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NCLEX Psychosocial Integrity Questions
1. Which benefit accompanies mild apprehension?
- A. Physiological functions are slowed.
- B. There is an increased alertness.
- C. Behavioral responses become automatic.
- D. Ego defense mechanisms are mobilized.
Correct answer: There is an increased alertness.
Rationale: A mild level of anxiety can be beneficial because it increases alertness and focuses attention. Physiological functions are actually amplified initially, not slowed, due to mild apprehension; however, prolonged anxiety can lead to decreased function due to exhaustion. Automatic behavioral responses and ego defense mechanisms may hinder an individual's awareness rather than enhancing it, making them less beneficial compared to increased alertness.
2. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
- A. Absent bowel sounds
- B. Abdominal tenderness
- C. Left upper quadrant pain
- D. Palpable abdominal mass
Correct answer: Palpable abdominal mass
Rationale: The correct answer is a palpable abdominal mass. In a 46-year-old woman with acute pancreatitis, a palpable abdominal mass may indicate the presence of a pancreatic abscess, which requires rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common symptoms in acute pancreatitis but do not necessarily indicate an immediate need for surgical intervention. Therefore, the presence of a palpable abdominal mass is the most concerning finding in this scenario.
3. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct answer: Instructing the parents to avoid administering medications unless prescribed.
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
4. When teaching a patient to use the three-point gait technique of crutch use:
- A. The injured leg moves ahead at the same time as both crutches.
- B. One crutch moves at a time and is then followed by the injured leg.
- C. Both crutches move ahead at the same time followed by both legs at the same time.
- D. None of the above are correct.
Correct answer: The injured leg moves ahead at the same time as both crutches.
Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.
5. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?
- A. ''Tell me more about being Joan of Arc.''
- B. ''We both know that you’re not Joan of Arc.''
- C. ''It seems like the world is a pretty scary place for you.''
- D. ''You’re safe here, because we won’t let you be burned.''
Correct answer: ''It seems like the world is a pretty scary place for you.''
Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client’s feelings, and help preserve the client’s integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client’s delusion and does not test reality. The statement, ''We both know that you’re not Joan of Arc,'' rejects the client’s feelings and does not address the client’s fears of being harmed; clients cannot be argued out of delusions. The statement, ''You’re safe here, because we won’t let you be burned,'' is false reassurance; the nurse is agreeing with the client’s false perceptions of reality, which is nontherapeutic.
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