Psychosocial Integrity

The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is best? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."

1. "Are you afraid of dying?" Encourages ventilation of thoughts and feelings regarding the concern

Which client statement indicates to the nurse the client is using the defense mechanism of conversation? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."

2. "I was unable to take my final exams because I was unable to write." Client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform.

The nurse manager of the psychiatric unit plans the biweekly, unit-wide interdisciplinary team case conference focused on one particular client. Which client is most important for the manager to select for discussion? 1. A client admitted after a 2nd serious suicide attempt and refuses to talk. 2. A client toward whom the staff have sharply conflicting attitudes and actions. 3. A client who experiences hallucinations, takes possessions from other clients, and paces continually. 4. A client, well known and well liked by staff, whose diagnostic testing revealts a brain tumor.

2. A client toward whom the staff have sharply conflicting attitudes and actions. Sharply confilcting attitudes and actions toward a client must be addressed, quickly and openly, and resolved in order to provide a therapeutic environment. The staff needs to be consistent in managing a client's behaviors. Staff conlict often stems from a client diagnosed with a personality disorder, particularly a client with borderline pd, as part of the manipulative pattern of behavior.

The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.) 1. Keep the voice even throughout conversations. 2. Explain the sounds in the environment. 3. Decrease background noise before speaking. 4. Stay in the client's field of vision. 5. Identify self by name and staff position

2. Explain the sounds in the environment. 4. Stay in the client's field of vision. 5. Identify self by name and staff position

The nurse provides care for a client experiencing alcohol withdrawl 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. Turn on the lights and remain with the client. 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.

The nurse provides care for a client hospitalized with a deep vein thrombosis. The client is a single parent of a young school-aged child. It is most important for the nurse to respond to which client statement? 1. "My work doesn't offer any sick leave." 2. "What am I going to do while I am stuck in bed?" 3. "I am not sure who is taking care of my child." 4. "I am missing my mother's 50th birthday party."

3. "I am not sure who is taking care of my child." Ensuring the child has a safe place and person to care for the child is a safety need. If the client is unable to make arrangement for the child's care, the nurse should contact social servides about arranging care for the child.

The nurse visits the home of a family whose mother dies 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1. A 3-year-old explains that mother is sleeping at grandmother's house. 2. A 6-year-old experiences enuresis and temper tantrums. 3. A 9-year-old state that no one will play with him. 4. a 12-year-old spends time away from home with friends.

3. A 9-year-old state that no one will play with him. The inability to enjoy play is masked by this typical statement and is a hallmark sign of depression in children.

A client is brought to the emergency department by friends who state, "Our friend has been ganing with the wrong crowd. We are worried about drug use." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, an eyes that are moving rapidly side to side and up and down. Which manifestation(s) is/are most important for the nurse to anticipate? 1. Torticollis 2. Hypotension, hypothermia, bradycardia 3. Aggression. 4. Nausea, vomiting, abdominal cramping

3. Aggression. The symptoms of blank stare, rigid muscles, ataxia, and nustagmus that are both vertical and horizontal indicate probable PCP intoxication. Aggression in all forms is another symptom that manifests with PCP use. This can take the form of assault, belligerence, impulsiveness, or suicidality, and it is very often bizarre in nature. It often occurs in upredictable outbursts. This manifestation impacts safety. Therefore, this is the most imporatant clinical manifestation for the nurse to monitor for when providing care for this client.

The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is best? 1. Encourage the client not to do anything without thinking it through very carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential. 3. Report this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what is being felt.

3. Report this to staff members in order to protect the client. Nurse must let the client know this information will be shared with the staff so the client's safety can be preserved.

A nurse provides care for a client diagnosed with a stroke located in the left hemisphere. Which characteristics of the client would the nurse expect to most influence the emotional response to this situation? 1. The client's ability to understand the illness and treatment. 2. The client's perception of the care received during the illness. 3. The client's personality and general health prior to the stroke. 4. The client's prognosis based on the type of lesion from the stroke.

3. The client's personality and general health prior to the stroke. A client's past experiences and coping mechanisms are major factors in determining client's reaction to having a stroke. It plays a factor in how well the client accepts and participates in the recovery phase.

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn 3. Want to discuss and plan meals 4. Have a close relationship with a parent.

3. Want to discuss and plan meals. Display a marked preoccupation with food.

The nurse in the community mental health center talks individually with a client with generalized anxiety disorder and who has been attending center programs for 4 months. Which statement made by the client best indicates that the anxiety is resolving? 1. "I have stopped biting my nails and picking at my skin." 2. "When things get to be too much, I go into my room." 3. "I still get anxious, but the episodes do not last as long." 4. "I am sleeping 7 hours a night and my dreams are calm."

4. "I am sleeping 7 hours a night and my dreams are calm." Sleeping well indicates major resolution of anxiety, as the sleeping and dreaming both reflect and affect body, mind, and spirit and are not conscious processess. In anxious states, there is a disturbed sleep pattern, sleep deprivation, and fatigue. Intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep.

The nurse provides care for a client admitted for abdominal surgery. During the admission interview, the client admits to drinking 1 pint of bodka per day. Which is the best initial response by the nurse? 1. "Why do you drink a whole pint of vodka per day?" 2. "How long have you been drinking that quantity of alcohol?" 3. "Do you drink with someone or at a particular place?" 4. "When did you have your last drink of alcohol?"

4. "When did you have your last drink of alcohol?" Alcohol withdrawal peaks 24-48 hours after the last drink. The nurse must have this information to prevent serious physiological complications, such as seizures.

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the initial priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activities. 4. Administer and monitor sedative and mood-stabilizing medications.

4. Administer and monitor sedative and mood-stabilizing medications. It is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents.

The school nurse notes that an 8-year-old child experiences stomach aches that are relieved after the nurse contacts the parents at work. Which action is the most important for the nurse to take? 1. Ask the child what is eaten for breakfast and dinner. 2. Ask the child to describe life at home. 3. Report this event to social services. 4. Ask the parents how the child behaves prior to school.

4. Ask the parents how the child behaves prior to school. The nurse needs to validate anxiety, especially separation anxiety. The child may be worrying about the parents and is relieved when the nurse talks to them.

The nurse cares for the client after an electroconvulsive therapy treatment. The nurse reports which observation to the health care provider? 1. Headache 2. Disruption in short-term and long-term memory. 3. Transient confusional state. 4. Backache.

4. Backache. Client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider.

The nurse interviews a college student involved in an auto accident 6 months ago that killed the client's best friend. The student reveals to the nurse an inability to study, trouble sleeping, and feeling of going crazy. Which action by the nurse is most important? 1. Complete a physical and social history. 2. Obtain a drug and alcohol history. 3. Review significant events from the past year. 4. Determine the student's past coping behaviors.

4. Determine the student's past coping behaviors. Obtaining information about how the client coped in the past will help the nurse determine interventions to assist the client to cope now.

The nurse provides care for clients in the ED. A nely married woman is brought to the ED by her parents, who related that their son-in-law was killed 3 days ago in a boating accident. The parents reprot their daughter has been uncontrollably screaming and crying since the accident. Which action does the nurse take first? 1. Administer diazepam 2. Ask the parents to leave the room 3. Refer the client and her parents to family therapy. 4. Silently sit with the client maintaining eye contact.

4. Silently sit with the client maintaining eye contact. It is important that the nurse convey warmth, caring, and empathy with the client. The nurse should structure the environment so the client can express feelings about her loss. It is important to allow the client to share painful feelings while the nurse is silent. Maintaining eye contact is healing and conveys concern.