NCLEX NCLEX-RN
NCLEX Psychosocial Questions
1. Which type of toy would be most suitable for enhancing the development of a toddler-age client?
- A. Clay
- B. Rattle
- C. Video games
- D. Musical mobile
Correct answer: Clay
Rationale: The most suitable toy to recommend for enhancing the development of a toddler-age child is clay. Clay promotes creativity and fine motor skills in toddlers. A rattle is typically recommended for infants as it aids in sensory development. Video games, which are often battery-operated, are not suitable for toddlers due to potential negative effects on development. A musical mobile is more appropriate for infants as it can aid in soothing and sensory stimulation.
2. When performing a cultural assessment with a patient from a different culture, what action should the nurse take first?
- A. Request an interpreter before interviewing the patient
- B. Wait until a family member is available to help with the assessment
- C. Ask the patient about any affiliation with a particular cultural group
- D. Tell the patient what the nurse already knows about the patient's culture
Correct answer: Ask the patient about any affiliation with a particular cultural group
Rationale: When conducting a cultural assessment, the first step is to inquire if the patient has any affiliation with a specific cultural group. This helps the nurse understand the patient's background and beliefs. Requesting an interpreter before interviewing the patient may be necessary if language barriers exist. Waiting for a family member to assist with the assessment may delay the process and compromise patient confidentiality. Telling the patient what the nurse knows about their culture assumes knowledge and may lead to misunderstandings or inaccuracies.
3. A client who exhibits blurred and double vision and muscular weakness is informed of the diagnosis of multiple sclerosis (MS). The client becomes visibly upset. Which response would the nurse make?
- A. That must have shocked you. Tell me what the health care provider told you about it.
- B. You should see a psychiatrist who will help you cope with this overwhelming news.
- C. Don't worry; early treatment often alleviates the symptoms of the disease.
- D. You should be glad that we caught it early so you can be cured.
Correct answer: That must have shocked you. Tell me what the health care provider told you about it.
Rationale: The response 'That must have shocked you. Tell me what the health care provider told you about it' acknowledges the effect of the diagnosis on the client and explores what is known. This response shows empathy and encourages the client to share their understanding. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary at this initial stage. The statement 'Don't worry; early treatment often alleviates symptoms of the disease' provides false reassurance as the course of MS varies for each individual and may not always respond well to treatment. The statement 'You should be glad we caught it early so it can be cured' does not address the client’s current emotional state and is inaccurate; MS is a chronic autoimmune disease that currently has no cure.
4. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode.
- B. Administer stool softeners daily as prescribed.
- C. Administer antidysrhythmics prn as ordered.
- D. Maintain the client on strict bed rest.
Correct answer: Administer stool softeners daily as prescribed.
Rationale: Administering stool softeners daily is crucial to prevent straining during defecation, which can lead to the Valsalva maneuver. Straining can increase intrathoracic pressure, decrease venous return to the heart, and reduce cardiac output, potentially worsening the client's condition. If constipation occurs, the use of laxatives may be necessary to avoid straining. Administering antidysrhythmics on an as-needed basis is not indicated for preventing the Valsalva maneuver; they are used to manage dysrhythmias. Strict bed rest is not necessary and may lead to complications such as deconditioning, DVT, and respiratory issues in the absence of specific medical indications.
5. Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct answer: A 58-year-old female with near-syncope
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
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