NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit?
- A. The child develops the superego.
- B. The child plays beside other children.
- C. The child concentrates on work and play.
- D. The child becomes casual about body appearance.
Correct answer: A
Rationale: According to Erikson's theory, a preschooler develops the superego or conscience during the initiative versus guilt stage. This stage occurs around ages 3 to 6 years old. The development of the superego is crucial for the child to start understanding and internalizing societal and parental values. Choice B is incorrect because playing beside other children typically occurs during the autonomy versus shame and doubt stage, which is seen in toddlers. Choice C is incorrect as concentrating on work and play is more characteristic of the industry versus inferiority stage, typically seen in school-aged children. Choice D is incorrect because becoming casual about body appearance is more aligned with the identity versus role confusion stage, which is seen in adolescents who have a marked preoccupation with appearance and body image.
2. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?
- A. EEG
- B. EKG
- C. Electrolytes
- D. Echocardiogram
Correct answer: C
Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.
3. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse
- B. Encourage the client to get to the toilet
- C. In a loud voice, call for help
- D. Gently lower the client to the floor
Correct answer: D
Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.
4. Which approach would the healthcare provider use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?
- A. Creating an anxiety-free environment for the client
- B. Assisting the client with the development of healthy, adaptive coping mechanisms
- C. Avoiding triggers that produce anxiety in the client
- D. Providing reinforcement that the client's anxiety issues can be eliminated
Correct answer: B
Rationale: The healthcare provider would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the healthcare provider to help the client replace the ineffective worrying with effective, healthy coping mechanisms. Creating an anxiety-free environment is not feasible or recommended; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is important, avoiding all triggers that produce anxiety is often impractical. Providing reinforcement that anxiety issues can be eliminated is not appropriate as anxiety is a normal human experience that needs to be managed effectively rather than eliminated completely.
5. 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. Assign an unlicensed assistive person to transport the client via a wheelchair.
- B. Remind the client to walk carefully down the stairs until reaching a lower floor.
- C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
- D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
Correct answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
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