PassPoint NCLEX Psychosocial Integrity
An emergency department nurse is conducting an assessment interview with an elderly client. The client states, "I was so frightened when I fell while crossing the street." Which statement would be the best response?
"That must have been frightening for you." Explanation: "That must have been frightening for you" acknowledges the client's experiences and is an empathetic response. "Why were you afraid on the street?" is asking a clarifying question but does not offer an empathetic response to the client. The statement, "Were you afraid because you were alone?" is a closed-ended question and therefore nontherapeutic. Finally, stating that the client will feel less frightened tomorrow is false assurance.
The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?
"You're very concerned when you think about how this will change your life." Explanation: The response should be attuned to the feelings of sadness and dejection the client is experiencing and should allow concerns to be shared. This response also addresses the content of the client's statement, namely how life will change. "This really saddens you." addresses the feelings but does not attend to the feelings about life. "Why" questions are nontherapeutic, and telling the client to be more hopeful negates what the feelings are.
The nurse understands that the client with severe dementia and motor apraxia may still be able to perform which action?
Brush the teeth when handed a toothbrush. Explanation: Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.
A depressed client on a psychiatric unit asks the nurse to call the hospital lawyer to discuss writing out a will. What is the nurse's priority intervention?
Discuss thoughts and explore intent for suicide with the client. Explanation: Exploration of thoughts and intent are a priority based on lethality of plan for suicide. Calling the lawyer is incorrect because it does not explore the intent of the client's question. The nurse would discuss the intent with the client prior to calling the physician. Administering anxiety medication does not address the problem.
A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse?
Explore other ways to control symptoms and address the family's concerns more effectively. Explanation: Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate for and support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the most support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority.
Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which is a characteristic of rituals?
common and observable expressions of culture Explanation: Rituals are common and observable expressions of culture. A preconceived and untested belief about people is called a stereotype. Viewing one's own culture as the only correct standard is ethnocentrism. A belief system held to varying degrees as absolute truth is referred to as culture.
The client is Asian and non-English speaking. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom?
pain Explanation: The client may be describing symptoms of pain. Culture specific symptoms for "feeling bad" include numbness, thinking too much, feeling hot under the skin. Asian clients may describe pain in terms of Yin and Yang (hot and cold). Nurse's knowledge of pain associated with health problems is necessary to assist this client manage pain. Clients from some cultures may associate mental health symptoms with evil spirits and will not report them as being unusual. Clients from Asian cultures may not describe symptoms locally but in a diffuse fashion.
In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is
self-disclosure. Explanation: Self-disclosure involves the nurse revealing personal information. Using self-disclosure as a therapeutic communication technique facilitates an open and authentic relationship between the nurse and client. Clarification involves the nurse asking the client for more information. Reflection involves reviewing the client's ideas. Restating is the nurse's repetition of the client's main message.
When the client tells the nurse that they believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing
theism. Explanation: Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.
The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. How would the nurse respond?
"Is there anyone else I can call to support you at this time?" Explanation: The clients are displaying evidence of spiritual pain and distress. The nurse acknowledges that this can be a normal part of the grieving process and does not pressure the clients to access spiritual supports if they have been refused. However, the nurse does not just accept this refusal and not explore other methods of support. Instead, the nurse should offer to call someone the clients may want to have with them as a support at this time. At this time of acute grief and spiritual pain, the nurse should not attempt to explore the client's spiritual beliefs. This can be explored later in the grieving process when the clients demonstrate readiness for this exploration.
While planning the care for a client with paranoid delusions, which will be the nurse's initial goal for the client?
Establish trust with staff. Explanation: Establishing a trusting relationship is the priority goal when working with clients with delusions. Only after trust is established can other assessment and goal setting or interventions take place. Being free of delusions, participating in unit activities, and performing tasks independently are important but are not initial priorities.
The wife of a client with bipolar disorder, manic phase, states to the nurse, "He's acting so crazy. What did he do to get this way?" The nurse bases the response on which understanding of this disorder?
It is the result of an imbalance of chemicals in the brain. Explanation: Bipolar disorder is a biochemical disorder caused by an imbalance of neurotransmitters in the brain. Manic episodes seem to be related to excessive levels of norepinephrine, serotonin, and dopamine. Psychopharmacologic therapy aims to restore the balance of neurotransmitters. In the past, it was thought that bipolar disorder may have been caused by early psychodynamics or disturbed families, but the current view emphasizes the role of biology. Bipolar disorder could be genetic or inherited from someone in the family, but it is best for the client and family to understand the disease concept related to neurotransmitter imbalance. This understanding also helps them to refrain from placing blame on anyone. Siblings and close relatives have a higher incidence of bipolar disorder and mood disorders in general when compared with the general population.
A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.
Provide an early opportunity for the couple to see the child if desired. Offer to stay with the grieving parents. Answer the parents' questions accurately. Explanation: Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace.
The nurse is caring for a client with a panic attack. Which nursing intervention is most helpful for this client?
Stay with the client and remaining calm, confident, and reassuring. Explanation: A panic-stricken client requires the assistance of a calm person who can provide support and direction. This approach is particularly important because the client already feels frightened and out of control. Having someone remain with the client helps prevent the client from feeling isolated and deserted. Encouraging the client to verbalize any fears, feelings, or concerns or encouraging the client to identify what precipitated the attack is futile because the client's level of anxiety prevents them from focusing on precipitating factors. Also, encouraging the client to learn relaxation techniques is not possible at this time as the client is unable to learn new information when the anxiety level is at the panic level. Staying with the client is the best action for the nurse.
A client who is in the end-stages of cancer is increasingly upset about receiving chemotherapy. Which approach by the nurse would likely be most helpful in gaining the client's cooperation?
Tell the client how the treatment can be expected to help. Explanation: The best course of action when the client has outbursts concerning treatments is to explain how the treatment is expected to help. Describing the effect if the client misses a treatment is a negative approach and may be threatening to the client. Explaining the effects of being upset does not deal with the client's feelings. Offering to arrange for a massage during the chemotherapy may be helpful, but does not deal with the client's immediate feelings.
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused?
absence of crying during the examination Explanation: Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event (an examination or procedure).
The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily:2/101700The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that. "What health problem is this client experiencing because of extended cannabis use?
amotivational syndrome Explanation: Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.
A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing which factor?
relief from anxiety. Explanation: A client who is exhibiting compulsive behavior is attempting to control his anxiety. The compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an attempt to express hostility.
Which statement made by the parent of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse?
"After this, I will never let her out of my sight again." Explanation: Parents of a child who has undergone neurosurgery can easily become overprotective. Yet, the parents must foster independence in the convalescing child. It is important for the child to resume age-appropriate activities, and parents play an important role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious illness or injury as a sign that the child is doing well.
When a client expresses feelings of unworthiness, the nurse should respond by saying:
"As you begin to feel better, your feelings of unworthiness will begin to disappear." Explanation: When the client feels unworthy, she reflects low self-esteem. Presenting another set of facts in a manner that is accepting of the client but avoids a power struggle is helpful. Telling the client that her family still loves her is a type of pep talk that serves to block the client's emotional expression. Telling the client that her feelings are imaginary shows disapproval and may shame the client for having such feelings. Telling the client that she should try to forget ideas of unworthiness disregards her feelings and may be perceived as rejection.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which response by the nurse would be most appropriate?
"I understand, but feel free to visit or call anytime to see how your child is doing." Explanation: The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she should not leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.
A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with her daily before-breakfast weigh-in. She states that she just drank a glass of water, which she feels will unfairly increase her weight. What is the nurse's best response to the client?
"You must weigh in every day at this time. Please step on the scale." Explanation: In responding to the client, the nurse must be nonjudgmental and matter of fact. Telling her that weight gain is in her favor ignores the client's extreme fear of gaining weight. Putting off the weigh-in for 2 hours allows the client to manipulate the nurse and interferes with the need to weigh the client at the same time each day. Threatening to call the health care provider is not likely to build rapport or a working relationship with the client.
Which of the following client behaviors indicates the nurse-client relationship is in the working phase?
The client makes an effort to describe his or her problems in detail. Explanation: The client's effort to describe his or her problems to the nurse indicates that nurse-client relationship is most probably in the working phase. The client's action illustrates that the client has gone beyond testing and acquainting himself or herself with a new relationship and is now working on his problems.The relationship is in an orientation phase when the client attempts to familiarize himself or herself with the nurse or when the client challenges the boundaries of the relationship. The relationship is in a termination phase when the client summarizes and evaluates his or her progress.
A client with schizophrenia states "I can't stay here. I have to get away." The nurse observes that the client is very agitated. What should be the nurse's first action?
Approach the client in a calm, nonthreatening manner. Explanation: Aggressive behavior occurs in stages from the triggering phase that starts the hostile response, to the escalation phase, to crisis, to recovery, and finally to post crisis. This client is in the triggering phase where the person is still able to see the situation and problem solve to a degree. The first action the nurse needs to do is to approach the client in a calm, nonthreatening manner. The nurse, however, needs to stay 6 feet away and avoid touching the person. This will show the client that the nurse is trustworthy. The client is still able to express feelings here so medication may or may not be needed. Calling for help will be done depending upon the client's response to the first action by the nurse.
