NCLEX RN Psychosocial Integrity Exam 2
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a client who has been diagnosed with major depressive
disorder and is experiencing anhedonia. Which of the following statements
by the client best indicates a positive response to the antidepressant
therapy?
A. "I am sleeping for about 10 hours every night."
B. "I have started to look forward to my granddaughter's visit next week."
C. "I still don't feel like eating much, but I am forcing myself to drink water."
D. "I feel like I can’t get out of bed in the morning."
Answer: B
Rationale: Anhedonia is the inability to experience pleasure in previously
enjoyable activities. The client stating they are looking forward to a visit
indicates a return of the capacity to anticipate pleasure, which is a key clinical
indicator of improvement. Option A focuses on sleep, which may be a symptom
or a side effect, not directly addressing pleasure. Option C addresses a basic
physiological need but not hedonic tone. Option D indicates persistent
psychomotor retardation and lack of motivation, suggesting no improvement.
2. A client with borderline personality disorder is frequently manipulative and
attempts to split the staff. The nurse manager is teaching a newly hired
nurse about how to handle this behavior. Which statement by the new
nurse indicates a need for further teaching?
A. "I will ensure that I communicate with the rest of the team about the client's
behavior."
,B. "I need to be aware of my own emotional reactions to the client's attempts to
provoke me."
C. "I will agree to the client's request to change the schedule just this once to help
them feel safe."
D. "I will maintain clear, consistent boundaries with this client."
Answer: C
Rationale: Agreeing to change the schedule for a manipulative client reinforces
splitting behavior and rewards maladaptive attempts to control the
environment. This undermines the therapeutic milieu and establishes
inconsistent boundaries. Options A, B, and D are all appropriate interventions.
Consistent communication among staff prevents splitting, self-awareness
prevents countertransference, and clear boundaries provide the structure
necessary for clients with borderline personality disorder.
3. A client with a history of alcohol use disorder is admitted to the medical
unit with a blood alcohol level of 0.40%. The nurse is monitoring the client
for withdrawal symptoms. Which clinical manifestation would the nurse
expect to observe approximately 6 to 12 hours after the last drink?
A. Bradycardia and hypotension.
B. Lethargy and unresponsiveness.
C. Tachycardia and fine tremors.
D. Grand mal seizures.
Answer: C
Rationale: Alcohol withdrawal syndrome typically begins 6 to 12 hours after the
last drink. Early symptoms include autonomic hyperactivity, which presents as
tachycardia, hypertension, diaphoresis, tremors, and anxiety. Option A describes
symptoms of alcohol intoxication or severe central nervous system depression.
Option B is more consistent with a sedative effect rather than withdrawal.
Option D (grand mal seizures) typically occur later, around 12 to 24 hours after
cessation, although they can occur early.
, 4. A nurse is conducting a crisis intervention session with a client who just
experienced a traumatic loss of their home in a fire. The client is crying
uncontrollably and unable to focus. What is the nurse's priority action?
A. Encourage the client to explore their feelings about the loss in depth.
B. Provide simple, concrete instructions and ensure physical safety.
C. Administer a PRN anti-anxiety medication as prescribed.
D. Ask the client to identify the specific triggers that led to the crisis.
Answer: B
Rationale: In the initial phase of a crisis, the client is overwhelmed and
disorganized. The priority is to ensure safety and provide structure to reduce
anxiety. Simple, concrete instructions help the client re-establish a sense of
control. Option A is appropriate later in the stabilization phase, but during the
acute phase, deep exploration may increase anxiety. Option C may be necessary,
but it is not the priority intervention. Option D is cognitive and requires a level of
focus the client does not currently possess.
5. A client is diagnosed with schizophrenia and is experiencing command
hallucinations that tell him to hit a staff member. The client states, "The
voices are telling me I am a bad person." Which response by the nurse is
the most therapeutic?
A. "I know you are not a bad person. You are a good person."
B. "I do not hear the voices, but I can see that they are distressing to you."
C. "You must ignore the voices. They are not real."
D. "Why do you think the voices are telling you that?"
Answer: B
Rationale: Acknowledging the client's perception without challenging or
validating the hallucination is a therapeutic technique. This response validates
the client's distress while reality-testing by stating the nurse's own perception.
Option A is a platitude and may feel dismissive to the client. Option C dismisses
the client's experience and is not therapeutic. Option D is a "why" question,
, which can be perceived as interrogative and is generally avoided in psychiatric
nursing.
6. The nurse is caring for a 78-year-old client who was admitted after a fall.
The client's daughter confides that she feels overwhelmed and is
considering placing her mother in a nursing home. The nurse's best
response is:
A. "You should do what is best for your mother, even if it feels difficult."
B. "It is important to keep your mother at home for as long as possible."
C. "Tell me more about the challenges you are facing in caring for your mother."
D. "Have you looked into assisted living facilities instead?"
Answer: C
Rationale: This response uses a therapeutic communication technique of offering
broad openings to encourage the daughter to express her feelings and explore
her burden. This supports the family member's emotional needs. Option A is
directive and dismissive. Option B imposes the nurse's values. Option D offers
premature advice before fully assessing the situation and the daughter's
emotional state.
7. A client with post-traumatic stress disorder (PTSD) is attending group
therapy. The nurse notices the client becomes hypervigilant and starts
pacing when another group member discusses a violent incident. Which
nursing action is indicated first?
A. Remind the client of the group rules regarding appropriate behavior.
B. Privately ask the client if they need to step out of the group for a few minutes.
C. Redirect the group discussion to a less triggering topic.
D. Administer a PRN dose of a sedative to the client.
Answer: B
Rationale: The first action is to assess the client's immediate safety and level of
distress. Offering the client a choice to step out gives them a sense of control
over their environment and removes them from the triggering stimulus. Option
A is punitive and not therapeutic. Option C may be helpful but does not address
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a client who has been diagnosed with major depressive
disorder and is experiencing anhedonia. Which of the following statements
by the client best indicates a positive response to the antidepressant
therapy?
A. "I am sleeping for about 10 hours every night."
B. "I have started to look forward to my granddaughter's visit next week."
C. "I still don't feel like eating much, but I am forcing myself to drink water."
D. "I feel like I can’t get out of bed in the morning."
Answer: B
Rationale: Anhedonia is the inability to experience pleasure in previously
enjoyable activities. The client stating they are looking forward to a visit
indicates a return of the capacity to anticipate pleasure, which is a key clinical
indicator of improvement. Option A focuses on sleep, which may be a symptom
or a side effect, not directly addressing pleasure. Option C addresses a basic
physiological need but not hedonic tone. Option D indicates persistent
psychomotor retardation and lack of motivation, suggesting no improvement.
2. A client with borderline personality disorder is frequently manipulative and
attempts to split the staff. The nurse manager is teaching a newly hired
nurse about how to handle this behavior. Which statement by the new
nurse indicates a need for further teaching?
A. "I will ensure that I communicate with the rest of the team about the client's
behavior."
,B. "I need to be aware of my own emotional reactions to the client's attempts to
provoke me."
C. "I will agree to the client's request to change the schedule just this once to help
them feel safe."
D. "I will maintain clear, consistent boundaries with this client."
Answer: C
Rationale: Agreeing to change the schedule for a manipulative client reinforces
splitting behavior and rewards maladaptive attempts to control the
environment. This undermines the therapeutic milieu and establishes
inconsistent boundaries. Options A, B, and D are all appropriate interventions.
Consistent communication among staff prevents splitting, self-awareness
prevents countertransference, and clear boundaries provide the structure
necessary for clients with borderline personality disorder.
3. A client with a history of alcohol use disorder is admitted to the medical
unit with a blood alcohol level of 0.40%. The nurse is monitoring the client
for withdrawal symptoms. Which clinical manifestation would the nurse
expect to observe approximately 6 to 12 hours after the last drink?
A. Bradycardia and hypotension.
B. Lethargy and unresponsiveness.
C. Tachycardia and fine tremors.
D. Grand mal seizures.
Answer: C
Rationale: Alcohol withdrawal syndrome typically begins 6 to 12 hours after the
last drink. Early symptoms include autonomic hyperactivity, which presents as
tachycardia, hypertension, diaphoresis, tremors, and anxiety. Option A describes
symptoms of alcohol intoxication or severe central nervous system depression.
Option B is more consistent with a sedative effect rather than withdrawal.
Option D (grand mal seizures) typically occur later, around 12 to 24 hours after
cessation, although they can occur early.
, 4. A nurse is conducting a crisis intervention session with a client who just
experienced a traumatic loss of their home in a fire. The client is crying
uncontrollably and unable to focus. What is the nurse's priority action?
A. Encourage the client to explore their feelings about the loss in depth.
B. Provide simple, concrete instructions and ensure physical safety.
C. Administer a PRN anti-anxiety medication as prescribed.
D. Ask the client to identify the specific triggers that led to the crisis.
Answer: B
Rationale: In the initial phase of a crisis, the client is overwhelmed and
disorganized. The priority is to ensure safety and provide structure to reduce
anxiety. Simple, concrete instructions help the client re-establish a sense of
control. Option A is appropriate later in the stabilization phase, but during the
acute phase, deep exploration may increase anxiety. Option C may be necessary,
but it is not the priority intervention. Option D is cognitive and requires a level of
focus the client does not currently possess.
5. A client is diagnosed with schizophrenia and is experiencing command
hallucinations that tell him to hit a staff member. The client states, "The
voices are telling me I am a bad person." Which response by the nurse is
the most therapeutic?
A. "I know you are not a bad person. You are a good person."
B. "I do not hear the voices, but I can see that they are distressing to you."
C. "You must ignore the voices. They are not real."
D. "Why do you think the voices are telling you that?"
Answer: B
Rationale: Acknowledging the client's perception without challenging or
validating the hallucination is a therapeutic technique. This response validates
the client's distress while reality-testing by stating the nurse's own perception.
Option A is a platitude and may feel dismissive to the client. Option C dismisses
the client's experience and is not therapeutic. Option D is a "why" question,
, which can be perceived as interrogative and is generally avoided in psychiatric
nursing.
6. The nurse is caring for a 78-year-old client who was admitted after a fall.
The client's daughter confides that she feels overwhelmed and is
considering placing her mother in a nursing home. The nurse's best
response is:
A. "You should do what is best for your mother, even if it feels difficult."
B. "It is important to keep your mother at home for as long as possible."
C. "Tell me more about the challenges you are facing in caring for your mother."
D. "Have you looked into assisted living facilities instead?"
Answer: C
Rationale: This response uses a therapeutic communication technique of offering
broad openings to encourage the daughter to express her feelings and explore
her burden. This supports the family member's emotional needs. Option A is
directive and dismissive. Option B imposes the nurse's values. Option D offers
premature advice before fully assessing the situation and the daughter's
emotional state.
7. A client with post-traumatic stress disorder (PTSD) is attending group
therapy. The nurse notices the client becomes hypervigilant and starts
pacing when another group member discusses a violent incident. Which
nursing action is indicated first?
A. Remind the client of the group rules regarding appropriate behavior.
B. Privately ask the client if they need to step out of the group for a few minutes.
C. Redirect the group discussion to a less triggering topic.
D. Administer a PRN dose of a sedative to the client.
Answer: B
Rationale: The first action is to assess the client's immediate safety and level of
distress. Offering the client a choice to step out gives them a sense of control
over their environment and removes them from the triggering stimulus. Option
A is punitive and not therapeutic. Option C may be helpful but does not address
