NCLEX Prep: Client Needs: Psychosocial Integrity (I)

Which assessment data would cause the nurse to suspect that a toddler-age client is experiencing physical neglect?

Abdominal distention Abdominal distention is a physical manifestation associated with malnutrition that is associated with physical neglect. Bloody underclothing and recurrent urinary tract infections are clinical manifestations associated with sexual abuse. Bruises in various stages of healing is a clinical manifestation associated with physical abuse, not physical neglect.

A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety.

Confirming that the client is experiencing verbal hallucinations is the priority. Determination of the nature of the message that the voices are delivering takes place next. The risk for injury to the client and others is assessed after the focus of the hallucination is identified. Finally the nurse will assist the client in managing the reaction to the hallucination.

The nurse is providing care to a client who dies suddenly in the emergency department (ED). Which psychosocial nursing action is the priority in this situation?

Dealing with personal feelings The priority psychosocial nursing action in this situation is to deal with personal feelings regarding the sudden death. Notifying the family, documenting the situation, and performing postmortem care are all appropriate nursing interventions; however, these are not psychosocial nursing actions but physiologic actions.

What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder?

Removing as many stimuli from the client's environment as possible Removing as many stimuli from the client's environment as possible helps reduce the client's anxiety by limiting the factors that must be confronted; decreasing stimuli usually decreases anxiety. Encouraging the client to verbalize feelings of anxiety will not decrease anxiety and may increase it. The anxiety level must be decreased before the client is asked to discuss coping strategies. Administering as-needed medications prescribed by the primary healthcare provider may or may not be necessary; it is not the first intervention before an assessment is completed.

A female client who physically abused her 9-year-old son is undergoing treatment to help her control her behavior. Which statement indicates that the client has developed a safe coping method to help her deescalate?

If I get angry at my son again, I'm going to need a pillow in the bedroom to punch. Verbalization of the need to take out her anger on an inanimate object indicates the potential for increased impulse control; this is important in the prevention of further abuse. Promising not to get angry is unrealistic because all parents become angry with their children at some time or another. Placing the blame on the child or the spouse, rather than on the mother's own behavior, indicates a lack of progress toward controlling anger

Which priority teaching point should the nurse include when educating parents how to facilitate the developmental task of trust for their newborn?

Breastfeeding the newborn on demand Breastfeeding on demand is the priority teaching point for parents of a newborn that will facilitate the development task of trust. Wrapping the newborn in a blanket is an age-appropriate nursing intervention; however, it is not one that will facilitate trust. Feeding the newborn on a rigid schedule and allowing the newborn to cry self to sleep do not facilitate trust, but mistrust.

A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place these interventions in priority order, from the least to the most restrictive.

Diversional activities should be the first intervention attempted, because they do not involve any restriction on client activities and manic patients are easily distracted. Limit-setting should be the next intervention attempted, because it is minimally restrictive. Medication administration, although considered a chemical restraint, is less restrictive than physical restraints or seclusion. Seclusion is more restrictive than medication but less restrictive than restraints. Restraints are the most restrictive intervention in psychiatric nursing.

The laboratory values shown here are returned on a male client being treated for bipolar disorder, type 2 diabetes, and peripheral vascular disease who is currently reporting chest pain. What is the priority nursing intervention?

Implementing seizure precautions immediately The normal range of therapeutic lithium levels is 0.6 to 1.4 mEq/L (0.6 to 1.4 mmol/L). A lithium level of 2.0 (2.0 mmol/L) or greater indicates intoxication and may present with symptoms including seizure activity. The normal hemoglobin A1c range for adults is 4% to 6%, with a level greater than 8% indicating poor diabetic control. This value is in the abnormal range, but another lab value takes priority. The creatine kinase level in men ranges from 55 to 170 units/L. There is no indication that the client has experienced or is about to experience a heart attack. A normal international normalized ratio (INR) is between 0.7 and 1.8; in an individual undergoing warfarin therapy it ranges between 2.0 and 3.0. This value is within the therapeutic range for a client being treated for peripheral vascular disease.

What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa?

Rewarding weight gain by increasing privileges Behavior modification programs are helpful treatment modes for many clients with anorexia nervosa. Discussing the importance of eating a balanced diet is ineffective. The person with anorexia nervosa is more concerned with losing weight than with eating a balanced diet. A well-balanced diet should be encouraged, but actual weight gain is critical and must be reinforced. Although family therapy may be helpful, emphasis on the anorexia may reinforce the negative behavior. Also, family therapy will not be a priority until the client gains weight.

Which nursing interventions can help a terminally ill client cope with feelings related to death? Select all that apply.

Feelings of connectedness are important for the client who is terminally ill; therefore, the nurse should promote connectedness by helping the client find meaning and purpose in life by listening to his or her concerns. Prayer and devotion can help the client cope with feelings related to death, so the nurse should allow time for religious readings, spiritual visitations, or attendance at religious services. The nurse can also encourage the client to pray if he or she wishes by facilitating privacy and a proper environment. To help the client to cope with the pain, the nurse should provide medications and therapies for pain management. To help the client manage other aspects of the illness, the nurse can educate the client about complementary medicine.

The parents of an adolescent who is experiencing posttraumatic stress disorder have decided to care for their child at home. What is the priority intervention that the home health nurse must include in the plan of care?

Helping the parents understand that their child may avoid emotional attachments The client will tend to avoid emotional attachment to significant others, because this is a common way to protect the self from the experience of potential future losses. The priority at this time is to have family members develop an understanding of what is happening to the client. Although it is important to keep the client safe and secure when in the home, the family should not restrict the client to the home environment. Although issues concerning the client's problems need to be resolved, this is not the priority. Although a discussion of the parents' feelings of ambivalence may be necessary, it is not the priority.

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?

Maintaining the highest level of safe, independent function The therapeutic milieu is directed toward helping the client develop effective ways of functioning safely and independently. Helping the client relate to others is one small part of the overall objectives. The therapeutic milieu allows some items from home to make the client less anxious; however, the objective is not to duplicate a home situation. Helping the client become accepted in a controlled setting is a worthwhile objective but not as important as working toward the maximal degree of safe, independent function.

The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take? Select all that apply.

Strategies that assist orientation without challenging the client and that encourage safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.