NCLEX 10000 Psychosocial Integrity Exam Study
Guide With Complete Solutions
A client with bulimia binges twice a day. The nurse interprets these binges as most likely
involving which of the following for the client? - ANSWER Feeling out of control and
disgusted with self.
For the client with bulimia, binges involve a loss of control that results in thoughts of
self-deprecation. Binges may reduce the feelings of anxiety felt before the bingeing
behavior.
The nurse is caring for a client on the psychiatric unit. The client states, "The voices are
bothering me. They are yelling and telling me stuff. They are really bad." Which of the
following responses by the nurse would be most appropriate? - ANSWER "I do not hear
any voices. What are you hearing?"
A hallucination is a false sensory perception. It involves all five senses and bodily
sensations. Initially, the nurse needs to assess what kind of voices are being heard. That
is, are they friendly, commanding, or controlling voices? Acknowledging that the client
is experiencing the voices but telling the client that the nurse does not may assist the
client to realize that the voices are not real.
A college foreign exchange student is living with a family in England and is confused
about the family's Catholic prayers and rituals. The student longs for her Protestant
practices and reports to the campus nurse for direction. The nurse recognizes the
student is experiencing which type of spiritual distress? - ANSWER Spiritual alienation
Spiritual alienation occurs when an individual is separated from her/his faith community.
On entering the room of a client who has undergone a dilatation and curettage (D&C;)
for a spontaneous abortion, the nurse finds the client crying. Which comment by the
nurse would be most appropriate? - ANSWER "I am truly sorry you lost your baby."
The death of a fetus at any time during pregnancy is a tragedy for most parents. After a
spontaneous abortion, the client and family members can be expected to suffer from
grief for several months or longer. When offering support, a simple statement such as "I
am truly sorry you lost your baby" is most appropriate. Therapeutic communication
techniques help the client and family understand the meaning of the loss, move less
stressfully through the grief process, and share feelings.
, The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent
from a health care provider's office. The client reports a decrease in fetal movement
over the past 24 hours. The nurse documents the above nursing note. Which nursing
statement is appropriate at this time? - ANSWER "I will check with the health care
provider to see if further tests are needed."
At this time, fetal demise is anticipated due to a lack of fetal heart rate and movement.
An ultrasound may be ordered to confirm status.
A nurse manager observes bruises in the shape of finger marks around the elbows of an
elderly, immobile client. The nurse should next: - ANSWER Report this finding to the
Adult Protective Services (APS).
Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for
falls or bumps should be reported to the APS. The location and shape of this bruise are
suggestive of abuse.
Parents report that their daughter, age 4, resists going to bed at night. After instruction
by the nurse, which statement by the parents indicates effective teaching? - ANSWER
"We'll read her a story and let her play quietly in her bed until she falls asleep."
The parents stating that they'll read the child a story and let her play quietly
demonstrates effective teaching because spending time with the parents and playing
quietly are positive bedtime routines that provide security and prepare a child for sleep.
A nurse caring for a client with schizophrenia goes into the client's room to administer
medication. While looking out the window at the trees, the client remarks, "That school
across the street has creatures in it that are waiting for me." Which of the following is
the most appropriate response by the nurse? - ANSWER "How do you feel when you see
the creatures?"
The most appropriate response by the nurse is "How do you feel when you see the
creatures?" The client is experiencing a delusion, a false belief that has no basis in
reality. When the client experiences a delusion, it is important to acknowledge the
delusion and to ask the client to describe it and how it makes them feel. These actions
help identify the type of delusions so that the correct intervention can be implemented
while establishing trust. If asked, the nurse should point out that they are not
experiencing the same stimuli but should not argue with the client
Guide With Complete Solutions
A client with bulimia binges twice a day. The nurse interprets these binges as most likely
involving which of the following for the client? - ANSWER Feeling out of control and
disgusted with self.
For the client with bulimia, binges involve a loss of control that results in thoughts of
self-deprecation. Binges may reduce the feelings of anxiety felt before the bingeing
behavior.
The nurse is caring for a client on the psychiatric unit. The client states, "The voices are
bothering me. They are yelling and telling me stuff. They are really bad." Which of the
following responses by the nurse would be most appropriate? - ANSWER "I do not hear
any voices. What are you hearing?"
A hallucination is a false sensory perception. It involves all five senses and bodily
sensations. Initially, the nurse needs to assess what kind of voices are being heard. That
is, are they friendly, commanding, or controlling voices? Acknowledging that the client
is experiencing the voices but telling the client that the nurse does not may assist the
client to realize that the voices are not real.
A college foreign exchange student is living with a family in England and is confused
about the family's Catholic prayers and rituals. The student longs for her Protestant
practices and reports to the campus nurse for direction. The nurse recognizes the
student is experiencing which type of spiritual distress? - ANSWER Spiritual alienation
Spiritual alienation occurs when an individual is separated from her/his faith community.
On entering the room of a client who has undergone a dilatation and curettage (D&C;)
for a spontaneous abortion, the nurse finds the client crying. Which comment by the
nurse would be most appropriate? - ANSWER "I am truly sorry you lost your baby."
The death of a fetus at any time during pregnancy is a tragedy for most parents. After a
spontaneous abortion, the client and family members can be expected to suffer from
grief for several months or longer. When offering support, a simple statement such as "I
am truly sorry you lost your baby" is most appropriate. Therapeutic communication
techniques help the client and family understand the meaning of the loss, move less
stressfully through the grief process, and share feelings.
, The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent
from a health care provider's office. The client reports a decrease in fetal movement
over the past 24 hours. The nurse documents the above nursing note. Which nursing
statement is appropriate at this time? - ANSWER "I will check with the health care
provider to see if further tests are needed."
At this time, fetal demise is anticipated due to a lack of fetal heart rate and movement.
An ultrasound may be ordered to confirm status.
A nurse manager observes bruises in the shape of finger marks around the elbows of an
elderly, immobile client. The nurse should next: - ANSWER Report this finding to the
Adult Protective Services (APS).
Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for
falls or bumps should be reported to the APS. The location and shape of this bruise are
suggestive of abuse.
Parents report that their daughter, age 4, resists going to bed at night. After instruction
by the nurse, which statement by the parents indicates effective teaching? - ANSWER
"We'll read her a story and let her play quietly in her bed until she falls asleep."
The parents stating that they'll read the child a story and let her play quietly
demonstrates effective teaching because spending time with the parents and playing
quietly are positive bedtime routines that provide security and prepare a child for sleep.
A nurse caring for a client with schizophrenia goes into the client's room to administer
medication. While looking out the window at the trees, the client remarks, "That school
across the street has creatures in it that are waiting for me." Which of the following is
the most appropriate response by the nurse? - ANSWER "How do you feel when you see
the creatures?"
The most appropriate response by the nurse is "How do you feel when you see the
creatures?" The client is experiencing a delusion, a false belief that has no basis in
reality. When the client experiences a delusion, it is important to acknowledge the
delusion and to ask the client to describe it and how it makes them feel. These actions
help identify the type of delusions so that the correct intervention can be implemented
while establishing trust. If asked, the nurse should point out that they are not
experiencing the same stimuli but should not argue with the client
