NCLEX NCLEX-RN
Psychosocial Integrity NCLEX PN Questions
1. Which of the following is a typical assessment finding of a 24-year-old female with anorexia nervosa?
- A. Weight loss of more than 2% body fat
- B. Frequent binge-eating episodes followed by induced vomiting
- C. A history of poor academic performance and mediocre achievements
- D. Lack of menstruation
Correct answer: D: Lack of menstruation
Rationale: The correct answer is D: Lack of menstruation. Amenorrhea, or lack of menstruation, is a common occurrence in individuals with anorexia nervosa. The induced starvation from anorexia can disrupt hormone levels, leading to menstrual irregularities. This hormonal imbalance can result in amenorrhea, which can have long-term consequences such as osteoporosis and infertility. Choices A, B, and C are incorrect. Weight loss of more than 2% body fat may be a consequence of anorexia but is not a specific assessment finding. Frequent binge-eating episodes followed by induced vomiting are more characteristic of bulimia nervosa, not anorexia nervosa. A history of poor academic performance and mediocre achievements is not a typical assessment finding related to anorexia nervosa symptoms.
2. In a pediatric clinic, a nurse is assessing a child recently diagnosed with cystic fibrosis. Which of the following later findings of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct answer: C: Moist, productive cough
Rationale: In a child newly diagnosed with cystic fibrosis (CF), noisy respirations and a dry, non-productive cough are typically the first respiratory signs to appear. The other options, including a positive sweat test, bulky greasy stools, and meconium ileus, are among the earliest findings of CF. CF is a genetic condition that affects the production of mucus, sweat, saliva, and digestive juices. Due to a defective gene, these secretions become thick and sticky instead of thin and slippery, leading to blockages in various passageways, especially in the pancreas and lungs. Respiratory failure is a severe consequence of CF, making it crucial to monitor respiratory symptoms closely in affected individuals. Therefore, a moist, productive cough would not be an expected finding in a newly diagnosed child with CF.
3. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?
- A. Assess for clotting in fistula tubing
- B. Apply a dressing over the fistula site
- C. Assess for a bruit or thrill at the site of the fistula
- D. Assess circulation proximal to the fistula site
Correct answer: Assess for a bruit or thrill at the site of the fistula
Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.
4. A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?
- A. In the rectum
- B. In the mouth
- C. On the temples
- D. In the armpit
Correct answer: In the armpit
Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (Choice A) is used for rectal temperature measurements, in the mouth (Choice B) for oral temperature measurements, and on the temples (Choice C) is not a common site for temperature assessment. Therefore, the correct placement based on the given instruction is in the armpit.
5. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?
- A. “I don’t remember anything about what happened to me.”
- B. “I’d rather not talk about it right now.”
- C. “It’s the other entire guy’s fault! He was going too fast.”
- D. “My mother is heartbroken about this.”
Correct answer: “I don’t remember anything about what happened to me.”
Rationale: The correct answer is, '“I don’t remember anything about what happened to me.”' Suppression involves willfully putting an unacceptable thought or feeling out of one’s mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '“I’d rather not talk about it right now,”' suggests avoidance or deflection rather than active suppression. Choice C, '“It’s the other entire guy’s fault! He was going too fast,”' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '“My mother is heartbroken about this,”' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.
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