NCLEX-PN
Psychosocial Integrity Nclex PN Questions
1. A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue
Correct answer: A
Rationale: The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.
2. When medications have an additive, synergistic, or antagonistic effect on a tissue, a ________ reaction has occurred.
- A. pharmaceutical
- B. pharmacodynamic
- C. pharmacokinetic
- D. drug incompatibility
Correct answer: B
Rationale: The correct answer is 'pharmacodynamic.' Pharmacodynamics pertain to the effect of a drug on receptors, explaining how drugs affect tissues. Pharmaceutical reactions refer to chemical reactions between drugs before administration or absorption, not their effect on tissues. Pharmacokinetic reactions involve how the body affects the drug, not the tissue. Drug incompatibilities are essentially pharmaceutical reactions, not the specific effects on tissues seen in pharmacodynamic reactions.
3. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
- B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
- C. inform the client that it was not her fault, and support the client through the physical examination.
- D. question whether the woman had consensual sex and now just feels guilty.
Correct answer: C
Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.
4. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
- A. Blood pressure monitoring every 15 minutes
- B. Insertion of a Levine tube
- C. Continuous cardiac monitoring
- D. Administration of pain medication every 4 hours
Correct answer: B
Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.
5. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
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