Free NCLEX-RN Psychosocial Integrity questions
22 original Psychosocial Integrity questions on abuse or neglect, substance use and other dependencies, crisis intervention / violence risk, grief and loss, sensory/perceptual alterations, therapeutic communication, in Next Generation NCLEX formats.
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NCLEX-RN Psychosocial Integrity questions
- 22 questions
- Psychosocial Integrity
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A client who was just told they have breast cancer says to the nurse, "I don't know how I am going to tell my children." Which response by the nurse is best?
Correct answer: B
The best reply keeps the focus on the client and invites them to keep talking. An open-ended lead that explores the client's concern does this. False reassurance, personal advice and why questions are blocking responses that shift the focus to the nurse or put the client on the defensive.
- A This is false reassurance, which discourages the client from expressing the fear.
- B Correct: an open-ended lead explores the client's concern and lets the client direct the conversation.
- C This gives a personal opinion and takes the decision away from the client.
- D A why question can sound like a challenge and make the client defensive.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
A nurse is talking with clients on a behavioral health unit. For each nurse response, indicate whether it is therapeutic or nontherapeutic.
Therapeutic Nontherapeutic "You look worried today. What's on your mind?" "Everything will turn out fine, I promise." The nurse sits quietly and nods while a client cries. "You shouldn't skip group. That's not good for you." "So you stopped the medicine because it upsets your stomach. Did I get that right?" "I went through a divorce too, so I know exactly how you feel." Select one option in each row.
Correct answer: "You look worried today. What's on your mind?": Therapeutic; "Everything will turn out fine, I promise.": Nontherapeutic; The nurse sits quietly and nods while a client cries.: Therapeutic; "You shouldn't skip group. That's not good for you.": Nontherapeutic; "So you stopped the medicine because it upsets your stomach. Did I get that right?": Therapeutic; "I went through a divorce too, so I know exactly how you feel.": Nontherapeutic
Therapeutic responses keep the focus on the client: making an observation followed by an open-ended question, providing silence, and summarizing to check understanding. False reassurance, disapproval with words like "should" and "not good," and personal self-disclosure shift the focus to the nurse and block communication.
- "You look worried today. What's on your mind?" Therapeutic: the nurse makes an observation and then offers an open-ended lead.
- "Everything will turn out fine, I promise." Nontherapeutic: false reassurance discourages the client from sharing fears.
- The nurse sits quietly and nods while a client cries. Therapeutic: silence with nonverbal attention gives the client time to reflect.
- "You shouldn't skip group. That's not good for you." Nontherapeutic: disapproving imposes the nurse's values instead of exploring the client's reasons.
- "So you stopped the medicine because it upsets your stomach. Did I get that right?" Therapeutic: summarizing shows active listening and lets the client correct the nurse.
- "I went through a divorce too, so I know exactly how you feel." Nontherapeutic: self-disclosure of personal information blurs professional boundaries and shifts the focus to the nurse.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication · Open RN Nursing: Mental Health and Community Concepts 2e, 1.5 Boundaries ·
A client tells the nurse, "The staff on this unit never listen to me." The nurse replies, "We are all good nurses here, and we always listen." This reply is an example of . It is nontherapeutic because it . A more therapeutic reply is .
Choose the best option from each list to complete the sentence.
Correct answer: a defensive response; discourages the client from explaining; "You feel the staff haven't listened. Tell me what happened."
Defending the staff is a defensive response: it protects the nurse and team instead of exploring the client's concern, so the client stops explaining. Listening to a complaint does not mean agreeing with it. Restating the client's feeling and asking for more information keeps the conversation open; the nurse can follow the chain of command afterward if needed.
- Defending the staff is a defensive response; presenting reality corrects distorted perceptions with facts, and restating repeats the client's own idea.
- Defensive replies discourage the client from explaining the concern; the reply is not a limit on behavior and is not a question.
- Restating the feeling and inviting more detail is therapeutic; handing the concern off avoids it, and a why question sounds accusing.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
A client admitted with major depressive disorder tells the nurse, "I have it all worked out. I've been saving up my pills for when the time is right." Which action will the nurse take first?
Correct answer: C
A client who describes a specific plan and has gathered the means is at high risk, so safety comes first. The nurse does not leave the client alone, gets help so the provider is notified, and then removes the saved medication and follows agency observation policy. Documentation is required but comes after the client is safe.
- A Documentation is needed, but it does not protect the client and is not the first action.
- B A group session does not address the immediate risk of a client with a plan and the means.
- C Correct: a client making suicidal statements with a plan must not be left alone, and the provider must be notified.
- D This is false reassurance; it blocks communication and ignores the immediate danger.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 7.5 Applying the Nursing Process to Depressive Disorders · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety ·
A nurse in the emergency department is reviewing the screening note for a 47-year-old client who came in for a sprained ankle. Click to highlight the findings that increase the client's risk for suicide.
Client reports that they three weeks ago. Has . Blood pressure . Client states, . Spouse says the client last week. Client has and is . Client also reports .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: lost their job; "My family would be better off without me"; gave away a favorite guitar; a suicide attempt 5 years ago; drinking alcohol more often than usual
Suicide risk comes from what the client says, what they do and their history. Job loss, feeling like a burden, giving away important items, a previous attempt and increased alcohol use are all recognized warning signs or risk factors. Universal screening in acute care exists because clients seen for medical problems can have hidden suicide risk.
- lost their job Job or financial loss is a recognized risk factor for suicide.
- no known drug allergies Allergy status is unrelated to suicide risk.
- 128/78 mm Hg A normal blood pressure is not a suicide risk factor.
- "My family would be better off without me" Talking about being a burden to others is a warning sign of suicide.
- gave away a favorite guitar Giving away important possessions is a warning sign of suicide.
- a suicide attempt 5 years ago A previous suicide attempt is one of the most consistent risk factors.
- able to bear some weight on the ankle Ankle function relates to the injury, not to suicide risk.
- drinking alcohol more often than usual Using alcohol or drugs more often is a warning sign, and substance use is a risk factor.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: NIMH: Warning Signs of Suicide · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety · Open RN Nursing: Mental Health and Community Concepts 2e, 4.3 Assessment ·
A client with severe depression started an antidepressant 10 days ago. For a week the client stayed in bed and spoke little. Today the client is smiling, calm and says, "I finally know what I need to do." Which actions will the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, D, F
A sudden calm or euphoric change after deep depression, especially early in antidepressant therapy, when a client may regain enough energy to act on suicidal thoughts, is a red flag for suicide risk. The nurse asks directly, reports the change so the whole team knows the risk level, and keeps the environment safe. Reducing supervision or sending the client out would increase risk.
- A A sudden mood lift after severe depression can signal higher risk, so observation should not be reduced.
- B Correct: asking directly about suicide does not increase risk and opens a safety conversation.
- C This assumes recovery and is false reassurance; it may stop the client from disclosing a plan.
- D Correct: changes that suggest suicide risk must be communicated so all team members can keep the client safe.
- E Leaving the protected setting during a possible high-risk period is unsafe.
- F Correct: removing items that could be used for self-harm is a priority safety measure.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 7.5 Applying the Nursing Process to Depressive Disorders · Open RN Nursing: Mental Health and Community Concepts 2e, 3.5 Crisis and Crisis Intervention · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety ·
A nurse is teaching a group of new graduate nurses about the timeline of alcohol withdrawal. Mild symptoms such as tremor and sweating usually begin after the last drink. Withdrawal seizures can occur after the last drink, and delirium tremens usually begins after the last drink.
Choose the best option from each list to complete the sentence.
Correct answer: 6 to 24 hours; 6 to 48 hours; about 2 to 4 days
Alcohol withdrawal follows a clock that starts at the last drink. Mild symptoms usually begin within 6 to 24 hours, seizures can occur from 6 to 48 hours, and delirium tremens usually begins about 2 to 4 days after the last drink (MedlinePlus gives 48 to 96 hours; Open RN gives 72 to 96 hours). Knowing the window tells the nurse which complication to prepare for next.
- Mild withdrawal begins 6 to 24 hours after the last drink (not 3 to 5 days or weeks later) and often resolves in 1 to 2 days without treatment.
- Withdrawal seizures occur early, within 6 to 48 hours, not weeks later.
- Delirium tremens is a later complication, usually starting about 2 to 4 days after the last drink, not within hours and not weeks later.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens ·
A client with a long history of heavy alcohol use is being treated for alcohol withdrawal. The nurse notes new confusion, an unsteady gait and jerky, involuntary eye movements. Which prescription does the nurse expect the provider to give?
Correct answer: C
Confusion, ataxia and nystagmus in a client with alcohol use disorder point to Wernicke encephalopathy, an acute, life-threatening condition caused by thiamine (vitamin B1) deficiency. Thiamine replacement treats it; untreated, it can progress to Korsakoff syndrome, a chronic memory disorder. The other drugs are used for opioid overdose or opioid withdrawal.
- A Naloxone reverses opioids; it does not treat thiamine deficiency.
- B Clonidine relieves autonomic symptoms of opioid withdrawal, not Wernicke encephalopathy.
- C Correct: thiamine treats and prevents Wernicke encephalopathy, which presents with confusion, ataxia and nystagmus.
- D Buprenorphine treats opioid withdrawal and opioid use disorder, not thiamine deficiency.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Wernicke-Korsakoff syndrome · MedlinePlus Drug Information: Naloxone injection ·
A client's last drink was 20 hours ago. The client is tremulous, sweating and has vomited twice. Which actions will the nurse include in the plan of care? Select all that apply.
Select all that apply.
Correct answer: A, D, E
At 20 hours after the last drink the client is in the window for withdrawal seizures, so seizure precautions are needed: lowest bed position, padded side rails, and oxygen and suction at the bedside. The CIWA-Ar tracks severity and guides medication. A quiet, low-stimulus room is preferred, and a client with vomiting needs help to the bathroom because of fall risk.
- A Correct: a low bed with padded rails is part of seizure precautions.
- B Caffeine is avoided to protect sleep, which withdrawal already disrupts; it does not make withdrawal safer.
- C A bright, busy setting increases stimulation; a quiet, low-stimulus environment is recommended.
- D Correct: suction and oxygen must be available at the bedside during seizure precautions.
- E Correct: the CIWA-Ar is used to monitor alcohol withdrawal and guide symptom-triggered treatment.
- F Clients with vomiting or diarrhea who go to the bathroom unassisted are at increased risk for falls.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The nurse reviews the 0600 assessment. Click to highlight the findings that require follow-up.
0600: Client awake most of the night, restless and asking to go home. . Skin . States, . Oriented to person and place; . Right lower leg red, warm and tender; . Heart rate . .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: Hands tremble when holding a cup; moist with sweat; "There are bugs crawling on the wall"; unsure of the date; 116/min
Tremor, sweating, visual hallucinations, new disorientation to time and a rising heart rate are new findings that fit early alcohol withdrawal and need follow-up. Redness that stays within the marked borders shows the cellulitis is not spreading, and an SpO2 of 96% is within the expected range. Recognizing withdrawal early matters because clients often underreport how much they drink.
- Hands tremble when holding a cup Tremor is a sign of early alcohol withdrawal.
- moist with sweat Diaphoresis is a sign of withdrawal and of autonomic overactivity.
- "There are bugs crawling on the wall" Seeing insects that are not there is a visual hallucination, typical of withdrawal 12 to 24 hours after the last drink.
- unsure of the date New disorientation to time is a change in mental status that needs follow-up.
- redness remains within the marked borders Redness staying within the marked borders means the infection is not spreading; this is reassuring.
- 116/min Heart rate rose from 84 to 116/min; tachycardia is a sign of withdrawal.
- SpO2 96% on room air An SpO2 of 96% on room air is within the expected range.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Alcohol withdrawal · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The client has two active problems. For each finding, indicate whether it is more consistent with the client's alcohol use and withdrawal or with cellulitis.
Alcohol use and withdrawal Cellulitis Hands tremble when holding a cup Warm, red skin on the right lower leg Sees bugs crawling on the wall Magnesium 1.4 mg/dL Tenderness of the right lower leg Blood pressure up from 134/82 to 164/92 mm Hg Select one option in each row.
Correct answer: Hands tremble when holding a cup: Alcohol use and withdrawal; Warm, red skin on the right lower leg: Cellulitis; Sees bugs crawling on the wall: Alcohol use and withdrawal; Magnesium 1.4 mg/dL: Alcohol use and withdrawal; Tenderness of the right lower leg: Cellulitis; Blood pressure up from 134/82 to 164/92 mm Hg: Alcohol use and withdrawal
Tremor, visual hallucinations and a rise in systolic blood pressure are signs of alcohol withdrawal, and heavy drinking depletes magnesium. Warm, red, tender skin in one area is the local picture of cellulitis. Sorting cues by cause helps the nurse avoid blaming every change on the admitting diagnosis.
- Hands tremble when holding a cup Tremor is a classic early sign of alcohol withdrawal.
- Warm, red skin on the right lower leg Warm, red skin in the affected area is a sign of cellulitis.
- Sees bugs crawling on the wall Visual hallucinations of insects are typical of alcohol withdrawal.
- Magnesium 1.4 mg/dL Low magnesium is linked to alcohol use disorder; chronic drinking depletes magnesium.
- Tenderness of the right lower leg Pain or tenderness in the affected area is a sign of cellulitis.
- Blood pressure up from 134/82 to 164/92 mm Hg Systolic hypertension is a physical sign of alcohol withdrawal.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Magnesium blood test · MedlinePlus: Potassium test · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The client is most likely experiencing . The client's last drink was about before the 0600 assessment. Based on this timing, the complication the nurse should be most prepared for during the next 24 hours is .
Choose the best option from each list to complete the sentence.
Correct answer: alcohol withdrawal; 18 hours; a withdrawal seizure
Tremor, sweating, tachycardia, rising blood pressure and visual hallucinations after heavy daily drinking point to alcohol withdrawal; the cellulitis is stable and the temperature is only slightly raised. The last drink was at 1200 on Day 1, about 18 hours before 0600. Withdrawal seizures occur 6 to 48 hours after the last drink, so the next 24 hours fall squarely in that window, while delirium tremens usually begins later, about 2 to 4 days after the last drink.
- The cluster of tremor, diaphoresis, tachycardia, hypertension and visual hallucinations after daily heavy drinking fits alcohol withdrawal; the leg redness is not spreading, and Korsakoff syndrome is a chronic memory disorder.
- From 1200 on Day 1 to 0600 on Day 2 is 18 hours; 14 hours counts from admission at 1600 instead of the last drink, and 42 hours is where the next 24 hours will end.
- From 18 to 42 hours after the last drink, the client is in the 6-to-48-hour seizure window; Korsakoff-type memory loss is chronic, and nothing suggests an antibiotic allergy.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The nurse is planning care for the client. For each potential intervention, indicate whether it is indicated or not indicated at this time.
Indicated Not indicated Keep the room lights bright and the television on Keep the bed in its lowest position with padded side rails Place oxygen and suction equipment at the bedside Apply wrist restraints so the client cannot leave Allow the client to walk to the bathroom unassisted Assess the client with the CIWA-Ar scale Select one option in each row.
Correct answer: Keep the room lights bright and the television on: Not indicated; Keep the bed in its lowest position with padded side rails: Indicated; Place oxygen and suction equipment at the bedside: Indicated; Apply wrist restraints so the client cannot leave: Not indicated; Allow the client to walk to the bathroom unassisted: Not indicated; Assess the client with the CIWA-Ar scale: Indicated
After airway, breathing and circulation, safety is the priority in alcohol withdrawal: seizure precautions (low bed, padded rails, oxygen and suction at the bedside), fall precautions, a quiet low-stimulus room and CIWA-Ar monitoring. Restraints are a last resort when alternatives fail and safety is in danger; wanting to go home is not a reason to restrain.
- Keep the room lights bright and the television on Not indicated: a quiet, low-stimulus environment is recommended during withdrawal.
- Keep the bed in its lowest position with padded side rails Indicated: a low bed with padded side rails is part of seizure precautions.
- Place oxygen and suction equipment at the bedside Indicated: suction and oxygen must be at the bedside for seizure precautions.
- Apply wrist restraints so the client cannot leave Not indicated: restraints are used only when alternatives are not effective and safety is at risk; a restraint-free environment is the standard of care.
- Allow the client to walk to the bathroom unassisted Not indicated: clients with nausea and vomiting who go to the bathroom alone are at higher risk for falls.
- Assess the client with the CIWA-Ar scale Indicated: the CIWA-Ar measures withdrawal severity and guides symptom-triggered treatment.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · Open RN Nursing: Mental Health and Community Concepts 2e, 5.5 Patient Rights ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L At 0700, the client's CIWA-Ar score is 17. The provider prescribes lorazepam per the symptom-triggered CIWA-Ar protocol (give for a score of 10 or higher), thiamine IV daily, and magnesium sulfate IV. Which actions will the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, E
A score of 17 meets the protocol threshold, so the nurse gives the benzodiazepine, gives thiamine to prevent Wernicke encephalopathy, and reassesses to see whether the dose worked. Agreeing with a hallucination reinforces it; the nurse instead presents reality calmly. Blaming the client is a nontherapeutic, aggressive response, and delaying treatment is unsafe.
- A Correct: benzodiazepines treat agitation and help prevent seizures and delirium tremens; the score meets the protocol threshold.
- B Agreeing with a hallucination reinforces it; the nurse presents reality without arguing.
- C Correct: thiamine is given to prevent Wernicke encephalopathy in clients with heavy alcohol use.
- D The spouse has already confirmed the history, and delaying treatment allows withdrawal to progress.
- E Correct: symptom-triggered treatment depends on repeated CIWA-Ar scoring and vital sign checks.
- F Blaming the client is a nontherapeutic response that damages trust.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L Day 3, 0800 (about 44 hours after the client's last drink). The client has received lorazepam per protocol, thiamine and magnesium. For each finding, indicate whether it shows the client is improving or not improving.
Improving Not improving Heart rate 88/min Cannot say where they are and pulls at the IV line States, "The bugs are gone now." Magnesium 1.9 mg/dL (1.7–2.2 mg/dL) Blood pressure 168/96 mm Hg Hands steady when holding a cup Select one option in each row.
Correct answer: Heart rate 88/min: Improving; Cannot say where they are and pulls at the IV line: Not improving; States, "The bugs are gone now.": Improving; Magnesium 1.9 mg/dL (1.7–2.2 mg/dL): Improving; Blood pressure 168/96 mm Hg: Not improving; Hands steady when holding a cup: Improving
A slower heart rate, no hallucinations, steady hands and a normal magnesium level show improvement. New disorientation to place with pulling at lines, together with blood pressure that is still rising, is not improvement; the client is approaching the period when delirium tremens usually begins (about 2 to 4 days after the last drink), so the nurse reports these findings promptly.
- Heart rate 88/min Heart rate has dropped from 116 to 88/min, so autonomic overactivity is easing.
- Cannot say where they are and pulls at the IV line Worsening disorientation and agitation can signal developing delirium tremens and need prompt follow-up.
- States, "The bugs are gone now." Hallucinations have resolved.
- Magnesium 1.9 mg/dL (1.7–2.2 mg/dL) Magnesium is now within the normal range of 1.7 to 2.2 mg/dL.
- Blood pressure 168/96 mm Hg Blood pressure is higher than at 0600 on Day 2; rising blood pressure is a sign of worsening withdrawal.
- Hands steady when holding a cup Tremor has resolved.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens · MedlinePlus: Magnesium blood test ·
A client with schizophrenia who has a history of auditory hallucinations is sitting alone in the dayroom, whispering and glancing toward an empty corner. The client looks frightened. Which statement by the nurse is best?
Correct answer: C
Assess first: when a client shows signs of hallucinating, the nurse finds out what the client is experiencing and then asks about the content, including whether the client hears commands to harm self or others. The nurse states what they observe and asks an open question rather than referring to the voices as if they were real. False reassurance, arguing that the voices are not real or giving medication before assessing does not address the client's fear or safety.
- A False reassurance dismisses the client's fear and skips assessment of what the client is experiencing, including possible commands to harm self or others.
- B Trying to convince the client the voices are not real is not helpful; the nurse offers their own perception and empathy instead.
- C Correct: the nurse names an observed behavior and asks an open question, which starts the assessment of the hallucination without implying the voices are real.
- D Giving medication before assessing the content and the client's response skips assessment, including the check for command hallucinations.
A 6-year-old is seen in the emergency department with a bruise on the face. While the parent is out of the room, the child says, "Daddy pushed me into the door." Which documentation entry by the nurse is most appropriate?
Correct answer: C
Suspected abuse is documented thoroughly and objectively: the client's own words in quotation marks and a precise description of each injury, including size, location and color, plus photos if policy allows. Conclusions, labels and opinions about who is lying do not belong in the record. The nurse also reports the suspicion to the agency state law names; proof is not required.
- A This is a conclusion, not an observation; the nurse documents facts and lets the protective agency investigate.
- B "Most likely from abuse" and "seemed evasive" are interpretations rather than measurable findings.
- C Correct: a direct quote and an exact description of the injury are objective, factual documentation.
- D Judging the parent's honesty is an opinion; the record states what was seen and heard.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.4 Abuse and Neglect · Child Welfare Information Gateway: Mandatory Reporting of Child Abuse and Neglect (State Statutes PDF, current through May 2023) ·
A home health nurse assesses several older adult clients. For each finding, indicate the type of abuse it most suggests.
Physical abuse Neglect Emotional abuse Financial abuse Grip-shaped bruises on both inner upper arms Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly The caregiver threatens to "put her in a home" and keeps her friends from visiting The client's daughter calls her "useless" and mocks her in front of guests Select one option in each row.
Correct answer: Grip-shaped bruises on both inner upper arms: Physical abuse; Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver: Neglect; A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly: Financial abuse; The caregiver threatens to "put her in a home" and keeps her friends from visiting: Emotional abuse; The client's daughter calls her "useless" and mocks her in front of guests: Emotional abuse
Elder abuse includes physical, sexual and emotional abuse, neglect, financial abuse, treatment without consent and unreasonable confinement. Bruises on the inner arms suggest restraint or defensive injury; pressure injuries, dehydration and poor hygiene suggest neglect; misuse of money suggests financial abuse; threats, isolation and humiliation are emotional abuse. Suspected abuse of an older or at-risk adult is reported according to state law, often to adult protective services.
- Grip-shaped bruises on both inner upper arms Bruising on the inner upper arms can suggest defensive injuries or forceful restraint, a pattern of physical abuse.
- Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver A pressure injury, dehydration and poor hygiene show failure to meet basic needs, which is neglect.
- A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly Using the client's money for someone else's benefit is financial abuse.
- The caregiver threatens to "put her in a home" and keeps her friends from visiting Threats and keeping the client away from others (isolation) are forms of emotional abuse.
- The client's daughter calls her "useless" and mocks her in front of guests Humiliation and disrespect are verbal behaviors that cause anguish, which is emotional abuse.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.4 Abuse and Neglect ·
A nurse in a prenatal clinic is screening a client for intimate partner violence. The client's partner came to the visit. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: A, B, E
Routine screening for intimate partner violence happens in private, so others are asked to leave; a partner who refuses is a warning sign. The nurse assures confidentiality within the limits of mandatory reporting, asks a few open-ended questions using words like "hurt" or "afraid" rather than "victim" or "abused," never asks why the client has not left and never discusses concerns with the partner. If abuse is disclosed, the priority is a personal safety plan and resources.
- A Correct: privacy makes disclosure safer; the interview and exam happen without the partner present.
- B Correct: asking about being hurt or afraid mirrors everyday words and feels less threatening.
- C Labels such as "victim" or "abuse" can feel shaming and make disclosure less likely.
- D Asking why the client hasn't left implies blame; leaving is often the most dangerous time.
- E Correct: the nurse assures confidentiality but is honest that mandatory reporting may apply.
- F Sharing concerns with the partner could put the client in danger.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.5 Intimate Partner Violence · Open RN Nursing: Mental Health and Community Concepts 2e, 15.7 Applying the Nursing Process to Clients Experiencing Trauma, Abuse, or Violence ·
A nurse is assessing clients whose spouses died 4 months ago. For each finding, indicate whether it is more consistent with normal grief or with major depression.
Normal grief Major depression Sadness comes in waves that are mixed with fond memories of the spouse Feels worthless and full of self-loathing Self-esteem is intact; says, "I was a good husband to her" Low mood all day, every day, with no ability to expect any pleasure Describes a hollow, empty feeling and longs to see the spouse again Select one option in each row.
Correct answer: Sadness comes in waves that are mixed with fond memories of the spouse: Normal grief; Feels worthless and full of self-loathing: Major depression; Self-esteem is intact; says, "I was a good husband to her": Normal grief; Low mood all day, every day, with no ability to expect any pleasure: Major depression; Describes a hollow, empty feeling and longs to see the spouse again: Normal grief
Grief and depression overlap, but they differ in pattern. In grief, painful feelings come in waves, ease over time, mix with positive memories and center on emptiness and longing, and self-esteem is usually preserved. In major depression, mood is constantly low, pleasure cannot be expected and worthlessness or self-loathing is common; depression can develop after a loss and needs referral.
- Sadness comes in waves that are mixed with fond memories of the spouse Waves of sadness mixed with positive memories are typical of the normal grieving process.
- Feels worthless and full of self-loathing Worthlessness and self-loathing point to major depression; self-esteem is usually kept in grief.
- Self-esteem is intact; says, "I was a good husband to her" Preserved self-esteem fits normal grief.
- Low mood all day, every day, with no ability to expect any pleasure A constant low mood with inability to expect pleasure is characteristic of major depression.
- Describes a hollow, empty feeling and longs to see the spouse again Emptiness and yearning for the deceased are core features of grief.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version · Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) ·
A client who had a miscarriage at 10 weeks has told no one at work and feels she is not allowed to be sad. This is an example of grief. Another client is grieving the expected death of her father, who has terminal cancer and is still alive. This is grief. A third client's adult daughter died suddenly 14 months ago; he still cannot accept the death, blames himself and has stopped working. This suggests grief.
Choose the best option from each list to complete the sentence.
Correct answer: disenfranchised; anticipatory; complicated
Disenfranchised grief is grief over a loss that others do not recognize or validate, such as a pregnancy loss, so the person feels unable to mourn openly. Anticipatory grief begins before an expected loss, such as during a terminal illness. Complicated grief is prolonged, intense grief that impairs functioning; a sudden death and the death of a child are risk factors.
- A pregnancy loss that others do not acknowledge, leaving her unable to grieve openly, is disenfranchised grief.
- Grieving a loss that has not happened yet, during a terminal illness, is anticipatory grief.
- Grief that stays intense long after the sudden death of a child, with self-blame and an inability to work, suggests complicated grief.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) · National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version ·
A hospice bereavement nurse reviews four family members after a loss. Which person is at highest risk for complicated grief?
Correct answer: B
Risk factors for complicated grief include sudden or traumatic death, suicide, homicide, the death of a child, a dependent relationship, multiple losses and a lack of support. Crying at reminders weeks after a death and feeling relief after a long illness are part of normal grief. The nurse monitors at-risk survivors during bereavement and refers them for counseling when grief does not ease.
- A An expected, peaceful death with active social support is a protective situation.
- B Correct: a child's death by suicide, plus few supports, combines several major risk factors for complicated grief.
- C Crying at reminders of the deceased a few weeks after the death is a normal grief response.
- D Relief is a normal emotion in grief, especially after a long illness.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) · Open RN Nursing Fundamentals 2e, 17.3 Applying the Nursing Process to Grief · National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version ·
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About this NCLEX-RN Psychosocial Integrity practice test
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NCLEX-RN format
| Client needs category | Share of the exam |
|---|---|
| Management of Care | 15–21% |
| Safety and Infection Prevention and Control | 10–16% |
| Health Promotion and Maintenance | 6–12% |
| Psychosocial Integrity | 6–12% |
| Basic Care and Comfort | 6–12% |
| Pharmacological and Parenteral Therapies | 13–19% |
| Reduction of Risk Potential | 9–15% |
| Physiological Adaptation | 11–17% |
The exam has 85 to 150 questions in up to 5 hours, including 15 unscored pretest questions and three unfolding case studies. An on-screen calculator is provided.
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