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NCLEX Psychosocial Integrity Questions
1. After giving birth to her third child, a client tearfully says to the nurse, 'How much more can I give of myself?' Which principle would the nurse consider in the care of any new mother?
- A. It is easier to adjust to the first child than to later ones.
- B. Feeling anger and resentment toward a child is pathological.
- C. Some parents experience feelings of being overwhelmed by multiple children.
- D. Parents usually have inborn feelings of love and acceptance of their children.
Correct answer: Some parents experience feelings of being overwhelmed by multiple children.
Rationale: A parent’s feeling of being overwhelmed by multiple children is a normal response. It is vital to help parents realize this as a means of easing feelings of guilt and shame. The first child causes the greatest amount of adjustment in one’s life. It is common for parents to feel anger and resentment toward their children at times due to the challenges of parenting. Stating that parents usually have inborn feelings of love and acceptance of their children is a false generalization and may not hold true for everyone. Therefore, the most appropriate principle for the nurse to consider in this situation is that some parents may experience feelings of being overwhelmed by multiple children.
2. A nurse is caring for a client who was recently diagnosed with breast cancer. The oncologist uses the TNM staging system to classify this case as T2, N2, M0. The nurse understands that TNM stands for:
- A. Tumor, Necrosis, Metastasis
- B. Tumor, Node Involvement, Mastectomy
- C. Tumor, Node Involvement, Metastasis
- D. Therapy, Necrosis, Metastasis
Correct answer: Tumor, Node Involvement, Metastasis
Rationale: The TNM staging system is a classification system for determining the size and extent of cancerous tissue. The TNM system helps providers to identify the most accurate forms of treatment. The T stands for tumor, the N stands for node involvement, and the M stands for metastasis. Choice A, 'Tumor, Necrosis, Metastasis,' is incorrect because it does not include the node involvement component. Choice B, 'Tumor, Node Involvement, Mastectomy,' is incorrect as it erroneously includes the treatment approach 'Mastectomy' instead of 'Metastasis.' Choice D, 'Therapy, Necrosis, Metastasis,' is incorrect because it includes 'Therapy' instead of the correct component 'Node Involvement.'
3. The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention?
- A. Promoting bed rest
- B. Restricting oral fluids
- C. Allowing the child to play
- D. Encouraging visits from friends
Correct answer: Promoting bed rest
Rationale: During the acute phase of glomerulonephritis, promoting bed rest is a priority to reduce stress on the kidneys and promote recovery. As the condition improves, activity can be gradually increased. Restricting oral fluids is not recommended as maintaining adequate hydration is crucial. Allowing the child to play quietly can be beneficial but is not the priority over rest during the acute phase. Encouraging visits from friends may disrupt the rest needed for recovery, so visitors should be limited.
4. The client reports nausea and constipation. Which of the following would be the priority nursing action?
- A. Collect a stool sample
- B. Complete an abdominal assessment
- C. Administer an anti-nausea medication
- D. Notify the physician
Correct answer: Complete an abdominal assessment
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.
5. When auscultating the patient's lungs during a shift assessment on a patient admitted in the early phase of heart failure, which finding would the nurse most likely hear?
- A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
- B. Continuous high-pitched musical sounds on inspiration and expiration
- C. Discontinuous, high-pitched sounds of short duration heard on inspiration
- D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Correct answer: C: Discontinuous, high-pitched sounds of short duration heard on inspiration
Rationale: In the early phase of heart failure, fine crackles are likely to be heard upon auscultation of the lungs. Fine crackles are characterized as discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration, which are often associated with airway secretions. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration, typically indicating fluid in the alveoli. Wheezes are continuous high-pitched musical sounds on inspiration and expiration, commonly heard in conditions like asthma or chronic obstructive pulmonary disease (COPD). Therefore, the correct choice is C, as it describes the expected lung sounds in a patient with early heart failure.
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