NCLEX-RN
NCLEX Psychosocial Questions
1. The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by the nurse is most appropriate?
- A. Avoid asking questions unless the patient initiates the conversation.
- B. Ask the patient whether it is important that cultural healers are contacted.
- C. Explain the usual hospital routines for meal times, care, and family visits.
- D. Obtain further information about the patient's cultural beliefs from a family member.
Correct answer: B
Rationale: When caring for a patient with traditional health beliefs, it is essential to respect and address their cultural practices. Asking the patient whether it is important to involve cultural healers, such as a shaman, aligns with providing culturally sensitive care. Avoiding asking questions unless initiated by the patient may hinder effective communication and understanding of the patient's needs. Consulting a family member for cultural beliefs assumes that all family members share the same beliefs, which may not be accurate. Additionally, the patient's personal beliefs should be prioritized over family input. Explaining hospital routines without considering the patient's cultural preferences may lead to a lack of patient-centered care. Therefore, the most appropriate action is to inquire about the patient's preference regarding cultural healers.
2. Which nursing intervention helps foster the development of a trusting parent-child relationship?
- A. Placing the infant in a crib with a mobile or soft toy
- B. Discouraging eye contact when the infant is irritable
- C. Putting objects several inches in front of the infant for viewing
- D. Encouraging face-to-face contact between the parents and infant
Correct answer: D
Rationale: Encouraging face-to-face contact between parents and infants is crucial in fostering a trusting parent-child relationship. Eye-to-eye contact promotes interaction and bonding, helping the infant develop trust in their caregivers. Placing the infant in a crib with a mobile or soft toy may provide stimulation but does not directly contribute to the emotional bonding necessary for trust. Discouraging eye contact when the infant is irritable can hinder communication and connection. Putting objects in front of the infant for viewing is beneficial for visual stimulation but does not actively promote the emotional attachment and trust that face-to-face contact does.
3. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?
- A. Suggest that the client requesting attention speak with another staff member.
- B. Leave the new client, saying, 'I'll talk with the other client until things calm down.'
- C. Introduce the two clients and suggest that the client join them on a tour of the facility.
- D. Say to the interrupting client, 'I'll be back to talk with you after I orient this new client.'
Correct answer: D
Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.
4. Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment?
- A. Continual pacing
- B. Suspicious feelings
- C. Inability to socialize with others
- D. Disturbed relationship with the family
Correct answer: B
Rationale: In the early phase of treatment for a client with schizophrenia, the nurse needs to address the client's suspicious feelings to establish trust and create a therapeutic environment. Suspicious feelings can hinder the development of a positive nurse-client relationship. Continual pacing, while a symptom, can be managed by the nurse and does not directly impact the therapeutic relationship. Inability to socialize with others and a disturbed relationship with the family are important factors but are of lesser concern in the early treatment phase as compared to addressing suspicious feelings to build trust and rapport.
5. When administering medications through a nasogastric tube connected to low intermittent suction, which action should the nurse do first?
- A. Clamp the nasogastric tube
- B. Confirm placement of the tube
- C. Use a syringe to instill the medications
- D. Turn off the intermittent suction device
Correct answer: D
Rationale: When administering medications through a nasogastric tube connected to low intermittent suction, the nurse should first turn off the intermittent suction device. This step is crucial to prevent the medications from being immediately suctioned out before they can be absorbed. Clamping the nasogastric tube is not the initial action because it may cause pressure buildup and lead to complications. Confirming the placement of the tube is important but should not be the first step in this scenario. Using a syringe to instill the medications comes after ensuring the suction is turned off to enable proper administration and absorption of the medications.
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