NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023

NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023 Psychosocial Integrity Practice Questions 1. Which couple is at greatest risk for domestic violence? A. A couple which consists of a husband and wife both of whom are affected with Alzheimer’s disease B. A poverty stricken couple without any healthcare resources in the community C. A pregnant woman and a husband who was physically abused as a young child D. A wealthy couple with feelings that they are immune from punishment and above the law Correct Response: C A pregnant woman and a husband who was physically abused as a young child is the couple is at most risk for domestic violence because pregnancy and a personal prior history of abuse are two commonly occurring risk factors among abused woman and male abusers, respectively. Current research indicates that abuse and neglect affect all people of all ages and of all socioeconomic classes including the wealthy as well as the poverty stricken. Other patient populations at risk of abuse and neglect include female gender, infants, children, the cognitively impaired, the developmentally challenged, the elderly and those with physical or mental disabilities; some of the other traits and characteristics associated with abusers include substance related use and abuse, a psychiatric mental health disorder, poor parenting skills, poor anger management skills, poor self-esteem, poor coping skills, poor impulse control, immaturity, and the presence of a current crisis. 2. You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client’s past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others? A. Restrain the client B. Place the client in seclusion C. Get an order for a sedating medication D. Establish trust with the client. Correct Response: D The first thing that you should do to prevent violence towards others is to establish trust with the client. The first step in the nurse-client relationship is to establish trust in this therapeutic relationship. Without trust future collaboration, interventions and client outcomes cannot be accomplished to facilitate appropriate and safe behaviors. Restraints and seclusion are not indicated until others are in imminent danger because of this client’s current violent behaviors and not a history of it. Lastly, sedating medications to prevent violence are also not the first things that are done. 3. You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they “suffer and feel lousy” when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client? A. Psychological dependence secondary to amphetamine use B. Substance abuse secondary to amphetamine use C. Addiction secondary to amphetamine use D. Physical dependence secondary to amphetamine use Correct Response: A The appropriate nursing diagnosis for this client is “Psychological dependence secondary to amphetamine use”. Psychological dependence is defined as the person’s need to continue the use of the substance to avoid any unpleasant feelings and experiences that can occur when the substance is not taken. Amphetamines and hallucinogenic drugs like LSD are often associated with psychological dependence. Substance abuse, simply defined, is one’s overindulgence of an addictive substance which can be alcohol, prescription drugs and/or illicit, illegal drugs. Substance abuse does not include prescribed medications, such as narcotic pain medications, that are being used for medical reasons; however, these same medications when used after there is no longer a medical need to use them is considered substance abuse. Addiction is defined as the unending and constant need for the person to have the chosen substance even when the use of the substance causes the client to have serious physical, psychological, social and/or economic consequences and harm including a loss of control over the substance abuse and use. Contrary to popular opinion, addiction can occur with and without physical dependence. Physical dependence occurs when the cessation of a drug causes adverse physical effects; these ill effects are typically greater and more intense when the cessation of the drug is rapid and abrupt. Some of the drugs that are most often associated with physical dependence include cocaine, opioid drugs, alcohol and benzodiazepines. As previously stated, physical dependence does not necessarily indicate addiction; addiction can be present with or without any physical dependency. 4. You are the supervising nurse in a physical rehabilitation center that has the philosophy that clients have the need to cope with their disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives. Which model of disability is this philosophy based on? A. Orem’s Self Care Model B. Nagi's Model C. A cognitive model of disability D. A biomedical model of disability Correct Response: B Nagi’s Model of disability model describes disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives. Although clients with disabilities should be assessed and have interventions related to their self care abilities, Dorothea Orem’s Self Care Model is not a model of disability. This model describes self care needs and abilities as wholly compensatory, partly compensatory and supportive educative. Cognitive models of disability focus on the importance of affected client’s ability to remain as independent as possible and ways that the empowered client can exercise their own self-determination, confidence, self efficacy, and control. Lastly, biomedical models address pathology, impairments and the manifestations of impairments that can be cured or lead to death. 5. Place the following phases of crisis in the correct sequential order. Order each response with a number from first to last, with #1 as the first phase of crisis to #4 which is the fourth phase of crisis. 1. The signs and symptoms of the General Adaptation Syndrome 2. Detachment and disorientation 3. Trying alternative methods of coping 4. The use of psychological ego defense mechanisms A. 3,2,1,4 B. 1,2,3,4 C. 4,3,2,1 D. 4,3,1,2 Correct Response: D The characteristics of the stages or phases of crisis, in the correct sequential order, are:  Level 1 Crisis Signs and Symptoms: Patients experiencing a level one crisis typically experience anxiety and they also typically begin to use one or more psychological ego defense mechanisms.  Level 2 Crisis Signs and Symptoms: Patients experiencing a level two crisis most likely exhibit some loss of their ability to function. They may also try to experiment with alternative methods of coping in order to deal with the crisis that is not being effectively coped with using one’s currently used coping mechanisms.  Level 3 Crisis Signs and Symptoms: Patients experiencing a level three crisis show the signs and symptoms of the General Adaptation Syndrome which is characterized with fight, flight and panic as discussed above under the section entitled “Coping Mechanisms: Introduction”.  Level 4 Crisis Signs and Symptoms: Clients experiencing a level four crisis exhibit severe signs and symptoms such as being totally detached and removed from others, feeling overwhelmed, becoming disoriented, and even with thoughts of violence toward self and others. 6. Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using? A. Displacement B. Sublimation C. Dissociation D. Reaction formation Correct Response: C Dissociation is the psychological ego defense mechanism occurs when the client detaches and dissociates with person or time to avoid the stress until they are ready to cope with it. Displacement transforms the target of one’s anger and hostility from one person to another person or object. Displacement allows the person to ventilate and act out on their anger in a less harmful and a more socially acceptable manner. A client uses the ego defense mechanism of sublimation when they transform and replace unacceptable urges and feelings into a socially acceptable urge or feeling. A client is using reaction formation when the client acts and behaves in a manner that is completely the polar opposite of their true feelings. 7. You are the Assistant Director of Nursing in a multiethnical and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing mutiethnicity and the culturally diverse nature of this facility for this philosophy? A. Jean Watson's B. Martha Rogers' C. Nagi's theory D. Madeleine Leininger’s theory Correct Response: D The theoretical framework that you would recommend that this committee should consider when addressing mutiethnicity and the culturally diverse nature of this facility for this philosophy is Madeleine Leininger’s theory. Madeleine Leininger’s theory of Transcultural Nursing and her book “Culture Care Diversity and Universality: A Theory of Nursing” “searches for comprehensive and holistic care data relying on social structure, worldview, and multiple factors in a culture in order to get a holistic knowledge base about care” (Leininger, 2006, p. 219) Jean Watson’s Jean Watson developed the Human Caring Theory which states that caring is the essence of nursing. Watson's theory has the four major concepts of health, nursing, society/environment and human being. Caring consists of the following 10 nursing interventions that demonstrate genuine caring. Martha Rogers’ theory is the Science of Unitary Human Beings which is based on general systems theory without any focus on multiethnicity and cultural diversity; and lastly, Nagi’s Model of disability model describes disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives. 8. You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients? A. The client will accept impending death B. Guilt related to past transgressions C. Spiritual distress related to guilt D. Pain related to end of life symptoms Correct Response: A “The client will accept impending death” is the client goal would be the most likely appropriate and expected for the vast majority of these clients. In fact, one of the primary goals of hospice and palliative care is to facilitate the client’s and family member’s acceptance. Other goals are the freedom for guilt, spiritual distress and pain at the end of life; therefore, these diagnoses are not expected. 9. You are caring for a hospice client who is at the end of life. Based on this client’s signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client? A. The client will be free of constipation B. The client will remain free of pain and distress C. The administration of an antiemetic to prevent vomiting and further dehydration D. The administration of an enema to correct the constipation Correct Response: B Based on this client’s signs and symptoms and the fact that the client is expected to die in a day or two, the appropriate client outcome for this client is that the client will remain free of pain and distress. “The client will be free of constipation” requires interventions such as an enema which are not indicated when death is imminent unless, of course, the client is adversely affected with pain and discomfort as the result of it which is not the case with this client. Additionally, the administration of an antiemetic to prevent vomiting is not indicated because there is no evidence in this question that the client is actually vomiting