NCLEX RN Psychosocial Integrity Exam
3 100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Question 1
A client with major depressive disorder tells the nurse, “My family would be
better off without me.” What is the nurse’s priority response?
A. “You should focus on the positive things in your life.”
B. “Why do you think your family would be better off without you?”
C. “Are you thinking about killing yourself?”
D. “Your family needs you.”
Answer: “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is the priority when a client
makes a statement suggesting hopelessness or perceived burdensomeness.
Asking about suicide does not increase suicidal behavior and helps determine
immediate risk.
Question 2
A client experiencing a panic attack is hyperventilating and trembling. Which
nursing action is most appropriate?
A. Encourage the client to discuss the source of the anxiety.
B. Leave the client alone in a quiet room.
C. Remain with the client and use short, simple statements.
D. Ask the client to practice complex relaxation exercises.
Answer: Remain with the client and use short, simple statements.
,Rationale: During a panic attack, the client's ability to process information is
severely reduced. Staying with the client provides safety and using simple,
brief communication helps decrease stimulation.
Question 3
A client with schizophrenia says, “The voices are telling me that the nurses are
poisoning my food.” Which response is best?
A. “The voices are not real, so you should ignore them.”
B. “I don't hear the voices, but I understand that you hear them.”
C. “The nurses would never poison your food.”
D. “Why do you think the nurses want to poison you?”
Answer: “I don't hear the voices, but I understand that you hear them.”
Rationale: The nurse should acknowledge the client's experience without
validating the hallucination. This response presents reality while recognizing
the client's perception.
Question 4
A client with bipolar disorder is experiencing acute mania and repeatedly
interrupts other clients during group therapy. Which intervention is most
appropriate?
A. Encourage participation in lengthy group discussions.
B. Establish clear, consistent limits on behavior.
C. Allow the client to continue talking until the client becomes tired.
D. Ask the client to explain why the interruptions are inappropriate.
Answer: Establish clear, consistent limits on behavior.
Rationale: Clients experiencing mania benefit from clear, concise limits and
consistent consequences. Lengthy explanations and discussions can increase
stimulation and are usually ineffective during acute mania.
,Question 5
A client with anorexia nervosa has a body mass index of 15.5 and refuses
meals. Which finding requires the most immediate intervention?
A. Lanugo
B. Amenorrhea
C. Heart rate of 42/min
D. Fear of gaining weight
Answer: Heart rate of 42/min
Rationale: Severe bradycardia can indicate significant cardiovascular
compromise associated with malnutrition and requires immediate attention.
Question 6
A client with post-traumatic stress disorder becomes distressed after hearing a
loud noise. Which nursing intervention is most appropriate?
A. Encourage the client to describe the traumatic event immediately.
B. Tell the client to stop thinking about the trauma.
C. Help the client identify grounding techniques.
D. Place the client in a stimulating group environment.
Answer: Help the client identify grounding techniques.
Rationale: Grounding techniques help clients with PTSD reconnect with the
present and reduce distress associated with trauma reminders.
Question 7
A client taking lithium for bipolar disorder reports diarrhea, vomiting, severe
tremors, and difficulty walking. What should the nurse do first?
A. Administer the next dose with food.
B. Encourage increased exercise.
C. Hold the medication and notify the provider.
D. Reassure the client that these effects are expected.
, Answer: Hold the medication and notify the provider.
Rationale: Severe gastrointestinal symptoms, coarse tremors, and ataxia
suggest lithium toxicity. The medication should be withheld and the provider
notified promptly.
Question 8
A client with obsessive-compulsive disorder spends several hours each day
washing the hands. Which nursing approach is appropriate?
A. Immediately prohibit all handwashing.
B. Ridicule the ritual to encourage insight.
C. Gradually decrease the amount of time spent performing rituals.
D. Encourage the client to perform the ritual whenever anxiety occurs.
Answer: Gradually decrease the amount of time spent performing rituals.
Rationale: Behavioral approaches may gradually reduce compulsive
behaviors while helping the client develop healthier coping mechanisms.
Abruptly preventing rituals can markedly increase anxiety.
Question 9
A client experiencing alcohol withdrawal is restless, tremulous, and
diaphoretic. Which finding is most concerning?
A. Mild nausea
B. Anxiety
C. Blood pressure of 158/92 mm Hg
D. Visual hallucinations with severe agitation
Answer: Visual hallucinations with severe agitation
Rationale: Severe agitation and hallucinations can indicate progression
toward severe alcohol withdrawal and delirium tremens, which can become
life-threatening.
3 100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Question 1
A client with major depressive disorder tells the nurse, “My family would be
better off without me.” What is the nurse’s priority response?
A. “You should focus on the positive things in your life.”
B. “Why do you think your family would be better off without you?”
C. “Are you thinking about killing yourself?”
D. “Your family needs you.”
Answer: “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is the priority when a client
makes a statement suggesting hopelessness or perceived burdensomeness.
Asking about suicide does not increase suicidal behavior and helps determine
immediate risk.
Question 2
A client experiencing a panic attack is hyperventilating and trembling. Which
nursing action is most appropriate?
A. Encourage the client to discuss the source of the anxiety.
B. Leave the client alone in a quiet room.
C. Remain with the client and use short, simple statements.
D. Ask the client to practice complex relaxation exercises.
Answer: Remain with the client and use short, simple statements.
,Rationale: During a panic attack, the client's ability to process information is
severely reduced. Staying with the client provides safety and using simple,
brief communication helps decrease stimulation.
Question 3
A client with schizophrenia says, “The voices are telling me that the nurses are
poisoning my food.” Which response is best?
A. “The voices are not real, so you should ignore them.”
B. “I don't hear the voices, but I understand that you hear them.”
C. “The nurses would never poison your food.”
D. “Why do you think the nurses want to poison you?”
Answer: “I don't hear the voices, but I understand that you hear them.”
Rationale: The nurse should acknowledge the client's experience without
validating the hallucination. This response presents reality while recognizing
the client's perception.
Question 4
A client with bipolar disorder is experiencing acute mania and repeatedly
interrupts other clients during group therapy. Which intervention is most
appropriate?
A. Encourage participation in lengthy group discussions.
B. Establish clear, consistent limits on behavior.
C. Allow the client to continue talking until the client becomes tired.
D. Ask the client to explain why the interruptions are inappropriate.
Answer: Establish clear, consistent limits on behavior.
Rationale: Clients experiencing mania benefit from clear, concise limits and
consistent consequences. Lengthy explanations and discussions can increase
stimulation and are usually ineffective during acute mania.
,Question 5
A client with anorexia nervosa has a body mass index of 15.5 and refuses
meals. Which finding requires the most immediate intervention?
A. Lanugo
B. Amenorrhea
C. Heart rate of 42/min
D. Fear of gaining weight
Answer: Heart rate of 42/min
Rationale: Severe bradycardia can indicate significant cardiovascular
compromise associated with malnutrition and requires immediate attention.
Question 6
A client with post-traumatic stress disorder becomes distressed after hearing a
loud noise. Which nursing intervention is most appropriate?
A. Encourage the client to describe the traumatic event immediately.
B. Tell the client to stop thinking about the trauma.
C. Help the client identify grounding techniques.
D. Place the client in a stimulating group environment.
Answer: Help the client identify grounding techniques.
Rationale: Grounding techniques help clients with PTSD reconnect with the
present and reduce distress associated with trauma reminders.
Question 7
A client taking lithium for bipolar disorder reports diarrhea, vomiting, severe
tremors, and difficulty walking. What should the nurse do first?
A. Administer the next dose with food.
B. Encourage increased exercise.
C. Hold the medication and notify the provider.
D. Reassure the client that these effects are expected.
, Answer: Hold the medication and notify the provider.
Rationale: Severe gastrointestinal symptoms, coarse tremors, and ataxia
suggest lithium toxicity. The medication should be withheld and the provider
notified promptly.
Question 8
A client with obsessive-compulsive disorder spends several hours each day
washing the hands. Which nursing approach is appropriate?
A. Immediately prohibit all handwashing.
B. Ridicule the ritual to encourage insight.
C. Gradually decrease the amount of time spent performing rituals.
D. Encourage the client to perform the ritual whenever anxiety occurs.
Answer: Gradually decrease the amount of time spent performing rituals.
Rationale: Behavioral approaches may gradually reduce compulsive
behaviors while helping the client develop healthier coping mechanisms.
Abruptly preventing rituals can markedly increase anxiety.
Question 9
A client experiencing alcohol withdrawal is restless, tremulous, and
diaphoretic. Which finding is most concerning?
A. Mild nausea
B. Anxiety
C. Blood pressure of 158/92 mm Hg
D. Visual hallucinations with severe agitation
Answer: Visual hallucinations with severe agitation
Rationale: Severe agitation and hallucinations can indicate progression
toward severe alcohol withdrawal and delirium tremens, which can become
life-threatening.
