NCLEX-RN Psychosocial Integrity Exam 4
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client with major depressive disorder has been prescribed sertraline (Zoloft)
50 mg daily. The client tells the nurse, "I don't think this medication is working
because I still feel sad." Which response by the nurse is most appropriate?
A. "It takes 2 to 6 weeks for the full therapeutic effects to be seen."
B. "You should ask your healthcare provider to increase your dose."
C. "Maybe you need a different medication that works faster."
D. "You shouldn't expect to feel better for at least 3 months."
Answer: A
Rationale: Sertraline is a selective serotonin reuptake inhibitor (SSRI) that
typically requires 2 to 6 weeks of consistent use before therapeutic effects are
fully realized. The nurse should provide education about the expected timeline
for medication effectiveness to manage the client's expectations and promote
adherence. Option B is incorrect because dose adjustments should be made by
the healthcare provider after adequate evaluation. Option C is incorrect as it
suggests medication change prematurely. Option D provides inaccurate
information about the timeline.
2. A nurse is assessing a client who recently lost their spouse of 45 years. The
client states, "I keep thinking I see him in his favorite chair, and I hear his voice
sometimes." Which interpretation of this data is most accurate?
,A. The client is experiencing pathological grief requiring immediate intervention.
B. The client is exhibiting signs of a psychotic disorder.
C. The client is experiencing normal grief responses including temporary
perceptual disturbances.
D. The client needs to be evaluated for dementia.
Answer: C
Rationale: Transient perceptual disturbances such as hearing the voice or seeing
the image of a deceased loved one are common and normal experiences during
the acute grief period. These phenomena typically resolve as the grieving
process progresses and do not indicate pathology. Option A is incorrect as this
represents normal grief. Option B is incorrect because these experiences lack
other features of psychosis. Option D is incorrect as these symptoms are not
indicative of dementia.
3. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback
during a group therapy session. Which nursing action should be prioritized?
A. Tell the client to stop and focus on the present.
B. Leave the client alone to work through the flashback.
C. Use grounding techniques to help the client return to the present.
D. Administer PRN antipsychotic medication immediately.
Answer: C
Rationale: Grounding techniques are the first-line intervention for managing
flashbacks in PTSD. These techniques help the client reconnect with the present
reality by focusing on sensory information such as feeling the floor beneath their
feet, touching a textured object, or identifying objects in the room. Option A is
not therapeutic as it dismisses the client's experience. Option B is unsafe as the
client needs support during the flashback. Option D is not the priority
intervention and would require assessment before administration.
,4. A nurse is caring for a client with anorexia nervosa who refuses to eat lunch.
The client's weight is 82% of ideal body weight. Which intervention should the
nurse implement first?
A. Allow the client to skip the meal and eat at the next scheduled time.
B. Offer the client a liquid nutritional supplement as an alternative.
C. Sit with the client and provide support while encouraging them to eat.
D. Notify the healthcare provider and obtain an order for tube feeding.
Answer: C
Rationale: The initial intervention for a client with anorexia nervosa refusing a
meal is to provide therapeutic support and encouragement while remaining
with the client during the meal. This approach maintains the therapeutic
relationship and addresses the underlying anxiety about eating. Option A would
reinforce maladaptive behavior. Option B may be appropriate later but does not
address the immediate refusal. Option D is premature as the client has only
missed one meal.
5. A client diagnosed with borderline personality disorder says to the nurse,
"You're the only one here who actually cares about me. The other nurses are all
incompetent." Which nursing response is most therapeutic?
A. "Thank you for saying that. I try to be a good nurse."
B. "I think you should discuss your concerns with the charge nurse."
C. "I understand you're feeling that way, but I need to maintain professional
boundaries."
D. "Why do you think the other nurses don't care about you?"
Answer: C
Rationale: This response acknowledges the client's feelings while maintaining
appropriate therapeutic boundaries. Clients with borderline personality disorder
often engage in splitting, idealizing one staff member while devaluing others.
The nurse must avoid being drawn into this dynamic. Option A reinforces the
splitting behavior. Option B redirects the issue without addressing the
, underlying dynamic. Option D is not therapeutic as it asks "why" questions
which can be perceived as confrontational.
6. A client with schizophrenia is experiencing auditory hallucinations telling them
that they are worthless. The client appears agitated and is pacing in the day room.
What is the nurse's priority intervention?
A. Ask the client what the voices are saying.
B. Tell the client to ignore the voices and sit down.
C. Administer PRN haloperidol as ordered.
D. Provide a quiet environment and offer PRN medication if needed.
Answer: A
Rationale: The priority is to assess the content of the hallucinations to determine
if the client or others are at risk. Asking what the voices are saying provides
essential safety information and establishes therapeutic communication. Option
B dismisses the client's experience. Option C may be appropriate but only after
assessment. Option D does not address the immediate need for safety
assessment.
7. A nurse is providing education to the family of a client with Alzheimer's disease
who exhibits sundowning behavior. Which statement by the family indicates
understanding of the teaching?
A. "We should keep the evening activities exciting to keep them stimulated."
B. "We need to maintain a consistent daily routine and limit evening activities."
C. "We should wake them up if they fall asleep during the day."
D. "We should give them caffeine in the evening to keep them awake."
Answer: B
Rationale: Maintaining a consistent daily routine and limiting activities in the
evening can help reduce sundowning symptoms in clients with Alzheimer's
disease. A calm, structured environment during late afternoon and evening
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client with major depressive disorder has been prescribed sertraline (Zoloft)
50 mg daily. The client tells the nurse, "I don't think this medication is working
because I still feel sad." Which response by the nurse is most appropriate?
A. "It takes 2 to 6 weeks for the full therapeutic effects to be seen."
B. "You should ask your healthcare provider to increase your dose."
C. "Maybe you need a different medication that works faster."
D. "You shouldn't expect to feel better for at least 3 months."
Answer: A
Rationale: Sertraline is a selective serotonin reuptake inhibitor (SSRI) that
typically requires 2 to 6 weeks of consistent use before therapeutic effects are
fully realized. The nurse should provide education about the expected timeline
for medication effectiveness to manage the client's expectations and promote
adherence. Option B is incorrect because dose adjustments should be made by
the healthcare provider after adequate evaluation. Option C is incorrect as it
suggests medication change prematurely. Option D provides inaccurate
information about the timeline.
2. A nurse is assessing a client who recently lost their spouse of 45 years. The
client states, "I keep thinking I see him in his favorite chair, and I hear his voice
sometimes." Which interpretation of this data is most accurate?
,A. The client is experiencing pathological grief requiring immediate intervention.
B. The client is exhibiting signs of a psychotic disorder.
C. The client is experiencing normal grief responses including temporary
perceptual disturbances.
D. The client needs to be evaluated for dementia.
Answer: C
Rationale: Transient perceptual disturbances such as hearing the voice or seeing
the image of a deceased loved one are common and normal experiences during
the acute grief period. These phenomena typically resolve as the grieving
process progresses and do not indicate pathology. Option A is incorrect as this
represents normal grief. Option B is incorrect because these experiences lack
other features of psychosis. Option D is incorrect as these symptoms are not
indicative of dementia.
3. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback
during a group therapy session. Which nursing action should be prioritized?
A. Tell the client to stop and focus on the present.
B. Leave the client alone to work through the flashback.
C. Use grounding techniques to help the client return to the present.
D. Administer PRN antipsychotic medication immediately.
Answer: C
Rationale: Grounding techniques are the first-line intervention for managing
flashbacks in PTSD. These techniques help the client reconnect with the present
reality by focusing on sensory information such as feeling the floor beneath their
feet, touching a textured object, or identifying objects in the room. Option A is
not therapeutic as it dismisses the client's experience. Option B is unsafe as the
client needs support during the flashback. Option D is not the priority
intervention and would require assessment before administration.
,4. A nurse is caring for a client with anorexia nervosa who refuses to eat lunch.
The client's weight is 82% of ideal body weight. Which intervention should the
nurse implement first?
A. Allow the client to skip the meal and eat at the next scheduled time.
B. Offer the client a liquid nutritional supplement as an alternative.
C. Sit with the client and provide support while encouraging them to eat.
D. Notify the healthcare provider and obtain an order for tube feeding.
Answer: C
Rationale: The initial intervention for a client with anorexia nervosa refusing a
meal is to provide therapeutic support and encouragement while remaining
with the client during the meal. This approach maintains the therapeutic
relationship and addresses the underlying anxiety about eating. Option A would
reinforce maladaptive behavior. Option B may be appropriate later but does not
address the immediate refusal. Option D is premature as the client has only
missed one meal.
5. A client diagnosed with borderline personality disorder says to the nurse,
"You're the only one here who actually cares about me. The other nurses are all
incompetent." Which nursing response is most therapeutic?
A. "Thank you for saying that. I try to be a good nurse."
B. "I think you should discuss your concerns with the charge nurse."
C. "I understand you're feeling that way, but I need to maintain professional
boundaries."
D. "Why do you think the other nurses don't care about you?"
Answer: C
Rationale: This response acknowledges the client's feelings while maintaining
appropriate therapeutic boundaries. Clients with borderline personality disorder
often engage in splitting, idealizing one staff member while devaluing others.
The nurse must avoid being drawn into this dynamic. Option A reinforces the
splitting behavior. Option B redirects the issue without addressing the
, underlying dynamic. Option D is not therapeutic as it asks "why" questions
which can be perceived as confrontational.
6. A client with schizophrenia is experiencing auditory hallucinations telling them
that they are worthless. The client appears agitated and is pacing in the day room.
What is the nurse's priority intervention?
A. Ask the client what the voices are saying.
B. Tell the client to ignore the voices and sit down.
C. Administer PRN haloperidol as ordered.
D. Provide a quiet environment and offer PRN medication if needed.
Answer: A
Rationale: The priority is to assess the content of the hallucinations to determine
if the client or others are at risk. Asking what the voices are saying provides
essential safety information and establishes therapeutic communication. Option
B dismisses the client's experience. Option C may be appropriate but only after
assessment. Option D does not address the immediate need for safety
assessment.
7. A nurse is providing education to the family of a client with Alzheimer's disease
who exhibits sundowning behavior. Which statement by the family indicates
understanding of the teaching?
A. "We should keep the evening activities exciting to keep them stimulated."
B. "We need to maintain a consistent daily routine and limit evening activities."
C. "We should wake them up if they fall asleep during the day."
D. "We should give them caffeine in the evening to keep them awake."
Answer: B
Rationale: Maintaining a consistent daily routine and limiting activities in the
evening can help reduce sundowning symptoms in clients with Alzheimer's
disease. A calm, structured environment during late afternoon and evening
