NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which source of stress would the nurse anticipate in a 5-year-old client?
- A. Jealousy
- B. Stubbornness
- C. Procrastination
- D. Companionship
Correct answer: C
Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.
2. After attending group therapy, the client says, 'It helps to know that I'm not the only one with this type of problem.' Which concept does this statement reflect?
- A. Altruism
- B. Catharsis
- C. Universality
- D. Transference
Correct answer: C
Rationale: The client's statement reflects the concept of universality. Universality in group therapy signifies the understanding that one is not alone in their struggles, providing a sense of commonality and support among group members facing similar challenges. Altruism in group therapy involves offering support, insight, and encouragement to others, fostering personal growth and self-awareness. Catharsis pertains to group members sharing and expressing both negative and positive emotions with each other. Transference occurs when a client inadvertently projects feelings and perceptions onto the therapist that originally belonged to someone significant in their past, impacting the therapeutic relationship.
3. What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
- A. Removing the child's undergarments
- B. Placing the child's toys on the bedside table
- C. Allowing the child to climb onto the stretcher
- D. Having the parents accompany the child to the operating suite
Correct answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
4. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
- B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
- C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct answer: C
Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith from malpractice claims, regardless of the client outcome. In this scenario, the nurse stopped at the scene voluntarily to render aid, which is protected under the Good Samaritan Act. This law shields individuals from legal liability when providing emergency care in good faith and without expectation of compensation. The Patient's Bill of Rights does protect clients, but in this case, the nurse's actions were protected by the Good Samaritan Act. Additionally, the state Board of Nursing would not likely revoke the nurse's license unless there was evidence of actions taken in bad faith or unreasonable care. The client would not win the lawsuit as the essential elements of malpractice, including duty, breach, causation, and damages, were not met in this situation.
5. A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct answer: D
Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.
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