NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which behavior would the nurse recognize as developmentally atypical in preschoolers?
- A. Thumb sucking during stress
- B. Feeling guilty for behaving inappropriately
- C. Feeling happy if there is a newborn in the family
- D. Curiosity about their surroundings
Correct answer: C
Rationale: The correct answer is feeling happy if there is a newborn in the family. Preschoolers are more likely to exhibit feelings of stress and jealousy rather than happiness with the arrival of a new baby in the family. Thumb sucking and bed-wetting are common behaviors displayed by preschoolers during times of stress. Guilt typically arises in children when they perceive that they have not behaved appropriately. Preschoolers are known to be naturally curious about their surroundings, showing an interest in exploring and learning about the environment around them. Therefore, feeling happy with the birth of a new baby is developmentally atypical for preschoolers.
2. What is a priority goal of involuntary hospitalization of the severely mentally ill client?
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct answer: C
Rationale: The priority goal of involuntary hospitalization of severely mentally ill clients is to ensure protection from harm to self or others. Involuntary hospitalization is often necessary for individuals who are deemed dangerous to themselves or others or who are considered gravely disabled. Re-orientation to reality, elimination of symptoms, and return to independent functioning are important aspects of mental health care but are not the primary goals of involuntary hospitalization. The main focus during involuntary hospitalization is to address safety concerns and prevent harm.
3. Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:
- A. document the other worker's assessment of the patient.
- B. assess the patient based on data collected from all sources.
- C. validate the worker's impression by contacting the patient's significant other.
- D. discuss the worker's impression with the patient during the assessment interview
Correct answer: B
Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.
4. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.
5. Which priority action would the nurse manager use to help the nurse who may be experiencing burnout?
- A. Transfer the nurse to another unit in the facility.
- B. Help the nurse choose a position on a low-stress unit.
- C. Encourage the nurse to attend educational programs.
- D. Help the nurse identify personal responses to job stress.
Correct answer: D
Rationale: The correct priority action for the nurse manager to help a nurse experiencing burnout is to assist the nurse in identifying personal responses to job stress. This involves recognizing work stressors in the environment and evaluating coping strategies to determine their effectiveness. While transferring the nurse to another unit could be a solution, the initial focus should be on self-awareness and coping strategies. Choosing a position on a low-stress unit and attending educational programs can be beneficial in reducing burnout, but they are not the primary steps to address burnout when it occurs.
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