PASSPOINT- Psychosocial Integrity

On the 3rd postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, "I look horrible! Will it ever look better?" Which response by the nurse would be mostappropriate?

"You're shocked by the sudden change in your appearance as a result of this surgery, aren't you?"

A client was found unconscious on the bathroom floor with self-inflicted wrist lacerations. An ambulance was called and the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Which nursing intervention is mostappropriate?

Continue suicide precautions.

What short-term goal for a client hospitalized with a stress related disorder is most realistic?

The client will write a list of strengths and needs.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior?

The client's anger is not intended personally.

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern?

suicide potential

A client recovering from Guillain Barré syndrome states, "I'm nervous that this disease will come back." Which nursing diagnoses is most suggested by this comment?

anxiety

A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The mosttherapeutic nursing intervention would be to

continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis.

The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate?

delusion of persecution

The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse?

ensuring relevance to, and quickly refocusing upon, the client's experience

A client hospitalized for depression remains extremely depressed and expresses increasing suicidal ideation to the client's primary nurse. What should be the nurse's priorityintervention?

ensuring that the client is not permitted to use anything that would be potentially dangerous

While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience?

fear of the unknown

A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of:

hallucination

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have?

impulsive acts of aggression

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior?

incr in energy level

The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?

limiting interaction with extended family and friends

An adolescent client took 300 acetaminophen tablets in an attempt to kill themself after a relationship breakup. The client is admitted to the adolescent psychiatric unit and is refusing to talk with the nurse. What is the most important nursing approach at this stage of the helping relationship?

supporting suicide precautions and safety measures for the client on the unit

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms?

neg ss

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

A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which response?

stage of grief reaction

The nurse is preparing to administer oral medication to an 8-year-old child who is resistant to taking the medication. Which is the most effective statement made by the nurse that would encourage the child to take the medication?

"I have your medication. Swallow these please."

A nurse notices that a client with obsessive-compulsive disorder dresses and undresses several times each day. Which comment by the nurse would be most therapeutic?

"I saw you change clothes several times today. Do you find this tiring?"

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

"Reviewing your losses is a way to help you work through your grief and loss."

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique is most helpful?

Ask the child to draw a picture.

The nurse is caring for a young adult with end stage leukemia. The client asks the nurse to "help end my suffering in this life because it has gotten to be too much to endure." Based on the ANA Code of Ethics for nurses, what would the nurse do next? Select all that apply.

Explain to the client that nurses cannot participate in assisted suicide. Allow the client to discuss their feelings and explore other options for comfort.

Which concept should the nurse incorporate into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization?

Preparation is a joint responsibility of the primary care provider, parents, and nurse.

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements.

A nurse is caring for a newly admitted client on the psychiatric unit. The nurse would most hinder therapeutic communication by performing what action?

offering advice and opinions