Psychosocial Integrity 2
The home health nurse visits a home occupied by two parents, their preschool-age child, and an older adult grandparent who has been living with them for 2 months. The nurse visits to assess the grandparent after treatment for a fall and broken arm. Which statement by the child most concerns the nurse? 1. "My grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?" 2. "Sometimes when I drink milk, I throw up." 3. "We never go anywhere anymore since my grandparent moved in with us." 4. "I want to be a doctor when I grow up and take care of hurt children and animals all over the world."
1 (1) CORRECT — The cat's injuries and behaviors may indicate pet abuse, which can be a sign of other abuse going on in the home. This home has three categories of people at risk for abuse: child, spouse, and older adult. The grandparent was treated for injuries that might have been related to abuse. The nurse should further assess the situation for indicators of abuse. 2) INCORRECT— This may indicate a lactose allergy and requires further investigation. However, this does not pose a risk of immediate physical harm. This is not the priority concern. 3) INCORRECT— This may indicate sadness or anger on the part of the child and requires further investigation. However, this does not pose a risk of immediate physical harm. This is not the priority concern. 4) INCORRECT— This is not a concern.)
The nurse cares for a Japanese American client. The nurse discusses preoperative procedures with the client. The client continually smiles and nods while the nurse is talking. How does the nurse interpret this behavior? 1. It reflects the cultural value of interpersonal harmony. 2. It indicates acceptance of the treatment plan. 3. It indicates agreement with what the nurse is saying. 4. It reflects the client's understanding of the procedure.
1 (1) CORRECT— The client's behavior only indicates the client's attempt to be agreeable. 2) INCORRECT — This is not an accurate interpretation of the cultural gesture. 3) INCORRECT — This is not an accurate interpretation of the cultural gesture. 4) INCORRECT — This is not an accurate interpretation of the cultural gesture.)
The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn? 1. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed. 2. A client who was just informed of a cancer diagnosis by the health care provider. 3. A client recovering from a stroke who has returned from physical therapy. 4. A client who received pain medication 5 minutes ago for relief of discomfort.
1 (1) CORRECT— This client should be rested and less distracted and is most likely not tired or hungry. 2) INCORRECT - This client will be preoccupied by the new cancer diagnosis. 3) INCORRECT - This client is most likely tired after therapy and will display cognitive deficits not conducive to learning. 4) INCORRECT - This client's pain is most likely not yet relieved so discomfort may be a distractor.)
A client scheduled for a CT scan says to the nurse, "The health care provider had me sign that form for the scan. I thought I understood what was said, but now I 'm not so sure. " Which is the best response by the nurse? 1. "What is it that you are not sure you understand? " 2. "I 'll contact the health care provider so that you can get your questions answered. " 3. "Maybe I can help you. " 4. "There is nothing to this test. "
1 (1) CORRECT— This response specifically addresses the client 's concerns so they can best be addressed. The nurse can clarify questions after the HCP has explained benefits and risks of the procedure to the client. 2) INCORRECT - This is not appropriate because the nurse should identify the client 's concerns and try to address them. 3) INCORRECT - This is not the best response because the tone is tentative and does not directly elicit the client 's specific concerns. 4) INCORRECT - This is a nontherapeutic response, and is dismissive of the client 's feelings and concerns.)
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.) 1. Sing or talk to the client throughout the activity. 2. Expose only one area at a time while bathing. 3. Complete the bath as quickly as possible. 4. Organize all supplies before starting the bath. 5. Bathe the client slowly and explain each action.
1, 2, 4, 5 (1) CORRECT - This strategy, continuous communication, can help the client relax and be more cooperative. 2) CORRECT - This strategy will help keep the client warm and provides privacy. 3) INCORRECT - Moving quickly may agitate the client. 4) CORRECT - An organized and efficient bath process prevents an interruption to retrieve a missing item needed for the bath. 5) CORRECT - Moving slowly and explaining each touch can help the client relax and prevent agitation and possible injury. )
The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.) 1. The nurse assessed a suicidal client every 15 minutes. 2. The nurse administered ziprasidone to a violent client. 3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. 4. The nurse allowed a suicidal client to remain in street clothes. 5. The nurse initiated a signed PRN prescription for physical restraints.
1, 3, 4, 5 (1) CORRECT - The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. 2) INCORRECT - It is appropriate to use a chemical restraint when a client is a risk to harm self or others. 3) CORRECT - Seclusion is never punitive. This intervention is only to be used to achieve the goal of client and others ' safety. 4) CORRECT - All clothing and personal belongings are secured to minimize the potential for self-harm. Clients are placed in hospital gowns only. 5) CORRECT - Restraints are never a PRN prescription. The nurse uses alternative measures prior to the use of restraints (such as reorientation, family involvement, frequent assistance with toileting).)
A client refuses to allow a student nurse to provide care stating, "They are going to hurt me." Which responses by the nursing student cause the nurse intervene? (Select all that apply.) 1. "Don't worry. We've never killed anyone." 2. "What specifically are you worried about?" 3. "We often look pretty scary." 4. "That sounds frightening." 5. "The nurse will assist you with your bath instead."
1, 3, 5 (1) CORRECT - Telling the client not to worry and that students have not killed anyone supports the client's belief. It also provides false reassurance, which is not a therapeutic response. 2) INCORRECT- Asking the client explain specific worries clarifies the client statement, which is an appropriate statement to make. 3) CORRECT - Stating that students look scary supports the client's belief and is not a therapeutic response. 4) INCORRECT- Saying that the client's statement sounds frightening reflects the client's feelings. 5) CORRECT - Saying that the nurse will help the client with the bath instead of the nursing student minimizes the client's concern. However, the tasks were delegated to the nursing student. This response supports the client's fears and beliefs. )
The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) 1. Remain with the client. 2. Contact the police to interview the client. 3. Administer prescribed lorazepam 1 mg orally. 4. Encourage client to describe the incident. 5. Provide privacy for the client. 6. Write down important information.
1, 3, 5, 6 ()
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, "Get it yourself!" The nurse recognizes the charge nurse is displaying which defense mechanism? 1. Compensation. 2. Displacement. 3. Conversion. 4. Projection.
2 (1) INCORRECT - Compensation is an attempt to overcome real or imagined shortcomings. 2) CORRECT— The charge nurse is displacing feelings of anger at the supervisor onto the client who is less threatening. 3) INCORRECT - Anxiety is repressed and converted into physical symptoms in conversion syndrome. 4) INCORRECT - Projection is the act of attributing one's feelings, impulses, thoughts, or wishes to others. )
A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client? 1. "This is not the first time I felt this way." 2. "I will not sign a no-suicide contract." 3. "This is my fifth hospitalization for depression." 4. "My mother attempted suicide at age 40."
2 (1) INCORRECT - These thoughts often recur and it is not an indication for one-to-one supervision. The nurse assists with problem-solving and decision-making to give client a sense of control other than through suicide. 2) CORRECT - Place the client on one-to-one observation and stay with client to help control self-destructive impulses. The client is never out of sight of a supervisory health care staff member. One-to-one observation is required for clients currently verbalizing a clear intent to harm self, unwilling to sign a no-suicide contract, with poor impulse control, and who have already attempted suicide in the past by a lethal method (hanging, gun). 3) INCORRECT - Repeated hospitalizations for depression does not indicate that the client is self-destructive. Depression is a response to a real or imagined loss with symptoms such as low self-esteem, self-deprecation, and feeling helpless or hopeless. 4) INCORRECT - Predisposing factors include males over age 50, age range of 15 to 19 years, poor social attachments, and previous suicide attempts.)
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which statement is best for the nurse to make to the parents at this time? 1. "You should focus on your baby's personality, not appearance." 2. "Let me show you pictures of some babies before and after surgery." 3. "There are other problems with this condition that go beyond surgical correction." 4. "Has anyone else in either of your families had cleft lip or palate?"
2 (1) INCORRECT - This statement is judgmental and does not allow for the parents' expression of feelings and concerns. Facial anomalies in a child are very visible and a shock to the parents when first seen. 2) CORRECT — This addresses the immediate fears and concerns of the parents, who are in a state of crisis. It offers concrete pictorial evidence of a brighter future for their child than they might otherwise have expected. 3) INCORRECT - This is a true statement, but could be frightening and discouraging to the parents at this time, particularly without having given them the reassurance that surgery can help deal with their immediate concern. 4) INCORRECT - Genetic factors might be etiologic factors, as family history of a cleft increases the risk of other children having a cleft. However, this is a history-taking question and does not respond the parents' emotional concerns. )
A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the woman wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take? 1. Make eye contact with the client and ask about the accident. 2. Accompany the client into the restroom to obtain a urine sample. 3. Ask the husband if the wife had been drinking alcohol. 4. Escort the couple to an examining room to await the health care provider.
2 (1) INCORRECT - Victims of domestic violence will not admit to abuse in the presence of the abuser. 2) CORRECT - A useful strategy to get women away from an abuser is to claim the need to assist in obtaining a urine sample so that the nurse can further assess the client without the client feeling as fearful. 3) INCORRECT - Substance abuse is not relevant or important at this time. The observations suggest abuse. 4) INCORRECT - The woman may not be safe with the spouse. Additionally, waiting in a room provides an opportunity for one or both people to decide to leave.)
The nurse provides care for a client experiencing alcohol withdrawal delirium. The client tells the nurse that bugs are crawling on the walls in the room. Which action by the nurse is appropriate? 1. Place a can of insecticide within the client's field of vision. 2. Turn on the lights and remain with the client. 3. Distract the client with simple activities. 4. Dim the lights and encourage the client to rest.
2 (1) INCORRECT — The nurse avoids validating the client's hallucination. 2) CORRECT— The client with alcohol withdrawal delirium may experience delusions and hallucinations. Place the client in a quiet, well-lighted room and stay with the client, if possible, to interpret the environment. 3) INCORRECT — The client experiencing alcohol withdrawal is not capable of engaging in activities. This is a physiological illness with severe cognitive alterations. 4) INCORRECT — The nurse will decrease stimuli, but a darkened room can produce hallucinations and incite fear rather than inhibit these experiences.)
A young adult client who is diagnosed with depression is prescribed duloxetine. The client has not showered or eaten in days. Which response by the nurse to the client is appropriate? (Select all that apply.) 1. "Why aren't you taking care of yourself? Do you just not care anymore?" 2. "When did you last take your prescribed medication?" 3. "Do you have thoughts of harming yourself?" 4. "Here is a menu. Let the nurses' aid know when you decide what you want to eat." 5. "I've brought you some towels and soap. You will feel better after you've had a shower." 6. "Have you been smoking more cigarettes lately?"
2, 3 (1) INCORRECT— Asking why the client is not participating in self-care is a leading question and judgmental. It is more important to assess the client's mood. 2) CORRECT — Duloxetine is used to treat depression. It is important to determine if the client is taking the medication as prescribed. 3) CORRECT — Suicidal ideation is increased in those who are under the age of 24 and prescribed duloxetine. 4) INCORRECT— Persons with depression may have difficulty making decisions. The nurse should offer the client one or two choices, then place the dinner order for the client. 5) INCORRECT— Due to an increased risk of suicidal ideation, the nurse should not send the client alone to shower. Assistance with personal hygiene should be provided. 6) INCORRECT— There is no interaction between nicotine and duloxetine.)
The nurse provides care for a client with a history of substance abuse. Which intervention does the nurse include in the plan of care for this client? 1. Refer the client to a Social Service Agency (SSA) for assistance with housing. 2. Refer the client to an aftercare center in the community. 3. Encourage the client to participate in Alcoholics Anonymous (AA) meetings with a sponsor. 4. Obtain a prescription for antidepressant medication.
3 (1) INCORRECT - A 12-step program is the most effective treatment for substance abuse. There is no evidence the client has an issue with adequate housing necessitating a referral to an SSA. 2) INCORRECT - A self-help program such as AA has been found to be most effective for clients with a history of substance abuse. An aftercare center in the community is likely not to have resources needed for the client with a history of substance abuse. 3) CORRECT— The 12-step program by AA has the concepts basic to all self-help groups. Individuals with substance use disorders feel powerless over their addictions and can benefit from a sponsor who has been successful in the program. 4) INCORRECT - An antidepressant would only be helpful if the client presents with symptoms of depression. The appropriate treatment option for this client is the self-help group to work through the addiction.)
The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene, and command hallucinations." Which action is most important for the nurse to take when caring for this client? 1. Note the quality and duration of the gestures. 2. Offer the client a fresh change of clothing. 3. Ask the client what the voices are saying. 4. Administer antipsychotic medication.
3 (1) INCORRECT - Bizarre gestures are common, meaningless symptoms of schizophrenia and are not the priority action. 2) INCORRECT - Hygiene needs are not as important as safety needs. 3) CORRECT- The nurse must assess the nature of command hallucinations and then take appropriate safety action, as the voices may be telling the client to harm self or others. 4) INCORRECT - While this may be an appropriate intervention for this client, it is not the priority. The nurse must assess for safety needs first.)
The parent of a child who was just diagnosed with hemophilia A is talking to the pediatric nurse. Which statement from the parent does the nurse respond to first? 1. "I feel so guilty—like it is all my fault." 2. "I do not know how we will afford this." 3. "It scares me to think my child will be bleeding all the time." 4. "We were looking forward to watching our child play sports."
3 (1) INCORRECT - It is common for parents to feel guilt when a child is diagnosed with a genetic condition. Reassurance and counseling may be required. 2) INCORRECT - The cost of treatment is a realistic concern. Treatment with factor VIII concentrate is quite expensive, particularly if the hemophilia is severe. There is also the cost of treating injuries as they occur. 3) CORRECT - This is a common misconception that is easily and readily addressed and underlies many of the other concerns. The client's misconceptions and fears about the child being a "free bleeder", the lay term, must be clarified before teaching continues. 4) INCORRECT - This is a valid concern, but it is not a priority. This is psychosocial in nature. Sports where contact is an ongoing component of the game should be avoided, but swimming is a type of sport to be encouraged, for example. )
The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take first? 1. Ride the elevator with the client. 2. Encourage the client to get into the elevator. 3. Allow the client to avoid the elevator. 4. Encourage the client to discuss the fear.
3 (1) INCORRECT - The spouse should acknowledge the client's concerns. While being present is important, the spouse should not expect the client to be able to ride the elevator immediately. 2) INCORRECT - The spouse should not attempt to remove the defense mechanism initially. 3) CORRECT— By allowing the client to avoid the elevator, the spouse will not increase the client's apprehension and anger. This maintains a better relationship. 4) INCORRECT - While appropriate, it is more important to allow the client to avoid the elevator. Phobia is not rational and responds best to systematic desensitization. )
The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take? 1. Tell the client that the hospital is a safe place. 2. Urge the client to reveal more information. 3. Focus on developing a trusting relationship with the client. 4. Introduce the client to other clients on the unit.
3 (1) INCORRECT - This is important, but the client needs to trust the nurse enough to share more information. The priority is establishing a trusting nurse/client relationship. 2) INCORRECT - The nurse should first establish trust with the client. Then the nurse should use open-ended questions to encourage sharing of information. The client is unlikely to share more information until trust is established. 3) CORRECT— When caring for a client who is resistant and paranoid, the first priority is to develop a trusting relationship with the client. 4) INCORRECT - This is not a priority and may provoke anxiety for this client. )
The nurse admits a client to the psychiatric unit. During the interview, the client frequently changes the subject. Which response by the nurse is appropriate? 1. Remind the client about the care goals. 2. Focus the interview on the client's symptoms. 3. Recognize the client's behavior relieves discomfort. 4. Ask the client to choose a topic for discussion.
3 (1) INCORRECT — The nurse should maintain an accepting and helpful attitude toward the client. The client cannot refocus on care goals at this time, and the nurse must recognize this. 2) INCORRECT — The nurse should obtain information about the client's psychiatric and psychosocial health, as well as physical status. The client is unable to provide helpful information at this point, though. 3) CORRECT— The client appears anxious and is having difficulty focusing. The nurse keeps environmental stresses to a minimum. 4) INCORRECT — When the nurse determines that a client is anxious, the nurse avoids offering alternatives.)
The nurse provides home care for an older adult client diagnosed with impaired hearing. Which action is most appropriate for the nurse to implement based on this data? 1. Checking expiration dates on food packages. 2. Providing large-print reading material. 3. Teaching the importance of changing position. 4. Obtaining an amplified telephone for the client.
4 (1) INCORRECT — While this may be an appropriate assessment when providing care in the home environment, checking expiration dates on food refers to an olfactory impairment. This client is diagnosed with impaired hearing. 2) INCORRECT — Providing large-print material is an intervention for a visual impairment, not a hearing impairment. 3) INCORRECT — Teaching position changes refers to a tactile impairment. 4) CORRECT— An amplified phone helps with hearing and provides a means for communicating more easily with others.)
