Psychosocial Integrity

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client?

reality orientation

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent?

Get help to handle the situation safely.

A client has just lost her husband with an apparent suicide. In the emergency department, the client tells the nurse that she has never lost an immediate family member and "feels so numb right now." Which response by the nurse is best?

"His death will be a terrible loss."

The nurse is preparing to administer oral medication to an 8-year-old child who is resistant to taking the medication. Which is the most effective statement made by the nurse that would encourage the child to take the medication?

"I have your medication. Swallow these please."

After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future?

"I know it is going to be hard and relapse is a possibility. I will need help."

A client who has been arrested eight times in the past year for driving under the influence is admitted for alcohol treatment by judicial mandate. Which statement is most suggestive of alcohol dependence?

"I never drink alone, so I don't have a problem."

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement bestindicates that the client understands the need for long-term treatment?

"I will begin with inpatient treatment and participate in an aftercare program." Inpatient treatment and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they do not address the client's need for long-term treatment.

A client with borderline personality disorder tells a nurse, "You're the only nurse who really understands me. The others are mean. They always ignore me when I ask for my extra antianxiety medication." How should the nurse respond?

"I'll inform the team of your concerns. Let's talk about how you're feeling."

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The client has not smoked a cigarette for 3 weeks and tells the nurse about fears of starting smoking again because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?

"It is good that you can talk about your concerns. Try calling a friend when you want to smoke."

A parent of a toilet-trained 3-year-old expresses concern over her child's bed-wetting while hospitalized. What should the nurse should tell the parent?

"It is very common for children to regress when they are in the hospital."

A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. On the way to the radiology department, the client looks around anxiously and tells the nurse, "The Interpol is coming to kill me." What is the nurse's bestresponse?

"It sounds like you're frightened."

The nurse is teaching a caregiver how to effectively interact with an older adult parent who suffers from impaired memory and judgment. What is the most important information for the nurse to provide? Select all that apply.

"Speak slowly and use understandable words and phrases." "Allow ample time for your parent to respond to a question." "Orient and re-orient your parent as needed throughout the day." "Approach your parent from the front when beginning a conversation."

A client, who was hospitalized after a fall sustained while intoxicated, experienced alcohol withdrawal delirium during the hospitalization. A few days after the client's sensorium clears, the client tells the nurse that drinking helps to cope with anxiety related to a recent divorce. Which response by the nurse would help the client view the drinking more objectively?

"Tell me about the last time you were under a lot of stress and drinking to cope."

A 15-year-old client with a urinary tract infection is admitted to the facility. The adolescent tells the nurse she hopes she's pregnant. How should the nurse respond?

"Tell me what being pregnant would mean to you."

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped

"What are you thinking about before you start to prepare supper?"

A nurse is assessing a client's spiritual needs when the client becomes angry and defensive about the questions being asked. What would the nurse say to make the client comfortable?

"You appear upset about these questions. Is this true?"

The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." How should the nurse respond?

"You're frightened. This is a hospital and these people are staff members. You're safe here."

The nurse who uses self-disclosure should:

refocus on the client's experience as quickly as possible.

Which nursing action is appropriate to include in the plan of care for a dying child to meet the child's emotional needs during the last days of life?

Answer the child's questions about illness and death honestly.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique is most helpful?

Ask the child to draw a picture.

The nurse is performing an assessment of a client admitted to the behavioral health unit with schizophrenia. Which behavior by the client would the nurse document as positive symptoms? Select all that apply.

Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client states, "Do you see all of the rats crawling on the floor? Kill them!"

Family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the patient's bedside to perform Anointing of the Sick. The nurse who is providing care for the client should recognize that the family is likely

Roman Catholic.

Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse should address which factor?

The emotional responses may be similar to those of other crime victims.

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

Two days after an ileostomy, the client refuses care and requests to be left alone. The nurse should first:

encourage the client to verbalize feelings.

Which clinical characteristic affects client compliance?

the nurse-client relationship

A dying client requests that the nurse and client pray together. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this client?

The nurse should select a formal prayer or bible passage to use to pray aloud.

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?"

The father of a 3-week-old infant who has developed sepsis says that he feels guilty because he did not realize his infant was sick. Which response by the nurse would be most appropriate?

"Babies can get sick quickly, and parents don't always realize it."

The child of a client with Alzheimer's disease reports feeling guilty for wishing, at times, that the parent would die. What is the nurse's best response?

"Being responsible for your parent's care must be difficult."

During the nurse's conversation with a depressed client, the client states, "I have no reason to be sad. I have a great job and a wonderful wife and family." Which comment would be best for the nurse to make at this time?

"Depression can be caused by a chemical imbalance in the brain."

A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the mostappropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

The caregiver of a hospitalized 3-year-old client expresses concern because the client is wetting the bed. What should the nurse say?

"It's common for a child to exhibit regressive behavior when anxious or stressed."

A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be mostappropriate?

"It's okay to cry when something hurts."

The nurse documents the initial care of a suspected abuse victim. Which information would be most helpful for others to know when caring for the client?

"Seems fearful to discuss how bruises on her body had been caused."

The parents of an adolescent client newly diagnosed with anorexia nervosa are meeting with the nurse during the admission process. Which remarks should the nurse interpret as typical for parents of a client with anorexia nervosa?

"She's been a model child. We've never had any problems with her."

The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate?

"Tell me what you've found in your reading that's leading you to that conclusion."

A nursing student and a charge nurse of a psychiatric unit are discussing the outcomes of clients with depression. Which if stated by the student, indicates that the student understands depression outcomes?

"There are patterns with this illness. If a person has one depressive episode, they have a 60% chance of experiencing another." If a person has a depressive episode, there is a 60% chance of a second episode. Factors related to depression include gender, age, socioeconomic status, race, and marital status, but are not necessarily situational. A major depressive disorder can be recurrent and could be chronic, but does not have to be a lifelong issue. Depression can occur in up to 25% of women and up to 12% of men.

A client with depression has not responded to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). Which statement should the nurse add when explaining the procedure to the client?

"This treatment has been proven to be effective, and we expect a positive outcome."

A client recovering from narcotic addiction states to the nurse, "I'm not going anymore to support group meetings. I felt out of place there." Which response by the nurse is best?

"Try attending a meeting at a different location; you may feel more comfortable there."

Which response demonstrates that the parents of a child with newly diagnosed schizophrenia understand their child's diagnosis?

"We'll watch our child take the pills and call the physician if the child doesn't swallow them."

The mother of an infant being admitted to the hospital is crying and very upset. Which statement by the nurse would be most therapeutic?

"What's making you cry right now?" The nurse's best response is an open-ended question that gives the mother an opportunity to verbalize fears, share concerns, and ask for information.In this situation, the mother is right to be worried. Telling her to not do so would be inappropriate.Telling the mother that that everyone will take excellent care of her infant may be appropriate to say but only after determining the mother's feelings at the present time.Telling the mother that she did the right thing to bring her infant to the hospital does not address her concerns or needs at this time.

One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse is most therapeutic?

"Your behavior is disturbing to other clients. I'll walk with you to help you release some energy."

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate?

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes." The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended. Stating that the client's behavior is a way of punishing the nurse is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as "I'm disappointed in you" and "You can't control yourself" may decrease the client's self-esteem.

A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. The client gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate?

Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of the spouse's alcoholism. The nurse should suggest that the family join which organization?

Al-Anon

A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which way should the hospital admission process be modified for the client?

Allow her sufficient extra time in which to gain an understanding of what is happening to her. SUBMIT ANSWER

The nurse is meeting weekly with an adolescent recently diagnosed with depression to monitor progress with therapy and antidepressant medication. The nurse should be most concerned when the client reports what information?

An acquaintance hanged herself two days ago. While all the occurrences could upset the client in the early stage of treatment, the one involving the most risk to safety is the suicide completion of a peer. Adolescents are susceptible to "copycat" suicides. The fact that she knows the method of suicide of the acquaintance and is at a critical period in treatment, when her antidepressant may have given her increased energy while still experiencing low self-esteem, can put her at significant risk for suicide.

A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which intervention by the nurse is most appropriate?

Calmly walk over to the client and say, "Tell me what's going on."

An older adult client has received a terminal lung cancer diagnosis. The client's adult children are tearful and afraid to leave their parent's bedside. What type of grieving is this family most likely experiencing?

Anticipatory

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

The nurse manager has employed three nurses from a culture that is different from that of most of the nurses who currently work 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.

A child with leukemia fails to respond to therapy. Which statement offers the nurse the bestguide in making plans to assist the parents in dealing with their child's imminent death?

Relatives are especially grieved when a child does well at first but then declines rapidly.

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).

The nurse is caring for a client whose spouse has just passed away. The nurse knows that according to the Kubler-Ross Model of Grief, there are five stages of grief that most grieving people progress through in order, although not everyone experiences all stages or in this order. Place the stages of grief in the order that is most commonly observed, and that the nurse would expect to see in this grieving client.

Denial Anger Bargaining Depression Acceptance

A client with dementia is eating off of other clients' meal trays. After the client with dementia is asked to stop, which action should be taken?

Distract the client.

When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, the nurse should include which action as the priority when the parents visit the infant for the first time?

Emphasize the infant's normal and positive features.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients?

Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors.

A nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action should the nurse take?

Encourage the parents to get connected with support groups such as the Cystic Fibrosis Foundation.

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic?

Initiate contact with the client frequently.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care?

Involve the client in usual at-home activities.

A client with end-stage heart failure is preparing for discharge. The client and their caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave the client feeling isolated. Which suggestion by the home care nurse bestaddresses this concern?

Set up the hospital bed in the family room so the client can be part of household activities.

A nurse is caring for a client with hypothyroidism. The client is extremely upset about altered physical appearance. The client doesn't want to take the medication because "it isn't doing any good." What should the nurse do?

Tell the client that as the medication corrects the hormone deficiency improvement in looks can be expected soon. Stating that the client will soon experience improvement is supportive and encouraging and offers direction in a way that motivates continued medication compliance. Stating that the client should ask the physician about the medication dosage might cause the client alter the dosage, and also is putting the client off instead of addressing the concerns. Stating that the client looks fine discounts the client's feelings. Advising the client to practice self-acceptance is parental and direct at a time when the client needs support and understanding.

A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening others, angry outbursts, and two episodes of hitting a coworker at the client's place of employment. The client is very anxious and tells the nurse, "I didn't mean to hit him. He made me so mad that I just couldn't help it. I hope I don't hit anyone here." To ensure a safe environment, what should the nurse do first?

Tell the client that hitting others is unacceptable behavior, and ask the client to tell a staff member when feeling angry.

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason?

The action indicates nonverbal agreement with the client's false ideas.

The nurse is teaching a client who is a refugee from Burma (Myanmar) about taking medication. Which responses by the client indicates a need for further education? Select all that apply.

The client stops taking prescribed medications when the symptoms are relieved. The client takes nonprescribed medications purchased from a neighborhood Burmese grocery

A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?

The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization.

When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem?

The injury isn't consistent with the child's history or age.

Which statement best explains why the nurse should acknowledge differences between his or her culture and the client's culture?

The nurse may hold values that could influence the care of the client.

The nurse is caring for a client with an irritable mood, grandiose thinking, impulsive hyperactive behaviors, and little sleep. What is the nurse's best initial approach?

Use a calm, firm approach, offering clear directions.

During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, "I can't gain weight. I'm fat enough as it is. I'll be really disgusting if I get fatter." When responding to this client, which response by the nurse would be mosttherapeutic?

Use nonjudgmental and realistic comments.

An older adult client is speaking to the nurse about the expected death of a spouse due to cancer 3 weeks ago. The client says, "My spouse is in a better place now, and I'm happy my spouse is not hurting anymore. But I just miss my spouse!" How should the nurse respond?

Validate the client's statement as evidence of a normal grieving process.

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When is he going to come get me out of here?" The nurse interprets the client's statements as indicative of which condition?

ambivalence

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation?

an exaggerated sense of well-being

What is the most appropriate long-term goal for an outpatient client with schizophrenia who has been withdrawn from friends and family for 3 weeks?

attending day therapy three times a week

A mute client begins to express herself verbally on occasion. Which nursing action should be credited with helping a mute client express herself verbally?

making open-ended statements followed with silence

During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?

caregiver role strain

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the client's injuries stem from abuse?

not crying when moved

The nurse is conducting a home visit with a school-age child with a physical disability. What behaviors by the child alert the nurse to overprotective parenting?

dependency, fearfulness, and lack of outside interests

The wife of a client with alcohol dependency tells the nurse, "I'm tired of making excuses for him to his boss and coworkers when he can't make it into work. I believe him every time he says he's going to quit." The nurse recognizes the wife's statement as indicating which behavior?

enabling

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called:

flight of ideas.

A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until admission, the client had been a virtual prisoner at home for 5 weeks, afraid to go outside even to buy food. When planning care for this client, the nurse's overall priority is to help the client:

function effectively in the environment.

During group therapy, a client constantly interrupts with impulsive behavior and exaggerated stories that cast the client as a hero. The client also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse assesses that these behavors are best correlated with which diagnosis?

histrionic personality disorder

Which intervention is essential when caring for a client who is experiencing delirium?

identifying the underlying causative condition or illness The most critical aspect of caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness?

overprotection

Arrangements are made for a member of the colostomy support group to meet with a client before bowel surgery. What is accomplished by having a representative from the group meet the client preoperatively?

providing the client with support and realistic information on the colostomy

In the community room, a nurse observes a client who suffers from depression. The client paces swiftly around the room, swings both arms, and rubs both hands together. What term should the nurse use to describe these behaviors to members of the health care team?

psychomotor agitation

A nurse approaches a client with a recent colostomy for a routine assessment and finds the client tearful. The nurse's most appropriate response would be to:

sit down and ask if the client would like to talk about any concerns.

Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy?

the cause of death can be discovered

The nurse is preparing the client with a cerebrovascular accident for discharge to home. Which will influence the client's continuing progress in rehabilitation at home?

the family's ability to provide support to the client

What information should the nurse plan to include when teaching the client and family about a substance abuse problem?

the physical, physiologic, and psychological effects of substances The nurse should include teaching the client and family about the physical, physiologic, and psychological effects of substances to educate them about the potential injury, illness, and disability that can result from substance use. Teaching about the role of the family in perpetuating the problem, the family's responsibility for the client, or the reasons that could have led the client to use the substance is inappropriate and based on an erroneous assumption. Including these topics blames the family for the problem and attempts to rationalize the use of the substance.

A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may be caused by which factor?

uncertainty and an underlying fear of recurrence