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

The most therapeutic response is to acknowledge the client's feelings and fear associated with the delusion without reinforcing or arguing about the delusion itself. This approach validates the client's experience while gently redirecting them to reality and offering support. Challenging the delusion (B) is ineffective and can damage the therapeutic relationship. Asking 'why' (C) can reinforce the delusional thought process. Dismissing the client's experience and changing the subject (D) invalidates their feelings.

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

Signs of early to moderate alcohol withdrawal include autonomic hyperactivity such as tachycardia, tremors, anxiety, and diaphoresis (sweating). These symptoms can begin within hours of the last drink. Bradycardia, somnolence, hypotension, and bradypnea are more indicative of central nervous system depression, not withdrawal. Constricted pupils and euphoria are associated with opioid use, not alcohol withdrawal.

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

Denial is the refusal to accept reality or facts to avoid dealing with the emotional impact. The client is refusing to accept the diagnosis despite evidence. Projection is attributing one's own unacceptable thoughts to another person. Rationalization is justifying behavior with logical-sounding reasons. Sublimation is channeling unacceptable impulses into socially acceptable actions.

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

The spouse's statements, 'If only...' and hoping for a second chance in exchange for prayer, are classic examples of bargaining. In this stage, the individual may try to make deals with a higher power to postpone the inevitable and change the reality of the loss. Denial would be an outright refusal to accept the death. Anger would involve directing frustration at others. Depression is characterized by sadness and hopelessness.

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

A mentally competent adult has the legal and ethical right to refuse medical treatment, including life-saving blood transfusions, based on their religious beliefs. The nurse's primary role is to act as a patient advocate, respecting their autonomy and communicating their wishes to the team. The team should then explore all available bloodless alternatives, such as volume expanders or cell-saver technology. Overriding a competent adult's wishes is a violation of their rights.

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Practice Test

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