NCLEX RN Psychosocial Integrity
Practice Exam 5 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1. A 32-year-old female client with a diagnosis of borderline personality disorder
is admitted to the psychiatric unit following a suicide attempt. The client has a
history of self-mutilation and unstable relationships. Which nursing intervention
should take priority during the first 24 hours of admission?
A. Establish a therapeutic relationship with the client
B. Maintain close observation and provide a safe environment
C. Encourage the client to express feelings about the suicide attempt
D. Administer prescribed antipsychotic medications
Answer: B. Maintain close observation and provide a safe environment
Rationale: The priority intervention for a client with borderline personality
disorder who has attempted suicide is to maintain close observation and ensure
client safety. Safety is always the primary concern in psychiatric nursing,
particularly during the acute phase following a suicide attempt. While
establishing a therapeutic relationship, encouraging expression of feelings, and
administering medications are all important aspects of care, they are secondary
to maintaining client safety. Clients with borderline personality disorder often
engage in impulsive, self-destructive behaviors, making close observation
essential to prevent further self-harm. Environmental safety measures should
include removing potentially harmful objects, frequent checks, and possibly one-
to-one observation to ensure the client does not attempt suicide again. This
,priority aligns with Maslow's hierarchy of needs, where physiological safety
needs must be met before higher-level needs can be addressed.
2. A 45-year-old male client with major depressive disorder has been prescribed
sertraline 50 mg daily. The client reports experiencing insomnia since starting
the medication. Which response by the nurse is most appropriate?
A. "You should stop taking the medication immediately and contact your provider"
B. "Insomnia is a common side effect that may improve with time; consider taking
the medication in the morning"
C. "Let's increase your dose to help with the insomnia"
D. "I will contact your provider to prescribe a sleeping aid"
Answer: B. "Insomnia is a common side effect that may improve with time;
consider taking the medication in the morning"
Rationale: Sertraline is a selective serotonin reuptake inhibitor (SSRI) commonly
prescribed for major depressive disorder. Insomnia is a well-documented side
effect of SSRIs, particularly when taken at bedtime. The most appropriate
nursing response is to educate the client about the side effect and suggest taking
the medication in the morning to minimize sleep disruption. This side effect often
diminishes after the first few weeks of treatment as the body adjusts to the
medication. It is important not to advise abrupt discontinuation of the
medication, as this can lead to withdrawal symptoms and worsening of
depression. Increasing the dose without provider consultation is unsafe and may
exacerbate side effects. While a sleeping aid might be considered, it should be
discussed with the provider after exploring less invasive options. The nurse
should provide reassurance, education, and practical strategies to manage side
effects while maintaining medication adherence.
3. A 28-year-old female client with generalized anxiety disorder is experiencing a
panic attack in the emergency department. The client is hyperventilating,
,trembling, and stating, "I think I'm dying." Which nursing intervention should
the nurse implement first?
A. Administer diazepam 5 mg intravenously
B. Encourage the client to breathe slowly into a paper bag
C. Stay with the client and use a calm, reassuring voice
D. Place the client in a supine position with legs elevated
Answer: C. Stay with the client and use a calm, reassuring voice
Rationale: During a panic attack, the priority nursing intervention is to provide a
calm, reassuring presence. The client's perception of dying and losing control
requires immediate therapeutic presence to establish a sense of safety and trust.
Staying with the client reduces feelings of abandonment and fear, which are
common during panic attacks. A calm, soothing voice helps to reduce the client's
anxiety and provides grounding. Although administering medication,
encouraging slow breathing, and positioning may be appropriate interventions,
they are secondary to establishing a therapeutic presence. Slow breathing with
a paper bag is not recommended as a first-line intervention because it can lead
to carbon dioxide retention and worsen symptoms. Administering medication
requires a provider's order and should be part of a comprehensive treatment
plan. A calming presence helps regulate the client's emotional state and
provides the foundation for implementing other interventions.
4. A 60-year-old male client with Alzheimer's disease is admitted to the medical-
surgical unit for treatment of pneumonia. The client becomes increasingly
agitated and attempts to pull out his intravenous line. Which nursing
intervention is most appropriate?
A. Apply soft wrist restraints to prevent the client from pulling out the IV
B. Redirect the client's attention to a familiar object and provide reassurance
C. Administer a dose of haloperidol as ordered for agitation
D. Leave the client in a quiet room to calm down
, Answer: B. Redirect the client's attention to a familiar object and provide
reassurance
Rationale: For clients with Alzheimer's disease experiencing agitation,
redirection and reassurance are the most appropriate initial interventions.
Redirecting attention to familiar objects or activities can help distract the client
from the source of agitation and reduce anxiety. Reassurance provides
emotional support and validates the client's feelings without confrontation.
Restraints should be avoided unless absolutely necessary and should only be
used as a last resort when all other interventions have failed and the client
poses an immediate threat to self or others. Restraints can increase agitation
and cause injury. While haloperidol may be prescribed for severe agitation,
medications should not be the first-line intervention and should be used
cautiously in elderly clients due to increased risk of adverse effects. Leaving the
client alone could increase fear and confusion, potentially worsening the
agitation. The focus should be on maintaining a calm environment and using
nonpharmacological interventions.
5. A 25-year-old female client with anorexia nervosa is admitted to the eating
disorders unit. The client weighs 85 pounds and refuses to eat meals with other
clients. Which nursing intervention is most appropriate?
A. Allow the client to eat alone in her room to reduce anxiety
B. Sit with the client during meals and encourage eating
C. Provide the client with a high-calorie supplement instead of meals
D. Withhold privileges until the client eats with the group
Answer: B. Sit with the client during meals and encourage eating
Rationale: For clients with anorexia nervosa, providing support and supervision
during meals is essential. Sitting with the client during meals offers emotional
support, reduces anxiety, and ensures the client consumes adequate nutrition.
Eating disorders are complex conditions that require therapeutic support to
address underlying fears and behaviors. Allowing the client to eat alone may
Practice Exam 5 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A 32-year-old female client with a diagnosis of borderline personality disorder
is admitted to the psychiatric unit following a suicide attempt. The client has a
history of self-mutilation and unstable relationships. Which nursing intervention
should take priority during the first 24 hours of admission?
A. Establish a therapeutic relationship with the client
B. Maintain close observation and provide a safe environment
C. Encourage the client to express feelings about the suicide attempt
D. Administer prescribed antipsychotic medications
Answer: B. Maintain close observation and provide a safe environment
Rationale: The priority intervention for a client with borderline personality
disorder who has attempted suicide is to maintain close observation and ensure
client safety. Safety is always the primary concern in psychiatric nursing,
particularly during the acute phase following a suicide attempt. While
establishing a therapeutic relationship, encouraging expression of feelings, and
administering medications are all important aspects of care, they are secondary
to maintaining client safety. Clients with borderline personality disorder often
engage in impulsive, self-destructive behaviors, making close observation
essential to prevent further self-harm. Environmental safety measures should
include removing potentially harmful objects, frequent checks, and possibly one-
to-one observation to ensure the client does not attempt suicide again. This
,priority aligns with Maslow's hierarchy of needs, where physiological safety
needs must be met before higher-level needs can be addressed.
2. A 45-year-old male client with major depressive disorder has been prescribed
sertraline 50 mg daily. The client reports experiencing insomnia since starting
the medication. Which response by the nurse is most appropriate?
A. "You should stop taking the medication immediately and contact your provider"
B. "Insomnia is a common side effect that may improve with time; consider taking
the medication in the morning"
C. "Let's increase your dose to help with the insomnia"
D. "I will contact your provider to prescribe a sleeping aid"
Answer: B. "Insomnia is a common side effect that may improve with time;
consider taking the medication in the morning"
Rationale: Sertraline is a selective serotonin reuptake inhibitor (SSRI) commonly
prescribed for major depressive disorder. Insomnia is a well-documented side
effect of SSRIs, particularly when taken at bedtime. The most appropriate
nursing response is to educate the client about the side effect and suggest taking
the medication in the morning to minimize sleep disruption. This side effect often
diminishes after the first few weeks of treatment as the body adjusts to the
medication. It is important not to advise abrupt discontinuation of the
medication, as this can lead to withdrawal symptoms and worsening of
depression. Increasing the dose without provider consultation is unsafe and may
exacerbate side effects. While a sleeping aid might be considered, it should be
discussed with the provider after exploring less invasive options. The nurse
should provide reassurance, education, and practical strategies to manage side
effects while maintaining medication adherence.
3. A 28-year-old female client with generalized anxiety disorder is experiencing a
panic attack in the emergency department. The client is hyperventilating,
,trembling, and stating, "I think I'm dying." Which nursing intervention should
the nurse implement first?
A. Administer diazepam 5 mg intravenously
B. Encourage the client to breathe slowly into a paper bag
C. Stay with the client and use a calm, reassuring voice
D. Place the client in a supine position with legs elevated
Answer: C. Stay with the client and use a calm, reassuring voice
Rationale: During a panic attack, the priority nursing intervention is to provide a
calm, reassuring presence. The client's perception of dying and losing control
requires immediate therapeutic presence to establish a sense of safety and trust.
Staying with the client reduces feelings of abandonment and fear, which are
common during panic attacks. A calm, soothing voice helps to reduce the client's
anxiety and provides grounding. Although administering medication,
encouraging slow breathing, and positioning may be appropriate interventions,
they are secondary to establishing a therapeutic presence. Slow breathing with
a paper bag is not recommended as a first-line intervention because it can lead
to carbon dioxide retention and worsen symptoms. Administering medication
requires a provider's order and should be part of a comprehensive treatment
plan. A calming presence helps regulate the client's emotional state and
provides the foundation for implementing other interventions.
4. A 60-year-old male client with Alzheimer's disease is admitted to the medical-
surgical unit for treatment of pneumonia. The client becomes increasingly
agitated and attempts to pull out his intravenous line. Which nursing
intervention is most appropriate?
A. Apply soft wrist restraints to prevent the client from pulling out the IV
B. Redirect the client's attention to a familiar object and provide reassurance
C. Administer a dose of haloperidol as ordered for agitation
D. Leave the client in a quiet room to calm down
, Answer: B. Redirect the client's attention to a familiar object and provide
reassurance
Rationale: For clients with Alzheimer's disease experiencing agitation,
redirection and reassurance are the most appropriate initial interventions.
Redirecting attention to familiar objects or activities can help distract the client
from the source of agitation and reduce anxiety. Reassurance provides
emotional support and validates the client's feelings without confrontation.
Restraints should be avoided unless absolutely necessary and should only be
used as a last resort when all other interventions have failed and the client
poses an immediate threat to self or others. Restraints can increase agitation
and cause injury. While haloperidol may be prescribed for severe agitation,
medications should not be the first-line intervention and should be used
cautiously in elderly clients due to increased risk of adverse effects. Leaving the
client alone could increase fear and confusion, potentially worsening the
agitation. The focus should be on maintaining a calm environment and using
nonpharmacological interventions.
5. A 25-year-old female client with anorexia nervosa is admitted to the eating
disorders unit. The client weighs 85 pounds and refuses to eat meals with other
clients. Which nursing intervention is most appropriate?
A. Allow the client to eat alone in her room to reduce anxiety
B. Sit with the client during meals and encourage eating
C. Provide the client with a high-calorie supplement instead of meals
D. Withhold privileges until the client eats with the group
Answer: B. Sit with the client during meals and encourage eating
Rationale: For clients with anorexia nervosa, providing support and supervision
during meals is essential. Sitting with the client during meals offers emotional
support, reduces anxiety, and ensures the client consumes adequate nutrition.
Eating disorders are complex conditions that require therapeutic support to
address underlying fears and behaviors. Allowing the client to eat alone may
