NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. What is the primary purpose served when an individual takes action to reduce anxiety?
- A. Reduction of tension
- B. Denial of the situation
- C. Avoidance of physical discomfort
- D. Resolution in decision-making
Correct answer: A
Rationale: The primary purpose of taking action to reduce anxiety is to alleviate emotional tension and prevent the exacerbation of anxiety symptoms. By reducing tension, anxiety levels decrease, leading to a sense of comfort, safety, and security. Denial of the situation is not the goal when addressing anxiety; rather, acknowledging and managing it is crucial. While physical discomfort may accompany anxiety, the focus is on alleviating the emotional aspect to mitigate physical manifestations. Although mild anxiety can sometimes improve decision-making skills, higher levels of anxiety typically impede cognitive functions, making resolution in decision-making less likely.
2. During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important?
- A. Understanding what will be discussed
- B. Knowing that the nurse is trying to be helpful
- C. Knowing what to expect from the relationship
- D. Preparing for termination of the relationship
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. During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?
- A. ''I usually avoid driving at night since lights sometimes seem to make things blur.''
- B. ''I take half of the usual dose for my sinuses to maintain my blood pressure.''
- C. ''I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
- D. ''I take extra fiber and drink lots of water to avoid getting constipated.''
Correct answer: D
Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.
4. Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?
- A. Ignore the client's behavior if the client is not harming anyone.
- B. Isolate the client until the behavior decreases or stops.
- C. Explain how the behavior affects other people on the unit.
- D. Seek to understand what the behavior means to the client.
Correct answer: D
Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.
5. A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
- A. Stay at the bedside with the family and the deceased.
- B. Direct activities related to funeral arrangements.
- C. Mobilize the support systems for the family.
- D. Present the full reality of the loss to the family.
Correct answer: A
Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.
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