a man who is admitted for a suicide attempt after the death of his child says i hear my son telling me to come over to the other side which psychotic
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NCLEX Psychosocial Integrity Questions

1. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?

Correct answer: D

Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.

2. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

3. What nonverbal action should the nurse implement to demonstrate active listening?

Correct answer: A

Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.

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

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.

5. Which of the following is an example of non-reversible dementia?

Correct answer: A

Rationale: Non-reversible dementia refers to a condition where individuals experience permanent and often progressive cognitive decline. Pick's disease is a type of non-reversible dementia characterized by changes in personality, behavior, and language difficulties. Syphilis (Choice B) is a reversible cause of dementia that can be treated with antibiotics. Encephalopathy (Choice C) is a broad term for brain dysfunction that can be reversible or irreversible depending on the cause. Hyperthyroidism (Choice D) can lead to cognitive impairment but is reversible with appropriate treatment. Therefore, Pick's disease is the correct example of non-reversible dementia among the options provided.

Similar Questions

Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?
Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant woman is cared for in her current residence?
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
A client has just died, and their son states, 'She was the most wonderful mother. There was no one who was a better mother than she was. She was perfect.' Which stage of grief is this son experiencing?
A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?

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