NCLEX NCLEX-RN
Psychosocial Integrity NCLEX Questions
1. Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?
- A. Hallucinations
- B. Error in judgment
- C. Delusion of persecution
- D. Self-accusatory delusion
Correct answer: Delusion of persecution
Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'
2. The nurse is caring for a 27-year-old female client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client’s nutrition status
- C. Initiate limb compression therapy
- D. Begin proteolytic debridement
Correct answer: Improve the client’s nutrition status
Rationale: Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. This leads to inadequate oxygen and nutrient supply to the cells in the lower extremities, resulting in cell death or necrosis. Venous stasis ulcers, characterized by shallow brown wounds with irregular margins, typically develop on the lower leg or ankle. The primary goal in managing clients with venous stasis ulcers is to promote healing. Proper nutrition plays a crucial role in wound healing. Nutritional deficiencies are common causes of venous ulcers, and a diet rich in protein, iron, zinc, and vitamins C and A is recommended to enhance wound healing. Applying dressings with sterile technique, initiating limb compression therapy, and beginning proteolytic debridement are important interventions in wound care but may not directly address the underlying issue of poor nutrition that is essential for healing venous stasis ulcers.
3. Which of the following interventions is most appropriate when working with the family of a client who is being treated for substance abuse?
- A. Advocate for the client before the family
- B. Provide referrals for community resources and support groups
- C. Take the side of the family before the client
- D. Both B and C
Correct answer: B: Provide referrals for community resources and support groups
Rationale: When working with the family of a client undergoing substance abuse treatment, it is crucial to support not only the client but also their family. Providing referrals for community resources and support groups is an effective intervention as it helps the family access additional support and information to cope with the challenges related to the client's substance abuse. This empowers the family to enhance their understanding of the situation and develop effective coping strategies. Advocating for the client before the family (choice A) may lead to conflicts and hinder the therapeutic process, while taking the side of the family before the client (choice C) can jeopardize the client's progress and trust. Therefore, the most appropriate intervention in this scenario is to provide referrals for community resources and support groups to ensure holistic care for both the client and their family.
4. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?
- A. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
- B. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
- C. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
- D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
Correct answer: pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
Rationale: The correct answer is D: pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%. These ABG results indicate uncompensated respiratory acidosis, a critical condition that requires immediate attention. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to a decrease in pH. The other options present normal or near-normal ABG values, indicating adequate oxygenation and ventilation. Therefore, these values would not be as urgent to report compared to the patient with respiratory acidosis in option D.
5. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: Stage 3
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
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