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NCLEX-PN Exam Questions - Part 21
1. A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse - s next action should be:
A) touching the client to help him return to reality.
B) leaving the client alone until reality returns.
C) asking the client to describe what is happening.
D) telling the client there are no voices.
2. A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse - s next action should be:
A) touching the client to help him return to reality.
B) leaving the client alone until reality returns.
C) asking the client to describe what is happening.
D) telling the client there are no voices.
3. A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse - s response should be based on which of the following pieces of information?
A) Male victims of sexual abuse seldom have long-term psychological problems.
B) Survivors of male sexual abuse might become confused about their sexual identity.
C) Unless treated, all male sex abuse survivors grow up to abuse other children.
D) All children who have been sexually abused have the same needs, regardless of gender.
4. A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
A) identify all psychosocial problems.
B) eliminate the client - s enticing behaviors.
C) resolve feelings of trauma and fear.
D) verbalize feeling about the event.
5. The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
A) enhance personal control over legal care decisions.
B) encourage medical treatment decision making prior to need.
C) give one federal standard for living wills and durable powers of attorney.
D) emphasize client education.
A) touching the client to help him return to reality.
B) leaving the client alone until reality returns.
C) asking the client to describe what is happening.
D) telling the client there are no voices.
2. A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse - s next action should be:
A) touching the client to help him return to reality.
B) leaving the client alone until reality returns.
C) asking the client to describe what is happening.
D) telling the client there are no voices.
3. A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse - s response should be based on which of the following pieces of information?
A) Male victims of sexual abuse seldom have long-term psychological problems.
B) Survivors of male sexual abuse might become confused about their sexual identity.
C) Unless treated, all male sex abuse survivors grow up to abuse other children.
D) All children who have been sexually abused have the same needs, regardless of gender.
4. A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
A) identify all psychosocial problems.
B) eliminate the client - s enticing behaviors.
C) resolve feelings of trauma and fear.
D) verbalize feeling about the event.
5. The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
A) enhance personal control over legal care decisions.
B) encourage medical treatment decision making prior to need.
C) give one federal standard for living wills and durable powers of attorney.
D) emphasize client education.
1. Right Answer: C
Explanation: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control. Psychosocial Integrity
2. Right Answer: A
Explanation: Nurses need to inform clients that there is a difference in perceptions and pay attention to the content of hallucinations. The other options are not therapeutic.Psychosocial Integrity
3. Right Answer: B
Explanation: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Psychosocial Integrity
4. Right Answer: D
Explanation: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment. Psychosocial Integrity
5. Right Answer: B
Explanation: The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The focus of the PSDA is individual health care decision- making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols. Coordinated Care
Explanation: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control. Psychosocial Integrity
2. Right Answer: A
Explanation: Nurses need to inform clients that there is a difference in perceptions and pay attention to the content of hallucinations. The other options are not therapeutic.Psychosocial Integrity
3. Right Answer: B
Explanation: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Psychosocial Integrity
4. Right Answer: D
Explanation: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment. Psychosocial Integrity
5. Right Answer: B
Explanation: The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The focus of the PSDA is individual health care decision- making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols. Coordinated Care
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