Psychosocial Integrity - NCLEX Prep
A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy?
"It's difficult to be a teenager. Tell me more about your experiences." Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the adolescent's feelings and conveys an understanding without intimidating the client. Asking how adults can help and reflecting on parental understanding or favorite coursework is helpful overall but does not demonstrate empathy for the client.
The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:
clang association Linking words together based on their sounds rather than their meanings is called clang association. Echolalia is the involuntary parrot-like repetition of words spoken by others. Echopraxia refers to meaningless imitation of others' motions. Neologisms are words that a person invents.
A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse?
"The injury happened a few days ago but I didn't think it was bad." A delay in seeking treatment for a child's serious injuries is a sign of abuse. Anxiety is expected and is a normal response. The parent's specific description of the origin of the injury is not congruent with child abuse. In abuse cases, vague descriptions of the injuries are more common than detailed ones, and abusers often prevent a child from explaining the nature of their injuries rather than encouraging it.
The parent of a preschool-age child tells the nurse that the child is hyperactive and something needs to be done. Which response by the nurse would be most appropriate initially?
"What makes you think your child is hyperactive?" The best approach by the nurse is to determine why the parent thinks the child is hyperactive. Some children are very active but do not have the necessary defining characteristics of hyperactivity. Asking what the parent thinks needs to be done, how the child behaves normally, and if the preschool teacher thinks the child is hyperactive would be an appropriate follow-up question once more information is gathered from the parent to determine whether the child indeed is hyperactive.
While in the facility, a client with obsessive-compulsive disorder (OCD) saves all used medicine cups and paper cups and arranges them in elaborate sculptures in the room. At home, the client saves mail and magazines and makes elaborate paper sculptures from them. Which action by the client indicates progression toward the treatment goals?
refraining from keeping some obsessive items With a client who has OCD, a goal of treatment is to throw away hoarded items. Keeping the hoarded items or moving and arranging them would not indicate progress, because these actions allow the inappropriate behavior to continue. Often, clients with a hoarding disorder will have plans for the hoarded items; the plans are not realistic or acted upon, but they allow the client to rationalize and perpetuate the hoarding behavior. Making a plan to sell the sculptures is one such unrealistic rationalization that should be discouraged.
The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling?
"Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.
The nurse cares for a 23-year-old male client with schizophrenia in the outpatient clinic. After a prescription change from olanzapine to ziprasidone, the client tells the nurse, "I don't want to take this ziprasidone either. I don't like the side effects, and I can't gain any more weight." Which response(s) by the nurse are appropriate for this client? Select all that apply. "Ziprasidone causes less weight gain than do the other atypical antipsychotics." "We can give it to you as an injection rather than in capsule form." "Abnormal movements are not as common with ziprasidone." "You can take it just before bedtime, so you won't need a snack." "I can request a referral for dietary counseling to help you manage the weight gain risk."
"Ziprasidone causes less weight gain than do the other atypical antipsychotics." "I can request a referral for dietary counseling to help you manage the weight gain risk." Most clients experience less weight gain when taking ziprasidone. Dietary counseling, exercise programs, and cognitive and behavioral strategies prevention and intervention strategies have been shown to have modest effects on weight. Although ziprasidone can be administered intramuscularly, it can be used only on an as-needed basis by this route. Ziprasidone has fewer extrapyramidal side effects, but that is not this client's major concern. Ziprasidone is better absorbed when taken with food, so a bedtime snack is needed.
The nurse suspects autism spectrum disorder (ASD). Which information should the nurse collect from the caregiver based on the DSM-5 criteria for ASD?
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the criteria for diagnosis of ASD includes the presence of at least 6 of 12 characteristics indicative of impaired social interaction, impaired communication, and restricted repetitive and stereotyped patterns of behavior, interests, and activities. Criteria indicative of impaired social interactions includes the absence of peer relationships and a lack of social or emotional reciprocity; therefore, asking about relationships with other children who are the same age and smiling with praise are appropriate assessment items. Criteria for impaired communication includes an inability to initiate or sustain conversation and idiosyncratic or repetitive language; therefore, it is appropriate to determine if the child initiates conversations with the caregiver and language repetition. Restricted repetitive and stereotyped patterns of behavior, interests, and activities includes an abnormal preoccupation with a restricted pattern of interest (e.g., lining up objects, such as blocks) and repetitive motor behaviors (e.g., rocking back and forth, especially when upset). A lack of imaginative play, such as pretending to cook or pretending to be a superhero, is a criteria for abnormal communication, not social interactions. A lack of eye contact is criteria for abnormal social interaction, not communication.
A newly admitted client with bone cancer tells the nurse that the folk healer has not been able to help him. What principle of culturally competent care will the nurse keep in mind during the client's conventional medical course of treatment?
All people have the right to care based on their personal preferences and values. To deliver culturally competent nursing care the nurse must remember that all people are to be treated as individuals who have the right to their personal beliefs, preferences, and practices. People in all cultures may disregard or refuse to participate in various forms of treatment protocols. The statement that the world is governed by forces of good and evil reflects the magico-religious view of illness, and the view of illness as being out of balance is the naturalistic perspective of what causes illness, and these views may not be germane to the client's cultural background.
An adolescent client with depression and a suicide attempt is admitted to an inpatient unit. The nurse notes that the client describes a recent breakup of a dating relationship with an emotionless tone and a flat facial expression. What will the nurse do next?
Ask the client if there is a plan in place for suicide. The priority for this client is the risk for suicide, and the nurse needs to seek more information about a plan. Listening and waiting for expression of suicidal ideation delay important safety measures. The client has turned anger inward and may not be able to express emotions, so the nurse must be alert for another suicide attempt. The nurse should avoid using platitudes like "life will get better.
The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene?
Assess the client's injury, notify the healthcare provider, and document the incident. The nurse should assess the injury, notify the healthcare provider, and thoroughly document the incident in accordance with facility protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the healthcare provider of the findings in accordance with facility protocol.
A client is admitted with an infectious wound. Contact precautions are initiated. To help the client cope with staff using isolation procedures, which nursing action is most helpful?
Discuss the rationale for contact precautions. When assisting the client cope with contact precautions, it is most helpful to understand the client's perspective of how the use of the precautions feels. When discussing, the nurse can explain the importance of the measures and the concerns of the client. Speaking from the door violates confidentiality. Putting stickers on the mask does not help the client cope. Although it is necessary to wear gloves, it does not assist in client coping.
A nurse working in the emergency department enters the room of a client who is agitated and swears at the nurse. The client stands up and moves toward the nurse in an aggressive fashion. What is the most appropriate action by the nurse to address this situation?
Move toward the door and leave to call the crisis response team. The nurse assesses and identifies that the nurse's safety is at risk because the client is agitated and moving aggressively toward the nurse. The nurse needs to leave and obtain help in the form of a crisis response team. The other options are incorrect because they do not provide for the safety of the nurse or the client.
A child with aggressive and impulsive behaviors is admitted to the child psychiatric unit with a diagnosis of a conduct disorder. Which intervention is appropriate?
Set limits. The nurse promotes consistent limit-setting for the client with the aggressive and impulsive behaviors of a conduct disorder. It is not appropriate for the nurse to allow autonomy or elicit a description of feelings; assertiveness classes are also inappropriate.
An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations?
alcohol withdrawal Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and risperidone have an additive effect, not one of causing hallucinations.
A client, brought to the emergency department by the police, is found wandering the streets of town and appears to be disoriented. During initial contact by the nurse, the client begins to laugh inappropriately and states feeling dizzy. Which client behaviors suggest that the client is symptomatic for huffing aerosols? Select all that apply. an unsteady gait an elevated temperature multiple bruises on the skin impaired memory of where they had been a slurred speech during conversation hallucinations of spiders crawling on the bed
an unsteady gait impaired memory of where they had been a slurred speech during conversation hallucinations of spiders crawling on the bed Huffing inhalants includes common household products such as hair spray, paints, and lighter fluids. Signs of abuse are similar to being under the influence of alcohol. These symptoms include: slurred speech, an unsteady gait, euphoria, dizziness, confusion, hallucinations, and delusions. An elevated temperature is common in cocaine use and bruising is common with intravenous drug users.
A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply. asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs reading aloud Bible passages that relate to the client's needs offering to pray with the client to help resolve the conflict
asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonable for the nurse to explore the client's faith origins as well as what the usual sources of spiritual support were or are. Commonly, a hospitalized client is separated from those of common faith practices so this should be explored. The nurse can also carefully explore what is contributing the challenges to faith the client is expressing. The scenario does not state that the client is Christian so reading from the Bible is an assumption by the reader, first. Second, the nurse would not take the step of reading to the client from a religious text unless this was a direct request by the client. Nurses should also not offer to pray with the client but should only engage in this if directly asked and if this is something the nurse is comfortable with.
The nurse is explaining the symptoms of dementia to a family member who has not seen their parent in 15 months. Which characteristics of neurocognitive disorder due to Alzheimer's disease would the nurse address in the teaching session? Select all that apply. experiences an impending sense of doom forgets that food is cooking on the stove becomes lost walking on their own street unable to write and to sign their name begins to fear using public transportation unable to understand new information
forgets that food is cooking on the stove becomes lost walking on their own street unable to write and to sign their name unable to understand new information Common symptoms of neurocognitive disorder due to Alzheimer's disease include forgetting things such as cooking food, and where specific items were placed, becoming lost in a familiar neighborhood, being unable to write or sign a document, and the inability to understand new information. A client experiencing an impending sense of doom and fearing public transportation is most likely dealing with a panic attack with agoraphobia.
Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness?
living each day as it comes as fully as possible When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.