which initial response would the nurse give to a husband who is upset that his wifes alcohol withdrawal delirium has persisted for a second day
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX PN Questions

1. What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?

Correct answer: A

Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.

2. During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important?

Correct answer: C

Rationale: During the initial stages of a therapeutic relationship, having a clear understanding of participants' roles is crucial as it helps in defining the structure and boundaries of the relationship. This clarity assists in setting expectations and establishing a framework for interaction, allowing the client to focus on the therapeutic process rather than on uncertainties regarding their role or the nurse's role. Option A, understanding what will be discussed, is important but not directly related to defining roles. Option B, knowing that the nurse is trying to be helpful, is about the intent of the nurse rather than the roles of the participants. Option D, preparing for termination of the relationship, is premature in the beginning phase and not directly related to understanding roles.

3. An adolescent reports irregularity in menses. Her mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image. Which could be the reason for irregular menses?

Correct answer: B

Rationale: The correct answer is 'Anorexia.' Anorexia is characterized by a lack of caloric intake motivated by a strong fear of gaining weight, leading to poor nutrition and potential irregular menses. Bulimia involves binge eating followed by compensatory behaviors. Orthorexia is characterized by an obsession with eating only healthy or 'pure' foods. Binge eating disorder is characterized by consuming large amounts of high-calorie food in a short period.

4. After being medicated for anxiety, the client says to the nurse, 'I guess you are too busy to stay with me.' Which response by the nurse is correct?

Correct answer: B

Rationale: The nurse should respond with empathy and reassurance to address the client's emotional needs. The correct response, 'I have to go now, but I will come back in 10 minutes,' acknowledges the client's feelings while providing a timeframe for the nurse's return, showing care and concern. Choice A, 'I'm so sorry, but I need to see other clients,' prioritizes other tasks over the client's emotional needs, which can increase anxiety. Choice C, 'You'll be able to rest after the medicine starts working,' offers false reassurance and does not address the client's immediate emotional distress. Choice D, 'You'll feel better after I've made you more comfortable,' does not acknowledge the client's concerns and fails to establish a supportive connection with the client.

5. A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?

Correct answer: C

Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.

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