NCLEX AQ Client Needs: Psychosocial Integrity
Which response would the nurse give to the common statement "But you don't understand" when caring for an adolescent?
"It would be helpful to understand; let's talk."
Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process?
"It's such a tiny baby."
Which characteristic would a nurse expect to be exhibited by an adolescent? Select all that apply. One, some, or all responses may be correct.
A belief in their own invulnerability Personal fable
Which aspect of psychosocial development is commonly observed in adolescents? Select all that apply. One, some, or all responses may be correct.
A search for personal identity Development of an ethical system
An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parent wonders if this is abnormal behavior picked up from playing video games. Which is the best response by the nurse?
"School-aged children are inquisitive and ask a lot of questions about death."
An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parent asks whether this is abnormal or morbid behavior picked up from playing video games. Which is the best response by the nurse?
"School-aged children are inquisitive and ask a lot of questions about death."
Which is the nurse's most therapeutic response for the child who is about to have an intravenous (IV) line inserted and cries out that he is afraid of IVs?
"Tell me what frightens you."
Which response would the nurse make to a client who says, "I'm a terrible, evil person. The voices are telling me that God needs to punish me"?
"Tell me what you're thinking about yourself."
Which estimated percentage of adolescents have used alcohol by the end of their high school years? Record your answer using a whole number.
85%
Which stage is a terminally ill client displaying by gradually moving towards resolution of feelings about impending death according to Kübler-Ross' theory of death and dying?
Acceptance stage
Which type of crisis has occurred when a sudden terrorist act causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation?
Adventitious
Which client may have concerns related to sexuality when hospitalized with a chronic illness?
An 18 year old
Which nursing intervention would help a client who exhibits physical symptoms when stressed?
Assisting the client in developing new coping mechanisms
How do adolescents establish group identity during psychosocial development?
By building close peer relationships to achieve acceptance in the society
How do adolescents establish health identity during psychosocial development? Select all that apply. One, some, or all responses may be correct.
By evaluating their own health with a feeling of well-being By having the ability to function normally in the absence of any disease or infirmity
When planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take?
Check on the client frequently.
Which member of the health care team has the primary responsibility for the success of the therapy and rehabilitation according to Alcoholics Anonymous?
Client
Which side effect would the nurse monitor for in a severely depressed client who received electroconvulsive therapy (ECT)?
Confusion immediately after the treatment
Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase?
Constant singing
Which term describes a client who drinks 2 drinks per day with no negative consequences?
Daily drinker
The objective of a therapy group is to assist the members to change behavior so they are able to participate in life in a more satisfying manner. Which leadership style is best to achieve this objective?
Democratic, guiding
Place the five stages of grieving identified and described by Elisabeth Kübler-Ross in order of progression from first to last.
Denial Anger Bargaining Depression Acceptance
According to Piaget, during which developmental stage is the pediatric client egocentric?
Early childhood
Which component of the human personality, according to Freud, allows an individual to judge reality accurately?
Ego
Which characteristic is most essential for the nurse to have in caring for clients with mental health disorders?
Empathy
The parent of a child with a terminal illness appears overwhelmed and anxious. Which is the best response by the nurse?
Encouraging the parent to express their feelings
In which period will the adolescent have a prevalence of egocentric thoughts according to Piaget's theory?
Formal operations
At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group?
Good boy-nice girl orientation
Which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with obsessive-compulsive disorder?
Has overwhelming feelings of anxiety
According to Erikson's developmental stages, which characteristic would the nurse anticipate when assessing a preschool-age child?
Having highly imaginative thoughts
Which characteristic is commonly associated with adolescent depression? Select all that apply. One, some, or all responses may be correct.
Having suicidal ideation Exhibiting tearfulness Avoiding previously enjoyed activities and relationships
Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes?
Help the client select appropriate attire and offer to help the client get dressed.
Which disorder is defined as a preoccupation with the fear of having a serious disease?
Hypochondriac disorder
Which statement would the nurse recognize as accurate about a preschooler's imaginary playmates?
Imaginary playmates experience what a preschooler wants to remember.
Which term descibes the behavior of a 15-year-old who plans to go to a nightclub without informing his or her parents but is afraid of being caught?
Invulnerability
Which rationale explains why the client who is displaying hyperactive and manic behaviors with flights of ideas is not eating?
Is too busy to take time to eat
Which action would the nurse take to minimize agitation in a disturbed client?
Limit unnecessary interactions with the client.
Which level of anxiety enhances the client's learning abilities?
Mild
A client does not take their medication regularly and is depressed. Which inference can the nurse make about the client's motivational level?
Not motivated
A child has a fractured arm and multiple old injuries. Child maltreatment is suspected. Which parental characteristic supports this suspicion?
Offering inconsistent stories about the injuries
Which factor may influence an adolescent to begin smoking? Select all that apply. One, some, or all responses may be correct.
Peer pressure Imitating adult behavior of smoking Imitating lifestyles portrayed in movies and advertisements
Which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"?
Persecution
Which technique would be appropriate for clients who exhibit mild neurocognitive impairment?
Reality orientation
Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?
Routines provide stability for clients with neurocognitive disorders.
Which type of group is Alcoholics Anonymous (AA)?
Self-help group
Which action would the nurse encourage for an adolescent diagnosed with a chronic illness to achieve independence from his or her family?
Socializing with peers
Which activity would the nurse ask an older adult client to do when testing short-term memory?
State three random words mentioned earlier in the examination.
Which statement describes adolescents according to Lawrence Kohlberg's theory of moral development? Select all that apply. One, some, or all responses may be correct.
"An individual's thoughts are influenced by moral decisions and behaviors." "An individual expands his or her focus from a relationship with others to societal concerns."
Which response would the nurse make to a client who has been attending a day treatment facility for 1 month with depressive disorder and is to be discharged in a week?
"I understand that your discharge is set for next week. I'm wondering how you feel about that?"
Which response would the nurse use when a client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS"?
"There is no cure for AIDS, but there are medications that can slow down the virus."
Which response would the nurse use after receiving instructions regarding dressing changes and care of a recently inserted nephrostomy tube when the client states "I hope I can handle all this at home; it's a lot to remember"?
"You seem to be nervous about going home."
Which response would the nurse make to a client who says, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy," after performing a complex ritual?
"You're concerned about what other people are thinking about you."
Which action would the nurse take for a client with an obsessivecompulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?
Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed.
Which explanation, when providing a change-of-shift report, would the nurse use to describe a client diagnosed with schizophrenia who is experiencing opposing emotions simultaneously?
Ambivalence
Which statement is true about the instrumental relativist orientation stage?
An individual recognizes that there is more than 1 correct point of view.
Which strategy would the nurse use to help a depressed, withdrawn client who exhibits sadness through nonverbal behavior?
Cope with painful feelings by sharing them.
Which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?
Exhibits lack of empathy for others
Which approach would the nurse take for a client who was involved in a near-fatal automobile collision and arrives at the crisis center with reports of anxiety and flashbacks?
Focusing on the present
A client is diagnosed with Alzheimer disease and is exhibiting hyperorality. Which parameter would the nurse closely monitor to keep this client safe?
For attempts at eating inedible objects
Which period of Piaget's theory covers the prevalence of egocentrism in adolescents?
Formal operations
Which period of Piaget's theory marks the end of cognitive development?
Formal operations
At which stage does an adolescent develop abstract thinking?
Formal operations period
Which communication pattern is defined as confabulation?
Imagination is used to fill in memory gaps.
A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation?
Immediately involve pastoral services while caring for the client.
Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior?
Sets limits
Which characteristic of adolescence is exemplified by risk-taking behavior without fear of consequences?
Sense of invulnerability
Which identity may fail to develop if an adolescent lacks physical evidence of maturity?
Sexual
Which parental description would the nurse recognize as characteristic of sleep terrors in a preschool-age child?
Sweating profusely
Which behavior would an adolescent exhibit?
Synchronization of moral skills
Which characteristic is found in an adolescent according to Erikson's theory of psychosocial development? Select all that apply. One, some, or all responses may be correct.
The adolescent is concerned about his or her appearance and body image. The adolescent acquires a sense of identity by participating in decisionmaking.
Which statement describes stage 4 of Kohlberg's theory? Select all that apply. One, some, or all responses may be correct.
The child shows respect for authority and maintains the social order. Adolescents choose to avoid a party where they know beer will be served.
Which priority objective would the nurse add to the plan of care for a male client who is withdrawn, shy, has low self-esteem and is afraid to talk to members of the opposite sex?
The client will increase his self-esteem.
Which goal is appropriate when treating anorexia nervosa? Select all that apply. One, some, or all responses may be correct.
The repairing of family interactions The reinstitution of normal nutrition to counteract a state of malnutrition The correction of deficits and distortions in psychological functioning via psychotherapy
Which action would the nurse take for a withdrawn client who suddenly screams, bursts into tears, and runs from the room to the far end of the hallway?
Walk to the end of the hallway where the client is standing.
Which consistent approach would the nurse use for a client diagnosed with an antisocial personality disorder?
Warm and firm without being punitive
