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-RN

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. 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.

3. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

Correct answer: A

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

4. During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?

Correct answer: D

Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.

5. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

Correct answer: B

Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.

Similar Questions

A 37-year-old woman with a history of fibroids and menorrhagia that have not been responsive to hormonal treatments is admitted with severe menorrhagia resulting in anemia. She also has depression and pelvic pain. She is crying and states, 'I don't know what to do"?my primary health care provider is recommending a hysterectomy, but I haven't had children yet!' Which response would the nurse provide?
The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?
A client says, 'The doctors lied about me. They said I murdered my mother. You killed her. She died before I was born.' Which psychotic feature is the client experiencing?
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

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