NCLEX 10000 Psychosocial Integrity

On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate?

"I am truly sorry you lost your baby." The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I am truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings.

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which of the following responses by the nurse would be most appropriate?

"I do not hear any voices. What are you hearing?" A hallucination is a false sensory perception. It involves all five senses and bodily sensations. Initially, the nurse needs to assess what kind of voices are being heard. That is, are they friendly, commanding, or controlling voices? Acknowledging that the client is experiencing the voices but telling the client that the nurse does not may assist the client to realize that the voices are not real.

Parents report that their daughter, age 4, resists going to bed at night. After instruction by the nurse, which statement by the parents indicates effective teaching?

"We'll read her a story and let her play quietly in her bed until she falls asleep." The parents stating that they'll read the child a story and let her play quietly demonstrates effective teaching because spending time with the parents and playing quietly are positive bedtime routines that provide security and prepare a child for sleep.

A nurse is interviewing a client with posttraumatic stress disorder (PTSD) when a loud, booming noise from a passing car's radio rattles the windows. The client jumps onto a chair, wide-eyed and frantic. Which statement by the nurse is the most therapeutic response?

"What kinds of feelings are you experiencing?" he client's response is out of proportion to the situation. This behavior is characteristic of clients with PTSD, who are reliving a traumatic event and can't process the situation logically. Asking what feelings the client is experiencing provides an opportunity for therapeutic ventilation of emotions by allowing the client to express feelings the external stimulus has triggered.

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

Continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. Safety is the nurse's first priority. The client is experiencing altered thought processes and is unlikely to be able to distinguish his spiritual beliefs at this time.

A client who is experiencing hallucinations asks if a nurse hears the voices that are telling him he should never have been born. The nurse's most appropriate response would be:

I don't hear any voices, but I believe you can hear them." The nurse admitting that she doesn't hear voices but that she believes the client can hear them is an honest, straightforward response that acknowledges the truth without negating the reality of the client's experience.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing. Interventions should be directed at helping the client complete activities of daily living with the assistance of staff members, who can provide needed structure by communicating tasks in clear, concise bits of instructions. This intervention promotes realistic independence.

A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

Spiritual alienation Spiritual alienation occurs when an individual is separated from her/his faith community.

A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which of the following is the most appropriate step for the nurse to take to help the client?

Support the client in developing attainable socialization goals. Supporting the client in goal-setting around social interaction is the first step in promoting change for wellness.

A client with schizophrenia tells the nurse that he does not go out much because he does not have anywhere to go and he does not know anyone in the apartment where he is staying. Which action is most beneficial for the client at this time?

arranging for the client to attend day treatment at the clinic Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time.

The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife asked him for a divorce. Which intervention is most appropriate?

directing the client to describe his feelings about his impending divorce The nurse helps the client to focus on his feelings about his impending divorce to decrease the client's anxiety and decrease his focus on physical ailments. The client with a somatoform disorder typically has problems with identifying, describing, and dealing with feelings. Internalizing feelings leads to increased anxiety and the need for protective mechanisms.

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal:

unpredictable behavior and intense interpersonal relationships. A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. His interpersonal relationships may be intense and unstable, and his behavior may be inappropriate and impulsive.

A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which of the following for the client?

Feeling out of control and disgusted with self. For the client with bulimia, binges involve a loss of control that results in thoughts of self-deprecation. Binges may reduce the feelings of anxiety felt before the bingeing behavior.

A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?

Past and current life actions. According to Hinduism, illness is the result of past and current life actions.

When developing a care plan for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds?

Preschool age Preschool-age children are most likely to view illness as a punishment for misdeeds.

A 13-year-old junior high school student has come to the school nurse, stating that her father has physically abused her for 3 years. Initially, the client accepted the abuse, thinking it was because her father had been laid off, but the abuse continued after he got a job 4 months ago. She fears that her mother will not believe her and her father will reject her if they discover she has revealed the abuse. The nurse should first:

Report the alleged abuse to Child Protective Services (Ministry of Children and Family) that day, and then provide for the child's safety. All suspected child abuse must be reported, but this child's age and ability to describe the abuse make this allegation particularly strong. Because parental reaction to her allegation is not predictable, the nurse must ensure the child's safety. The nurse should not discuss the situation with the client or the parents. The nurse must refer this case to Child Protective Services (Ministry of Children and Family).

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next:

Report this finding to the Adult Protective Services (APS). Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse.

The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent from a health care provider's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the above nursing note. Which nursing statement is appropriate at this time?

"I will check with the health care provider to see if further tests are needed." At this time, fetal demise is anticipated due to a lack of fetal heart rate and movement. An ultrasound may be ordered to confirm status.

A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of "Anxiety." A short-term goal is established as follows: "The client will identify physical, emotional, and behavioral responses to anxiety." Which nursing interventions will help the client achieve this goal? Select all that apply.

• Observe the client for overt signs of anxiety. • Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise. • Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. The nurse should observe the client for overt signs of anxiety to assess anxiety and establish care priorities. He or she should also help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. To modify the automatic response to stress, the client needs to connect the anxiety experience with the unpleasant symptoms. The nurse should also introduce new coping strategies, such as relaxation techniques and exercise, which can enable the client to take personal responsibility for making changes. The nurse should work with the client to identify sources of stress.

A nurse caring for a client with schizophrenia goes into the client's room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse?

"How do you feel when you see the creatures?" The most appropriate response by the nurse is "How do you feel when you see the creatures?" The client is experiencing a delusion, a false belief that has no basis in reality. When the client experiences a delusion, it is important to acknowledge the delusion and to ask the client to describe it and how it makes them feel. These actions help identify the type of delusions so that the correct intervention can be implemented while establishing trust. If asked, the nurse should point out that they are not experiencing the same stimuli but should not argue with the client