NCLEX Prep for Psychosocial Integrity

These questions are one of the NCLEX prep samples for Psychosocial Integrity. This post has a 25 set of questions with the accompanying answers and rationale located at the bottom. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.

1. Jannah, a 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?

a. You don’t have to eat. It’s your choice
b. I hope you’ll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable
c. Why do you think you’re fat? You’re underweight. Here — look in the mirror
d. You really look terrible at this weight. I hope you’ll eat

2. Nurse Sofia is assessing a 15-year-old female who’s being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

a. Tachycardia
b. Warm, flushed extremities
c. Parotid gland tenderness
d. Coarse hair growth

3. A client who’s at high risk for suicide needs close supervision. To best ensure the client’s safety, nurse Leslie should:

a. Check the client frequently at irregular intervals throughout the night
b. Assure the client that the nurse will hold in confidence anything the client says
c. Repeatedly discuss previous suicide attempts with the client
d. Disregard decreased communication by the client because this is common in suicidal clients

4. During which phase of alcoholism is loss of control and physiologic dependence evident?

a. Prealcoholic phase
b. Early alcoholic phase
c. Crucial phase
d. Chronic phase

5. Nurse Tony is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

a. Restrict visits with the family until the client begins to eat
b. Provide privacy during meals
c. Set up a strict eating plan for the client
d. Encourage the client to exercise, which will reduce her anxiety

6. In a toddler, which of the following injuries is most likely the result of child abuse?

a. A hematoma on the occipital region of the head
b. A 1-inch forehead laceration
c. Several small, dime-sized circular burns on the child’s back
d. A small isolated bruise on the right lower extremity

7. A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time?

a. Keeping the client restrained in bed
b. Checking the client’s blood pressure every 15 minutes and offering juices
c. Providing a quiet environment and administering medication as needed and prescribed
d. Restraining the client and measuring blood pressure every 30 minutes

8. A client is admitted for an overdose of amphetamines. When assessing this client, nurse Pauleen should expect to see:

a. Tension and irritability
b. Slow pulse
c. Hypotension
d. Constipation

9. A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4″ (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can’t remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. Nurse Kisses suspects that she has:

a. Bulimia nervosa
b. Anorexia nervosa
c. Depression
d. Schizophrenia

10. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority?

a. Client’s physical needs
b. Client’s safety needs
c. Client’s psychosocial needs
d. Client’s medical needs

11. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, nurse Willy should expect early withdrawal symptoms to:

a. Not occur at all because the time period for their occurrence has passed
b. Begin anytime within the next 1 to 2 days
c. Begin within 2 to 7 days
d. Begin after 7 days

12. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug?

a. Clozapine (Clozaril)
b. Thiothixene (Navane)
c. Lorazepam (Ativan)
d. Lithium carbonate (Eskalith)

13. When monitoring a client recently admitted for treatment of cocaine addiction, nurse Gem notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

a. Norepinephrine (Levophed) and lidocaine (Xylocaine)
b. Nifedipine (Procardia) and lidocaine
c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc)
d. Nifedipine and nitroglycerin

14. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, “I’m not going to those meetings anymore. I’m not like the rest of those people. I’m not a drunk. “What is the most appropriate response?

a. If you aren’t an alcoholic, why do you keep drinking and ending up in the hospital?
b. It’s your decision. If you don’t want to go, you don’t have to
c. You seem upset about the meetings
d. You have to go to the meetings. It’s part of your treatment plan

15. A client with anorexia nervosa describes herself as “a whale.” However, nurse Melissa’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s unrealistic body image, which intervention should be included in the plan of care?

a. Asking the client to compare her figure with magazine photographs of women her age
b. Assigning the client to group therapy in which participants provide realistic feedback about her weight
c. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift
d. Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy

16. Which of the following is important when restraining a violent client?

a. Have three staff members present, one for each side of the body and one for the head
b. Always tie restraints to side rails
c. Have an organized, efficient team approach after the decision is made to restrain the client
d. Secure restraints to the gurney with knots to prevent escape

17. Nurse Dennis in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:

a. You must first stop drinking
b. Your physician must refer you to this program
c. Admit you’re powerless over alcohol and that you need help
d. You must bring along a friend who will support you

18. Nurse Betty is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client?

a. Providing one-on-one supervision during meals and for 1 hour afterward
b. Letting the client eat with other clients to create a normal mealtime atmosphere
c. Trying to persuade the client to eat and thus restore nutritional balance
d. Giving the client as much time to eat as desired

19. A client who’s actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?

a. Dilated pupils
b. Nystagmus
c. Paranoia
d. Altered mood

20. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should nurse Joy make to suspect that the child was abused?

a. The child cries uncontrollably throughout the examination
b. The child pulls away from contact with the physician
c. The child doesn’t cry when the shoulder is examined
d. The child doesn’t make eye contact with the nurse

21. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client’s husband arrives, shouting that he wants to “finish the job.” What is the first priority of the health care worker who witnesses this scene?

a. Remaining with the client and staying calm
b. Calling a security guard and another staff member for assistance
c. Telling the client’s husband that he must leave at once
d. Determining why the husband feels so angry

22. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm’s employee assistance program. Nurse Lyn knows that the client’s behavior most likely represents the use of which defense mechanism?

a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization

23. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Based on this finding, nurse Lika should formulate a nursing diagnosis of:

a. Ineffective individual coping related to feelings of guilt
b. Situational low self-esteem related to feelings of loss of control
c. Risk for violence: Self-directed related to impulsive mutilating acts
d. Risk for violence: Directed toward others related to verbal threats

24. A client is admitted for detoxification after a cocaine overdose. The client tells nurse Mercy that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?

a. Withdrawal
b. Logical thinking
c. Repression
d. Denial

25. Which of the following groups are considered to be at highest risk for suicide?

a. Adolescents, men over age 45, and persons who have made previous suicide attempts
b. Teachers, divorced persons, and substance abusers
c. Alcohol abusers, widows, and young married men
d. Depressed persons, physicians, and persons living in rural areas

ANSWERS AND RATIONALE for Psychosocial Integrity

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