NCLEX psychosocial integrity practice questions

Answer: D — "Are you having thoughts of ending your life?".

Talking about being a burden to others is a warning sign of suicide. The nurse asks directly and without judgment about suicidal thoughts, then explores plan, means and timeline; changing the subject or minimizing the statement leaves the risk unassessed.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 16.3 Self-Harm and Suicide, Conversations About Suicide (source)

Answer: B — Withdrawing from friends and giving away important possessions.

NIMH lists withdrawing from friends, saying goodbye and giving away important items among the behavior changes that may signal suicidal thinking. The other choices show future-oriented, engaged behavior.

Checked against: NIMH, Warning Signs of Suicide (source)

Answer: D — Continuous one-to-one observation, including during personal activities.

A client with a specific plan and available means is at high risk and needs continuous one-to-one observation, sometimes even during activities such as showering. Intermittent checks leave gaps in which an attempt can occur.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 16.3 Self-Harm and Suicide, Continuous Client Monitoring (source)

Answer: A — Watch the client swallow each dose to prevent hoarding.

Clients at risk may pretend to take medication and save it to accumulate a lethal dose, so direct observation of medication administration is important in high-risk populations. Holding prescribed medication is not a nursing decision.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 16.3 Self-Harm and Suicide, Medication Hoarding (source)

Answer: C — The 988 Suicide & Crisis Lifeline, by calling or texting 988 or chatting at 988lifeline.org.

NIMH directs people with thoughts of suicide to the 988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org. A safety plan also lists personal warning signs, coping strategies and trusted contacts.

Checked against: NIMH, Warning Signs of Suicide (source)

Answer: C — Find a way to speak with the client alone, for example by asking her to come to the restroom for a urine sample.

IPV screening is done in a private, safe setting with the client alone, away from the partner, family or caregiver; asking the patient to follow the nurse to the restroom is one way to do this. Screening in front of a possible abuser puts the client at risk and is unlikely to be honest.

Checked against: OpenStax Maternal-Newborn Nursing, 9.2 Domestic and Intimate Partner Violence, IPV Screening table (source)

Answer: A — Report the suspected abuse according to state law and facility policy, even without proof.

Every U.S. state has laws requiring certain professionals, including nurses, to report suspected child abuse; reasonable suspicion is enough and proof is not required. Mandatory reporting laws allow this disclosure even though it would otherwise be protected health information.

Checked against: OpenStax Clinical Nursing Skills, 20.3 Abuse and Neglect Assessment, Mandatory reporting laws (source)

Answer: D — Reconciliation (honeymoon) phase.

After the violent episode, the abuser may apologize, promise change or act unusually kind; this reconciliation or honeymoon phase gives the victim hope and makes leaving less likely. Tension building comes before the violence, and in the calm phase the abuser may deny or minimize what happened.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 9.3 Anger, Abuse, and Violence, Cycle of Abuse (source)

Answer: B — The client is in soiled clothing, has no food in the home and has missed medical appointments.

Elder neglect is the failure to meet an older adult's basic needs, including food, water, shelter, clothing, hygiene and access to medical care. Personal choices and requested help with finances do not by themselves suggest neglect.

Checked against: OpenStax Clinical Nursing Skills, 20.3 Abuse and Neglect Assessment, Elder Abuse and Neglect (source)

Answer: A — Obtain a urine specimen, because infection is a common cause of acute confusion in older adults.

Sudden confusion that develops over hours suggests delirium, which signals an underlying medical problem; in older adults a urinary tract infection is one of the most common causes and may present with confusion and incontinence rather than pain. Dementia develops slowly over years.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 14.2 Delirium, Incidence and Causes of Delirium (source)

Answer: C — Respond calmly to his feelings, avoid arguing about the facts and redirect him to a soothing activity.

With dementia, reorienting a client when it causes distress can increase frustration; the nurse speaks calmly, uses simple questions, watches for rising anxiety and goes along with the client's reality while redirecting. Confronting him with facts tends to escalate agitation.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 14.3 Dementia, Nursing care and Real RN Stories (source)

Answer: B — Between 48 and 96 hours after his last drink.

Delirium tremens typically begins 48 to 96 hours after the last drink and can include hallucinations, fever, tachycardia, hypertension and diaphoresis. This client is entering the period of highest risk, so close assessment with a withdrawal scale continues.

Checked against: OpenStax Psychiatric-Mental Health Nursing, 19.2 Alcohol Use Disorder, Treatment for Withdrawal from Alcohol Use (source)