PassPoint - Psychosocial Integrity

Which question should the nurse ask to best determine the seriousness of a client's suicidal ideation?

"How are you planning on harming yourself?"

A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells a nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk." What is the most appropriate response?

"The meetings are a part of your treatment. You seem upset about attending them."

The nurse is caring for a client 2 days post-cesarean section who is scheduled for discharge today. The client states, "I do not want to go home." What response by the nurse is most appropriate?

Ask the client the reason she does not want to go home.

A client who has smoked cigarettes has been diagnosed with coronary artery disease. The client states, "My spouse is always telling me I should quit. Maybe I should start listening to them." What is the nurse's best initial action?

Ask the client what benefits they might expect if they stopped smoking.

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills?

Assist the client to identify coping mechanisms used in the past

A nurse has been called into a room by another nurse to assist with a client who is acting provocatively and overly dramatic. What action is most important for the nurse to take to assist the client in receiving appropriate care during this visit?

Communicate in a way that models the expected behavior of the client.

The community health nurse is assessing a family consisting of a single parent, a grandparent, and two teenage children. The family has faced several challenges recently, including the parent losing their job and the grandparent being diagnosed with a chronic illness. The family has been referred for family therapy. Which nursing action should be the priority with this family?

Complete a thorough assessment of the family's support system, including extended family, friends, and community resources.

A client who underwent cardiac surgery 2 days ago is recovering well. The client's spouse, who is assisting with care, says, "My spouse is doing too much. I want to help, but they won't let me." The nurse says to the spouse, "It sounds like you need to feel you can be more helpful." In order to make the nonverbal behavior complement the words, what should the nurse do?

Direct the body and eyes at the spouse and client.

A nurse assesses an 82-year-old client for depression. Because of the client's age, the nurse's assessment should be guided by which factor?

Sadness of mood may be masked by other symptoms.

The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care?

cleaning the dayroom tables

The nurse is helping a client deal with personal issues and painful feelings. What does the nurse identify as a crucial goal of therapeutic communication?

conveying client respect and acceptance even if not all of the client's behaviors are tolerated

In a predischarge program to educate clients with bipolar disorder and their family members, the nurse emphasizes that which symptom is the most significant indicator for the onset of relapse?

decreased need for sleep and racing thoughts

Which factors should be the primary factor in a nurse's decision whether to pray with a client?

the client's openness to being prayed for

An overweight adolescent client has lost 12 lb (5.4 kg) in 8 weeks using diet strategies. The client reaches a weight loss plateau and is discouraged. The nurse instructs the client to keep a food diary for what purpose?

to help the client analyze how much food is consumed and when

The nurse is caring for an 8-year-old girl with frequent urinary tract infections who is withdrawn and quiet. The nurse learns the child is left with a male caregiver while the mother is at work. The child states, "It hurts down there." What is the best response to the child?

"Are there other times you have hurt down there?"

A 3-year-old child of Vietnamese descent with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, welt-like lesions on the child's upper back and chest. Which question should the nurse ask next?

"Can you tell me about any cultural practices in your family?"

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" Explanation: The first task during the introductory, or orientation, phase of the nurse-client relationship is to formulate a contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship. These tasks should precede the exploration of relevant stressors and new coping mechanisms. Offering false reassurance is never therapeutic.

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." Explanation: 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. Asking the client whether they are experiencing a great deal of uterine pain is inappropriate because this is a "yes-no" question and does not allow the client to express their feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that they contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not their fault. Telling the client that they can get pregnant again after a normal period may be factual, but it does not address the feelings of the expectant client who had already begun to bond with the fetus.

The nurse evaluates the progress of a client being treated for somatoform disorder. Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?

"I understand my pain will feel worse when I am worried about my divorce."

A nurse works in a suicide crisis clinic. The clients that represent the highest risk for suicide are those who state:

"I'm thinking of driving my car into a tree on the way home."

The parent tells the nurse that the diagnosis of colic upsets them because they know the infant will continue to have colicky pain. Which response by the nurse would be most appropriate?

"It can be difficult to listen to your baby cry so loud and so long, so try to make sure that you get some free time."

The nurse is caring for a client who has been physically abused. Which statement by the nurse expresses empathy for this client?

"It must be difficult what you have been going through." Explanation: Empathy is a person's ability to understand what another person is going through and be objective at the same time. The nurse does not carry those feelings or that situation with them as in sympathy but is still able to relate to the person well. "It must be difficult what you have been going through" is such an example. It gives the client an opening to express any feelings regarding the abuse. "Our staff will do the best they can to make you feel comfortable" is a stereotypical response that does not empathize with the client. "Do you have questions about what is happening?" is a closed question and also a stereotypical question that nurses often ask when no other statement is known to them. "I am so sad to see you going through so much pain" is an example of a sympathetic response because the nurse is showing feelings of sadness over the client's situation.

A female client who was raped in their home was brought to the emergency department by their spouse. After being interviewed by the police, the spouse talks to the nurse. "I don't know why they didn't keep the doors locked like I said. I can't believe they had sex with another person now." How should the nurse respond?

"Let's talk about how you feel. Maybe it would help to talk to other people who have been through this."

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."

A client with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. This client was found wandering the streets disheveled, shoeless, and confused. The client points to the police officer and states, "That person was sent by the devil to kill me." Which response by the nurse is best?

"That sounds scary. That person is a police officer and brought you to the hospital." Explanation: This client is experiencing a psychotic break as evidenced by the delusion and disorganized behavior. The nurse should address the client's feelings and provide factual information. Stating the client's thinking is "untrue" is confrontational. Asking the client to ignore the police officer dismisses the client's feelings. Telling the client the nurse has taken care of others in the same situation focuses on the nurse and other clients. The most therapeutic response should address the client's feelings and provide correct information.

During a private conversation, a client with borderline personality disorder asks a nurse to "keep this secret," then displays multiple, self-inflicted, superficial lacerations of the forearms. What is the nurse's best response?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

A client who has received a poor prognosis tells the nurse, "I have not been to church in decades even though I was raised Catholic. Can you arrange for a priest to come see me?" What is the nurse's best response?

"We will try to get in touch with one and ask him to come and see you."

The health care provider (HCP) recommends that a client have a partial bowel resection and an ileostomy. Later, the client says to the nurse, "That doctor of mine surely likes to play big. I will bet the more the doctor can cut, the better they like it." Which reply by the nurse is most therapeutic?

"What do you mean by that statement?"

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the most therapeutic response by the nurse?

"You are concerned that the client is receiving too much narcotic medication?"

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process?

"You cannot have any visitors while you're here involuntarily."

A school-age child is referred to the mental health clinic by the school nurse because they are fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with their parent, who says, "It's that school nurse again. They have done nothing but try to make trouble for our family since my child started school. And now you're in on it." What is the nurse's most appropriate response?

"You sound pretty angry with the school nurse. Tell me what's happened."

A nurse is caring for multiple grieving clients. Which client is most likely to experience disenfranchised grief?

A 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident

The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, "Bastard," under their breath. Which nursing action is most appropriate?

Approach the client to interrupt the hallucinations.

The nurse is speaking to a client about a recent cancer diagnosis. The family is also in the room discussing their needs and concerns. The nurse wants to build trust with the family to most effectively assess their needs. What should the nurse do to build rapport with the client and their family? Select all that apply.

Ask the client and family open-ended questions. Rephrase back to the family what they have said. Use the same terms that the family is using when appropriate. Maintain a position at eye level to the client and family.

The pediatric nurse is working with a family whose toddler is receiving palliative care as a result of a malignant sarcoma. The interdisciplinary care team has recommended family therapy as a means of supporting the family's ongoing needs, but a member of the family states, "I'm probably not going to attend. What's the use?" What is the nurse's best initial action?

Encourage the family member to elaborate on the reasons for their reluctance.

Which interaction is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client?

Equal sharing of time for discussion of problems so there is mutuality in the relationship

A nurse meets frequently with a depressed client. The client stays mostly in their room and speaks only when addressed, answering briefly and abruptly while keeping their eyes on the floor. Initially, the nurse should focus on the client's ability to do which function?

Express themself verbally.

The nurse manager on the urology unit has employed three nurses from a culture that is different from that of most of the nurses and patients on this unit. Which strategy would help the newly employed nurses socialize into the team and promote the cultural competence of all of the nurses?

Hold a culture-sharing session at monthly meetings.

In the hospital setting, the child of a client who is dying tells the nurse, "It is hard to just sit here for hours and not say or do anything." As the nurse responds to the child's statement, what issue is most important for the nurse to focus on during their discussion?

Know that being present with the person is important.

A nurse on the crisis team in the emergency department is caring for a client who is angry and is experiencing delusional episodes. The client says to the nurse, "I'm going to kill my wife and chop her up to get rid of her." What is the nurse's priority action in this situation?

Notify the wife that she may be in danger. Explanation: The client is making statements that may be acted on. The nurse is obliged to notify the wife that she might be in danger. If the nurse believes the statements reflect a new symptom, such as delusions, the attending psychiatrist should be contacted for further direction. The other options are incorrect because they do not protect the client's wife, whom he has clearly indicated he has a plan to harm.

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

Refer the client to a community support program.

A client is complaining to other clients about not being allowed by staff to keep food in their room. What action should the nurse take?

Set limits on the behavior.

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.

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.

The pediatric nurse is caring for a client with multiple fractures from a motor vehicle collision in which the parents also sustained injuries. The family has complex needs because they have two other school-age children at home. When assessing the family's current needs and available social supports, the nurse should perform what action?

Use active listening and ask open-ended questions.

The partner of a 22-year-old client dies in a drunk-driving accident. The client complains of difficulty eating, sleeping, and working. The reaction is considered:

a crisis caused by traumatic stress.

A school-age client 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?

a stage of grief reaction

The nurse is caring for a client who recently lost an infant to sudden unexplained infant death syndrome (SUIDS). The client talks about going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate?

acceptance

In assessing a postmastectomy client, the nurse determines that the client is in denial. The nurse can best respond by

accepting the denial. Explanation: When a client is faced with body image alterations and, possibly, terminal illness and death, the nurse should allow the client to express their feelings. By accepting the initial denial, the nurse acknowledges the role that denial plays in the coping process. Interpreting the client's denial and then confronting the client with it will increase their anxiety, hinder the development of a trusting relationship, and delay the client's acceptance of their condition. Accepting the client's denial doesn't imply that the nurse supports it.

The nurse is working on a psychiatric unit with new admissions with suicidal ideation. What characteristic is being described by a client who states, "I want to live, but maybe the answer is to die"?

ambivalence

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior?

avolition Explanation: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.

A partner of a client diagnosed with Kaposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving?

denial stage

A nurse is assessing a client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is:

diarrhea.

A client with a diagnosis of schizophrenia is experiencing paranoia and tells the nurse about hearing a voice saying, "Don't take those poisoned pills from that nurse!" Which objective assessment regarding this statement will the nurse report to the healthcare team?

disturbed perceptions

The nurse is evaluating the test results of a client undergoing testing for depression. Which results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression?

elevated afternoon serum cortisol

A client receiving dialysis directs profanities at the nurse and then abruptly hangs their head and pleads, "Please forgive me. Something just came over me. Why do I say those things?" The nurse interprets this as which finding?

emotional lability

A nurse is caring for a client with illness anxiety disorder. Which behavior is the nurse most likely to encounter?

expression of fear of colorectal cancer following 3 days of constipation

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

health habits, family relationships, affect, and thought patterns

A client who has paranoid personality disorder is participating in a treatment group. Which behavior should the nurse observe for as the client participates in the group?

hypervigilance

The client states they wash their feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling?

intolerable anxiety

A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that

it is normal for the child to want to sleep with them at night.

A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does not experience further confusion. Which measure if suggested by the family would the nurse discourage?

keeping lights dimmed during daylight hours

Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit?

keeping the door closed to provide privacy Explanation: Keeping the client's door closed is likely to contribute to feelings of isolation and sensory deprivation. Such activities as watching television, visiting with a relative, and reading a newspaper help prevent sensory deprivation and yet do not require physical effort.

A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client?

lithium and valproic acid

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:

may be experiencing increased energy and is at increased risk for suicide. Explanation: As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until the risk of suicide has diminished. The client's elevated mood is a response to the antidepressant, not an indication of a split personality.

A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on:

providing emotional support and individual counseling.

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client?

rape-trauma syndrome

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 nurse is caring for a client with chronic pain. In planning care, what will the nurse focus on as part of incorporating spiritual health into the client's plan for pain control?

spiritually linked actions that the client has used to manage pain in the past

A client walks into the clinic and tells the nurse they have run out of money for crack and have crashed and they want something to help them feel better. Which factor is most important for the nurse to assess?

suicidal ideation

A client has become increasingly afraid to ride in elevators. While in an elevator one morning, the client experiences shortness of breath, palpitations, dizziness, and trembling. A physician can find no physiological basis for these symptoms and refers the client to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which type of therapy is most likely to reduce the client's anxiety level?

systematic desensitization Explanation: Phobias are commonly viewed as learned responses to anxiety that can be unlearned through certain techniques such as behavior modification. Systematic desensitization, a form of behavior modification, attempts to reduce anxiety, and thereby eradicate the phobia, through gradual exposure to anxiety-producing stimuli. Psychoanalytically oriented therapy also may be effective in this situation, but years of treatment are required to achieve results. Group psychotherapy could be used as an adjunct treatment to increase the client's self-esteem and reduce generalized anxiety. Electroconvulsive therapy is reserved primarily for clients with severe depression or psychosis who respond poorly to other treatments; it's rarely indicated for phobic disorders.