NCSBN - National Council of State Boards of Nursing Psychosocial Integrity Questions and Answers

Question 1

A nurse is caring for a client with schizophrenia who states, 'The aliens are sending me messages through the television and they want to take me away.' Which of the following responses by the nurse is most therapeutic?

Accepted Answer

"That sounds very frightening. Let's turn off the TV and we can talk about how you're feeling."

Answer

"There are no aliens. You are safe here in the hospital and we are not going to let anyone take you away."

Answer

"Why do you think the aliens are trying to send you messages through the television?"

Answer

"I don't hear any messages from the television. Let's go play a game of cards."

Question 2

A client is admitted to the medical-surgical unit for a cholecystectomy. The client has a history of heavy alcohol use and the last drink was 24 hours ago. The nurse should prioritize monitoring for which of the following signs of alcohol withdrawal?

Accepted Answer

Tachycardia, tremors, and diaphoresis

Answer

Bradycardia and somnolence

Answer

Hypotension and bradypnea

Answer

Constricted pupils and euphoria

Question 3

A client who was recently diagnosed with type 2 diabetes mellitus states, 'There's no way I have diabetes. The lab must have made a mistake with my blood work. I feel perfectly fine.' The nurse recognizes the client is using which defense mechanism?

Accepted Answer

Denial

Answer

Projection

Answer

Rationalization

Answer

Sublimation

Question 4

A nurse is caring for the family of a client who has just died. The client's spouse states, 'If only I had made him go to the doctor sooner, this wouldn't have happened. Maybe if we pray hard enough, God will give us a second chance.' This statement is characteristic of which stage of grief?

Accepted Answer

Bargaining

Answer

Denial

Answer

Anger

Answer

Depression

Question 5

An adult client who is a Jehovah's Witness has been in a motor vehicle accident and requires emergency surgery for internal bleeding. The client is alert and oriented and has a signed advance directive refusing all blood products. Which action should the nurse take?

Accepted Answer

Advocate for the client's wishes and explore bloodless alternative treatments with the healthcare team.

Answer

Inform the surgeon to proceed with the transfusion because it is a life-threatening emergency.

Answer

Contact the hospital's ethics committee to get an order to override the client's refusal.

Answer

Explain to the client that a court order will be obtained to administer the necessary blood.

Question 6

A client is admitted to the inpatient psychiatric unit with severe anxiety. The client is pacing the hallway and wringing their hands. Which initial action by the nurse is most appropriate?

Accepted Answer

Acknowledge the behavior and ask about the client's feelings.

Answer

Tell the client to sit down and try to relax.

Answer

Administer a prescribed PRN anxiolytic medication immediately.

Answer

Encourage the client to participate in a quiet group activity.