PassPoint - Psychosocial Integrity

A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention?

providing a quiet environment

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Fowler

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

tachycardia, weight loss, and mood swings

The nurse has recently accepted a position in a community with an ethnically and culturally diverse population. What action should the nurse first perform in order to enhance cultural competence?

Thoughtfully reflect on the characteristics of their own culture.

A nurse is counseling an adolescent client for depression. The client's father died 2 months ago of cancer, and the client's mother died when the client was 11 years old. During the interview the client states, "I just feel like I can't do anything." Which of the following would be most appropriate response to this client?

"I will stay here with you."

A birthing couple informs the nurse that they would like to have the placenta after the baby is born. What is the nurse's best response?

"Let me check about how to go about doing this."

The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate?

"Tell me what you've found in your reading that's leading you to that conclusion."

The nurse cares for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department?

"What can I do to help while you are here?"

A nurse wants to ensure inclusiveness in language regarding family when developing a plan of care for a client. Which action is the most important for the nurse to take to ensure that the plan is inclusive?

Ask the client to identify who is considered family.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients?

Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors.

An 8-year-old child, immobilized with a hip spica cast, says to the nurse, "I am so bored! Do you have any video games I can play?" What is the best nursing action?

Give child access to the unit's portable video game console and age-appropriate games.

A client in the manic phase of bipolar disorder constantly belittles other clients and is demanding special favors from the nurses. Which intervention by the nurse would be most appropriate for this client?

Set limits with specific and consistent consequences for belittling or demanding behavior.

The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive?

The client asks a roommate to put away dirty clothes because the untidiness bothers the client.

A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the charge nurse to intervene?

calling the Narcotics Anonymous group for the client

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:

consistently enforcing unit rules and facility policy.

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child?

engaging in play therapy

For which signs and symptoms should an adult victim of childhood sexual abuse be monitored? Select all that apply.

- depression - substance abuse - posttraumatic stress

A 7-year-old child has recently been diagnosed with a chronic illness. The parents ask the nurse if this new diagnosis might affect the child's 4 year-old sibling's behavior. Which reactions in siblings of children with chronic illness should the nurse discuss with the parents? Select all that apply.

- jealousy - embarrassment

An older adult has few health problems, performs self-care, plays cards, and talks about "the good old days." The client wants to make "final" arrangements, such as completing an advance directive and planning and paying for a funeral and burial. What interpretation does the nurse make about the client?

The request is age appropriate and should be honored.

Which is an important consideration when the nurse is providing culturally competent care in a community clinic?

asking about cultural beliefs related to health, illness, treatments, and dietary practices