process of adjusting to a new colostomy.

4. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

Correct answer: B

Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.

5. Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?

Correct answer: A

Rationale: Recognition is a form of therapeutic communication in which the nurse points out a positive aspect of the client's behavior. Noting that a client brushed her hair herself indicates that the nurse recognizes the client's attempts at self-care. This recognition shows the client that the nurse is paying attention and may be open to further communication. Choices A, B, and C do not demonstrate recognition. Choice A focuses on a directive statement, Choice B involves informing the client about a situation without acknowledging their actions, and Choice C informs the client about a meeting without providing recognition for any behavior.

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