Examkin

Psychosocial Integrity

346 questions

All types346Multiple choice178Multiple select89Matching19Ordering60
Question 201Question →

A client on a medical-surgical unit is placed on contact precautions for a multidrug-resistant organism. The client tells the practical nurse, "Everyone who comes in here covers themselves up like I am radioactive. I feel completely diseased." Which of the following responses by the practical nurse use therapeutic communication techniques? Select all that apply.

Select all that apply

Show answer & explanation

Answer: It sounds as though you are feeling isolated and upset about the protective equipment.; I have some time right now to sit and talk with you if you would like.

Answer

The therapeutic responses involve reflecting the client's feelings of isolation and offering oneself to provide emotional support.
The correct responses utilize validated therapeutic communication techniques. Stating that the client seems isolated and upset uses 'reflection', which helps the client feel understood and validates their emotional state. Stating a willingness to sit and talk utilizes 'offering self', which demonstrates genuine care and provides comfort to a client feeling stigmatized and alone.

Step-by-Step Solution

1
Analyze the client's statement to identify the core emotion.
The client is expressing feelings of isolation, stigma, and loneliness due to the required contact precautions.
Understanding the underlying emotion is essential to selecting a response that appropriately addresses the client's psychosocial needs.
2
Evaluate each option to determine if it is a therapeutic or non-therapeutic communication technique.
Reflecting feelings and offering self are therapeutic. Minimizing feelings, asking 'why', and acting defensively are non-therapeutic.
Therapeutic communication should foster trust, validate feelings, and encourage the client to share, rather than shutting down the conversation.

Key Concept

Therapeutic Communication
Question 202Question →

A practical nurse finds a client unresponsive on the floor of their room with a respiratory rate of 6 breaths per minute. A visitor in the room states, "I think they just injected a lot of heroin." Which of the following is the priority action for the nurse?

Show answer & explanation

Answer: Call for immediate emergency assistance and open the client's airway.

Answer

The priority action is to call for immediate emergency assistance and open the client's airway.
In any emergency situation, especially a suspected opioid overdose presenting with severe respiratory depression, the nurse must follow the Airway, Breathing, and Circulation (ABC) prioritization framework. Calling for help and opening the client's airway are the most critical first steps to prevent hypoxic brain injury or death.

Step-by-Step Solution

1
Recognize the signs of a life-threatening emergency, specifically severe respiratory depression (6 breaths per minute) in a suspected opioid overdose.
The client is identified as having a compromised airway and inadequate breathing.
Identifying the immediate threat to life dictates the order of interventions.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework and Basic Life Support (BLS) principles.
Activating the emergency response system and securing the airway are prioritized over secondary assessments or out-of-scope medication administration.
BLS principles require calling for help and securing the airway before investigating the cause or obtaining full vital signs.

Key Concept

Prioritization of Care in Overdose Emergencies
Question 203Question →

A practical nurse (PN) is reviewing the lunch tray for a hospitalized client who is a practicing Muslim and strictly adheres to a Halal diet. The PN notes that the standard tray contains baked chicken, rice, green beans, and a gelatin dessert, but the meal ticket does not specify that the food is Halal-certified. Which of the following actions is the most appropriate for the PN to take?

Show answer & explanation

Answer: Return the tray to the dietary department and request a verified Halal meal.

Answer

Return the tray to the dietary department and request a verified Halal meal.
Providing culturally competent care involves accommodating a client's religious dietary practices. A strict Halal diet requires specific preparation of meats and the complete avoidance of pork products, which are commonly found in gelatin. Returning the tray ensures the dietary department provides a verified meal that is safe, culturally congruent, and free from cross-contamination.

Step-by-Step Solution

1
Assess the client's specific dietary requirements against the provided meal tray.
The client requires a Halal diet, but the tray contains unverified meat and gelatin (which often contains pork).
Verifying that meals meet cultural and religious restrictions is a critical component of culturally competent nursing care.
2
Determine the safest and most culturally appropriate nursing intervention.
The entire tray must be replaced by the dietary department.
Removing individual items does not eliminate the risk of cross-contamination from non-Halal preparation methods and leaves the client with an incomplete meal.

Key Concept

Culturally Congruent Care and Dietary Restrictions
Question 204Question →

During morning rounds on a medical-surgical unit, a newly admitted client is crying softly in bed. The client tells the practical nurse, 'I just cannot believe I have to be in the hospital for another week. I miss my family so much.' Which response by the practical nurse is most therapeutic?

Show answer & explanation

Answer: It sounds like you are feeling very lonely and missing your family right now.

Answer

The most therapeutic response uses empathy to reflect the client's feelings and acknowledges their distress without judgment.
The correct response utilizes empathy and reflection. By validating that the client feels lonely and misses their family, the nurse demonstrates active listening. This builds trust and invites the client to share more about their feelings without feeling judged or dismissed.

Step-by-Step Solution

1
Analyze the client's statement to identify their core emotional state.
The client is crying and explicitly states they miss their family, indicating feelings of sadness and homesickness.
Understanding the underlying emotion is the first step in selecting an appropriate therapeutic response.
2
Evaluate the response options against established therapeutic communication techniques.
The correct response reflects the client's emotion (empathy), while the other options represent communication blocks (false reassurance, asking 'why' questions, giving advice).
The nurse must avoid communication blocks that minimize feelings or make the client defensive.

Key Concept

Therapeutic Communication Techniques and Blocks
Question 205Question →

A practical nurse is caring for a postpartum client whose newborn was recently transferred to the neonatal intensive care unit (NICU) due to respiratory distress. The client begins crying and states, "I should have done something differently during my pregnancy. This is all my fault that my baby is sick." Which of the following responses by the nurse is most therapeutic?

Show answer & explanation

Answer: It sounds like you are experiencing a heavy sense of guilt regarding your baby's condition.

Answer

The most therapeutic response is to reflect the client's feelings by stating, 'It sounds like you are experiencing a heavy sense of guilt regarding your baby's condition.'
The correct response utilizes the therapeutic communication technique of reflection. By restating the underlying emotion (guilt) heard in the client's message, the nurse validates the client's feelings and provides a safe, non-judgmental space for the client to continue sharing her concerns.

Step-by-Step Solution

1
Analyze the client's statement and emotional state.
The client is expressing self-blame, guilt, and emotional distress over the newborn's admission to the NICU.
Understanding the core emotion is necessary to select a response that addresses the client's immediate psychological needs.
2
Evaluate each option for therapeutic versus non-therapeutic communication techniques.
Options providing advice, asking 'why', or offering general reassurances are identified as communication blocks. The option that reflects the client's feelings is identified as therapeutic.
Therapeutic communication should remain client-centered, non-judgmental, and encourage the expression of feelings.
3
Select the response that best facilitates further communication.
The reflective statement is chosen as the most therapeutic response.
Reflection validates the client's emotional experience and leaves the door open for the client to elaborate on her feelings of guilt.

Key Concept

Therapeutic Communication: Reflection and Validation
Question 206Question →

An older adult client with a history of major depressive disorder is receiving intravenous antibiotics for severe pneumonia on a medical-surgical unit. During the night shift, the client suddenly becomes extremely restless, repeatedly attempts to climb over the bed rails, and yells, "You are all trying to poison me!" Which action should the practical nurse (PN) take first?

Show answer & explanation

Answer: Remain at the bedside and ask an assistive personnel to immediately notify the registered nurse (RN).

Answer

Remain at the bedside and ask an assistive personnel to immediately notify the registered nurse (RN).
The correct answer prioritizes the immediate physical safety of the client while adhering to the practical nurse scope of practice. The sudden onset of paranoia and agitation in an older adult with pneumonia strongly suggests acute delirium, likely due to hypoxia or the systemic infection itself. Because the client is attempting to climb out of bed, they are at an imminent risk for falls. The PN must not leave the client alone; staying at the bedside provides immediate safety through a least-restrictive intervention. Simultaneously, instructing an assistive personnel to notify the RN ensures that the acute medical change is promptly assessed and managed by the appropriate provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The older adult client with an active infection (pneumonia) is exhibiting a sudden onset of extreme restlessness and paranoia.
Recognizing that sudden behavioral changes in the presence of an infection point to acute delirium, which is a medical emergency often caused by hypoxia or systemic infection, rather than a psychiatric baseline issue.
2
Determine the most immediate risk to the client.
The client is actively attempting to climb over the bed rails, placing them at severe risk for a fall and traumatic injury.
Maslow's hierarchy of needs and basic nursing principles dictate that physical safety and injury prevention are the highest immediate priorities.
3
Select the appropriate intervention within the PN scope of practice.
The PN must secure immediate safety by staying with the client while delegating another staff member to alert the RN.
The PN cannot leave an actively agitated and unsafe client alone. Simultaneously, the PN must recognize that this acute change in condition requires a comprehensive assessment by the RN and potentially the healthcare provider.

Key Concept

Prioritizing client safety and recognizing acute delirium in older adults
Question 207Question →

A client with terminal lung cancer has recently been transitioned to comfort care measures. While the practical nurse is assisting with morning hygiene, the client angrily pushes the washbasin away and states, 'Why is everyone acting like I am already gone? You have all just stopped trying!' Which of the following responses by the practical nurse are therapeutic? Select all that apply.

Select all that apply

Show answer & explanation

Answer: It sounds as though you are feeling very frustrated and abandoned right now.; You seem very angry this morning. Please tell me more about what you are experiencing.; I will sit here with you for a while, just in case you would like to talk.

Answer

The therapeutic responses involve reflecting the client's feelings of frustration and abandonment, making an observation while encouraging the client to elaborate, and offering a supportive presence by sitting with the client.
Therapeutic communication with a distressed, grieving client must prioritize validation, active listening, and emotional support. Acknowledging the client's frustration (reflection), noting their anger while inviting them to share (making observations/exploring), and providing a quiet presence (offering self) directly address the client's emotional crisis without judgment.

Step-by-Step Solution

1
Analyze the client's statement and emotional state.
The client is experiencing anger, fear, and feelings of abandonment related to their terminal diagnosis and recent transition to comfort care.
Understanding the underlying emotion (anger masking fear or anticipatory grief) is essential to selecting a response that addresses the client's psychosocial needs rather than reacting defensively to their aggressive behavior.
2
Evaluate each option for validated therapeutic communication techniques.
Reflecting feelings, making observations combined with open-ended exploration, and offering self are recognized therapeutic techniques.
These techniques validate the client's distress, encourage the expression of difficult emotions, and demonstrate the nurse's unconditional supportive presence.
3
Identify and eliminate options containing non-therapeutic communication blocks.
Asking 'why', defending the healthcare team, invalidating feelings, and changing the subject to focus on hygiene tasks must be eliminated.
These communication blocks shut down therapeutic dialogue, cause defensiveness, and prioritize the nurse's agenda over the client's immediate emotional crisis.

Key Concept

Therapeutic Communication
Question 208Question →

While facilitating a therapeutic group activity, a client diagnosed with bipolar disorder in a manic phase begins rapidly pacing the perimeter of the room. The client repeatedly interrupts other participants, speaks in a loud, pressured manner, and ignores initial verbal redirection. What is the priority nursing intervention for this client?

Show answer & explanation

Answer: Escort the client to a quiet area away from the group and offer a simple, repetitive physical activity

Answer

The priority intervention is to escort the client to a quiet area away from the group and offer a simple, repetitive physical activity.
The correct answer focuses on modifying the environment and accommodating the client's current physical needs. Clients experiencing mania are highly distractible and sensitive to environmental stimuli. Escorting the client away from the group reduces the sensory input and removes the audience. Offering a simple, repetitive physical activity allows the client to safely expend their excess motor energy in a constructive manner.

Step-by-Step Solution

1
Analyze the client's clinical presentation and underlying diagnosis.
The client is exhibiting symptoms of acute mania (hyperactivity, pressured speech, impulsivity, pacing) and is unable to process verbal redirection.
Identifying the root cause of the behavior dictates the therapeutic approach, recognizing that the client currently lacks impulse control.
2
Evaluate the impact of the current milieu (environment).
The group setting is highly stimulating and provides an 'audience,' which typically exacerbates manic behaviors and disrupts the recovery environment for others.
Nurses must manage the milieu to protect the therapeutic environment for all clients while keeping the agitated client safe.
3
Determine the least restrictive and most effective de-escalation strategy.
Removing the client from the stimulating environment and channeling their excessive energy into a safe, solitary, and repetitive task is identified as the best course of action.
This approach addresses the physiologic need for movement without relying on unsafe physical blocking, ineffective logical reasoning, or non-therapeutic threats.

Key Concept

Milieu Management and De-escalation in Acute Mania
Question 209Question →

A practical nurse (PN) is assisting in the care of a client on an inpatient psychiatric unit who begins pacing rapidly, clenching their fists, and shouting obscenities at staff. Arrange the following behavioral interventions in the correct sequence from least restrictive to most restrictive.

Drag items to arrange them in the correct order

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Answer

The correct sequence from least restrictive to most restrictive is: verbal de-escalation, directing to an unlocked quiet room, offering voluntary PRN oral medication, involuntary locked seclusion, and finally, applying mechanical restraints.
The principle of the least restrictive alternative mandates that nurses utilize the least invasive interventions to ensure safety before progressing to more restrictive measures. The hierarchy dictates progressing from verbal communication techniques, to environmental milieu changes, to voluntary chemical interventions, to involuntary seclusion, and finally to physical mechanical restraints only in extreme emergencies.

Step-by-Step Solution

1
Identify the primary goal of the clinical scenario.
The goal is to manage escalating agitation using the least restrictive alternative doctrine.
Client rights mandate that safety must be maintained using the least invasive methods possible.
2
Identify the absolute least restrictive intervention.
Verbal communication (calm tone, de-escalation).
Verbal de-escalation respects the client's autonomy completely while attempting to defuse the situation.
3
Evaluate the next appropriate level of restriction.
Environmental controls (unlocked quiet room).
This limits sensory stimuli without restricting physical freedom or introducing chemicals into the body.
4
Rank chemical interventions versus physical spatial restrictions.
Voluntary oral medication follows environmental controls.
Medications alter the physiological state (making them more restrictive than the environment), but taking them voluntarily is less restrictive than forced physical isolation.
5
Sequence the most restrictive measures.
Involuntary seclusion, followed by mechanical restraints.
Seclusion isolates the client against their will, and mechanical restraints physically immobilize them. Both represent the highest levels of restriction and are absolute last resorts.

Key Concept

Least Restrictive Environment and Intervention Hierarchy
Question 210Question →

A client receiving inpatient treatment for post-traumatic stress disorder (PTSD) suddenly becomes severely agitated in the communal lounge. The client begins overturning chairs, pacing aggressively, and shouting about an imminent attack. Which actions are appropriate for the practical nurse (PN) to implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Position oneself to maintain an unobstructed pathway to the nearest exit door; Adopt a non-threatening body posture and speak using a calm, low-pitched tone; Coordinate with other nursing staff to clear all uninvolved peers from the lounge area immediately

Answer

The correct actions are positioning oneself to maintain an unobstructed exit pathway, adopting a non-threatening posture while speaking in a calm tone, and coordinating with staff to clear uninvolved peers from the area.
The correct actions prioritize immediate physical safety for both the staff and the milieu while utilizing established non-pharmacological de-escalation techniques. Maintaining a clear exit path and removing uninvolved peers prevents injury during a severe behavioral crisis. Using a calm, low-pitched voice with an open posture helps reduce the client's autonomic arousal without posing a physical or psychological threat.

Step-by-Step Solution

1
Assess the immediate environment for physical safety risks to staff and bystanders.
Staff secure an exit path and remove other clients from the immediate vicinity.
During an acute behavioral escalation, ensuring physical safety for the milieu is the absolute first priority before attempting individual psychosocial interventions.
2
Determine the appropriate communication style for a highly agitated client experiencing a flashback.
A calm, low-pitched tone and open posture are utilized by the nurse.
Loud, authoritative, or confrontational communication can exacerbate the autonomic fight-or-flight response in a client with PTSD.
3
Identify the practical nurse (PN) scope of practice regarding pharmacological de-escalation.
IV push medications are excluded from the PN's planned interventions.
Administering IV push medications requires RN-level licensure and is strictly outside the PN scope of practice, regardless of client acuity.

Key Concept

Mental Health Concepts: Crisis Intervention and PN Scope of Practice
Question 211Question →

A practical nurse working in a substance use rehabilitation facility discovers a client unresponsive on the bathroom floor. The client has a respiratory rate of 6 breaths per minute, cyanotic lips, and pinpoint pupils. A syringe is visible on the sink. Arrange the following practical nursing actions in the priority order they should be performed from first to last.

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Answer

The correct sequence is to first activate the emergency response system, then assess the pulse, initiate ventilation, administer naloxone, and finally obtain a complete set of vital signs.
The correct sequence of actions follows the American Heart Association (AHA) Basic Life Support (BLS) guidelines for healthcare providers managing a suspected opioid overdose. First, upon discovering an unresponsive client, the nurse must immediately activate the emergency medical response system to ensure help arrives. Second, the nurse must assess the client's breathing and palpate the carotid pulse simultaneously for 5 to 10 seconds. Third, because the client has a pulse but severe respiratory depression (6 breaths/minute), the nurse must immediately support the airway and initiate positive pressure ventilation. Fourth, once ventilation is established, the nurse administers the prescribed opioid antagonist, naloxone. Finally, after life-threatening priorities are addressed, the nurse obtains a complete set of vital signs to monitor the client's status.

Step-by-Step Solution

1
Identify the client's unresponsive state and immediately activate the emergency medical response system.
Additional healthcare personnel and life-saving equipment, such as an AED, are dispatched to the scene.
Basic Life Support (BLS) protocols dictate that activating the emergency response system is the first step upon finding an unresponsive client.
2
Assess the client's breathing and palpate the carotid pulse simultaneously for no more than 10 seconds.
The nurse determines that the client has a central pulse but is experiencing severe respiratory depression.
This brief assessment dictates the resuscitation pathway, distinguishing between the need for full cardiopulmonary resuscitation (CPR) versus respiratory support.
3
Initiate positive pressure ventilation using a bag-valve-mask device.
The client receives immediate oxygenation, addressing the life-threatening hypoxia.
Hypoxia is the primary cause of cardiac arrest in an opioid overdose. Airway and breathing must be supported immediately when a pulse is present.
4
Administer the prescribed standing order of intranasal naloxone.
The opioid antagonist begins to reverse the central nervous system and respiratory depression.
Naloxone is the specific antidote for opioid toxicity, but AHA guidelines state that its administration should never delay the initiation of rescue breathing.
5
Obtain a complete set of vital signs including oxygen saturation.
Baseline clinical data is established to monitor the client's response to the interventions.
Detailed data collection is a secondary priority performed only after all life-threatening ABC issues have been managed.

Key Concept

Prioritization of Basic Life Support (BLS) and nursing interventions in acute opioid overdose emergencies.
Estimated Time:1m 30s
Question 212Question →

A practical nurse is caring for a client who recently received a terminal prognosis. The client's sibling pulls the nurse aside in the hallway and states, "Please promise me you will not mention hospice care to my sibling. If they hear that word, they will completely give up hope and stop fighting." Which response by the nurse is most therapeutic?

Show answer & explanation

Answer: It sounds like you are deeply concerned about your sibling's reaction. Tell me more about what you are feeling.

Answer

The most therapeutic response validates the sibling's distress using reflection and an open-ended statement, such as acknowledging their concern and asking them to tell the nurse more about what they are feeling.
The correct response utilizes therapeutic communication techniques by reflecting the sibling's feelings back to them and providing an open-ended prompt. This approach validates the family member's distress, builds trust, and allows them to safely explore their fears about the dying process without the nurse making inappropriate promises or arguing.

Step-by-Step Solution

1
Identify the core issue in the family member's statement.
The sibling is experiencing significant anticipatory fear and distress, which is leading them to request that vital information be withheld from the client.
Recognizing the underlying emotion is essential for selecting a response that addresses psychosocial needs rather than just reacting to the literal request.
2
Evaluate the response options against the principles of therapeutic communication.
Responses that contain 'why' questions, offer inappropriate promises to hide information, or rely on cold legal facts must be eliminated as they represent communication blocks.
Non-therapeutic communication blocks hinder the establishment of trust and fail to support the family member's emotional needs.
3
Select the option that best facilitates open communication and emotional support.
The option that reflects the sibling's concern and invites them to share more is identified as the correct response.
This approach validates the family member's feelings and keeps the lines of communication open, which is the priority in end-of-life psychosocial interventions.

Key Concept

Therapeutic Communication in End of Life Care
Question 213Question →

A practical nurse is providing care for a client admitted with major depressive disorder and psychotic features. During the shift, the client exhibits several distinct behaviors and makes specific statements. Match each client behavior or statement to the most therapeutic initial nursing response. (Note: Some responses are non-therapeutic and will not be used).

Click a left item, then click its matching right item

Items

"My internal organs have rotted away, leaving only an empty shell."
The client hands the nurse a prized watch and says, "I don't need this anymore. I won't be here to wear it tomorrow."
The client turns away toward the wall and says, "Everyone pretends to care, but you all wish I would just disappear."
"Do you believe I deserve to be punished for the pain I've caused my parents?"

Matches

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Answer

The correct matches pair the somatic delusion with empathy for the feeling, the covert suicide threat with a direct safety assessment, the expression of hopelessness with offering self, and the feelings of guilt with open exploration.
Each correct match applies a validated therapeutic communication technique (translating into feelings/empathy, direct questioning for safety, offering self, and exploring) tailored to the specific psychiatric needs of the client. These responses avoid common communication blocks and maintain the therapeutic alliance.

Step-by-Step Solution

1
Analyze the client's statement about their internal organs rotting.
Identify this as a somatic delusion.
Requires responding to the underlying emotion (terror/fear) using empathy rather than attempting to logically disprove the fixed false belief.
2
Evaluate the client giving away a prized watch with a morbid statement.
Recognize this as a covert suicidal behavior.
Direct safety assessment for self-harm is the highest priority when lethality cues are present.
3
Assess the client turning away and expressing that staff want them to disappear.
Identify this as profound hopelessness and testing behavior.
Offering self provides unconditional support and presence without dismissing their feelings with false reassurance.
4
Review the client's question about deserving punishment.
Identify profound guilt and seeking of external validation.
Exploring the topic encourages communication, while avoiding judgmental or probing non-therapeutic approaches.

Key Concept

Therapeutic Communication Techniques in Psychiatric Settings
Estimated Time:2m 30s
Question 214Question →

A practical nurse (PN) is caring for a client from a culturally diverse background who is recovering from a recent surgical procedure. The client's extended family is visiting, and the client mentions using traditional cultural health practices at home. Which actions by the PN demonstrate culturally congruent care? Select all that apply.

Select all that apply

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Answer: Ask the client how they prefer their family members to be involved in their healthcare decisions and daily care routines.; Explore the client's use of traditional health practices to identify any potential conflicts with the prescribed postoperative treatment.; Request a facility-approved medical interpreter to explain medical information if the client exhibits limited English proficiency.

Answer

The correct actions include asking the client about family involvement, exploring traditional health practices for potential conflicts, and utilizing a professional medical interpreter when language barriers exist.
Culturally congruent care involves assessing individual client preferences regarding family involvement, safely exploring traditional practices, and ensuring clear communication through professional interpreters. These actions promote safety, respect the client's beliefs, and build a therapeutic relationship.

Step-by-Step Solution

1
Evaluate how to integrate the client's cultural background into the nursing assessment.
The nurse identifies the need to inquire about family involvement and traditional health practices.
Understanding the client's specific cultural context ensures that care is individualized, safe, and respectful of their beliefs.
2
Determine the most appropriate method for communicating complex medical information.
The nurse selects a facility-approved medical interpreter.
Using trained interpreters rather than family members prevents miscommunication and adheres to safety standards for clients with limited English proficiency.
3
Identify actions that represent cultural insensitivity or non-therapeutic communication.
The nurse avoids giving false reassurance, ignoring dietary needs, and outright rejecting traditional remedies.
Such actions block therapeutic communication, ignore potential dietary restrictions, and damage the nurse-client trusting relationship.

Key Concept

Culturally congruent care requires individualized assessment of dietary needs, family dynamics, and safe integration of traditional practices, while consistently utilizing therapeutic communication techniques.
Question 215Question →

A 22-year-old client with a history of borderline personality disorder is receiving care on a medical-surgical unit for infected lacerations resulting from self-injury. The client becomes highly agitated, begins pacing the room, and states to the practical nurse (PN), 'You are the only one who understands me! The nurse yesterday was cruel and wanted me to suffer. If she comes back, I'm going to rip these bandages off!' Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Respond by stating, 'It sounds like you felt very frustrated and unsupported yesterday.'; Report the client's statements and escalating behavior to the registered nurse (RN).; Remove any unnecessary medical supplies or sharp objects from the client's immediate environment.

Answer

The correct actions are to respond by therapeutically reflecting the client's feelings, report the behavior to the registered nurse to maintain team consistency, and remove potential hazards from the environment to ensure safety.
Clients with borderline personality disorder frequently employ splitting as a defense mechanism, which involves idealizing one staff member while devaluing another. The most effective approach requires a combination of therapeutic communication, strict interdisciplinary consistency, and immediate safety measures. Reflecting the client's underlying emotions validates their distress without agreeing with their derogatory remarks about colleagues. Reporting the interaction to the RN is essential because splitting requires a unified team response to prevent manipulation and maintain boundaries. Finally, because the client is agitated and threatening to disturb their wound, prioritizing environmental safety by removing potential hazards is a critical first-line intervention within the PN scope of practice.

Step-by-Step Solution

1
Identify the client's clinical presentation and defense mechanisms.
The client has borderline personality disorder, is exhibiting splitting behavior by idealizing the current nurse and devaluing the previous nurse, and is displaying agitation with threats of self-harm.
Recognizing the defense mechanism (splitting) and the acute risk for injury dictates the priority nursing interventions.
2
Prioritize immediate safety interventions.
The PN must secure the environment by removing sharps or unnecessary medical supplies.
The client's explicit threat to disturb their wound and history of self-inflicted injuries requires immediate action to prevent further harm.
3
Determine the most therapeutic communication approach.
The PN should validate the client's emotional state without agreeing with the derogatory comments about the other nurse.
Reflecting feelings builds trust and de-escalates agitation while avoiding reinforcing the splitting behavior.
4
Execute appropriate collaborative actions within the PN scope of practice.
The PN must report the behavior to the RN and the broader interdisciplinary team.
Managing splitting requires consistent limits and communication among the entire healthcare team to ensure a unified approach and prevent manipulation.

Key Concept

Managing Borderline Personality Disorder, Splitting, and Client Safety
Question 216Question →

A client with a history of generalized anxiety disorder is waiting in a crowded outpatient clinic. The client suddenly becomes highly agitated, clenching their fists, pacing rapidly, and shouting at the clinic staff about the wait time. Which action should the practical nurse (PN) take first?

Show answer & explanation

Answer: Maintain a safe physical distance and discreetly direct other clients out of the immediate area.

Answer

The practical nurse should prioritize safety by maintaining a safe physical distance and discreetly directing other clients out of the immediate area.
When a client is acutely agitated and exhibiting signs of potential violence (rapid pacing, clenched fists), the primary nursing responsibility is to ensure the physical safety of everyone in the vicinity. Maintaining a safe distance protects the nurse, and clearing the room of bystanders removes an audience, decreases stimulation, and prevents injuries. Once the area is secure, verbal de-escalation techniques can be attempted safely.

Step-by-Step Solution

1
Assess the situation for immediate safety risks.
The client is highly agitated, pacing, and clenching fists in a crowded waiting room, indicating a risk of imminent violence or harm.
Safety of the client, bystanders, and staff is the absolute priority in any psychiatric emergency.
2
Identify the most appropriate first-line intervention for acute agitation.
Clearing the environment of bystanders and maintaining a safe distance is selected as the primary action.
This removes potential targets, decreases environmental stimulation, and prevents the client from feeling trapped, which is the foundational step before verbal de-escalation can begin.

Key Concept

Crisis De-escalation and Environmental Safety
Question 217Question →

A provider has just pronounced the death of a client receiving palliative care in a skilled nursing facility. The family is en route to the facility to view the body. In what order should the licensed practical nurse (LPN) perform the following post-mortem care actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is: verify autopsy status, elevate the head of the bed and close the eyelids, remove medical tubes and lines, wash the body and apply a clean gown, and finally position the client with the sheet drawn up to the shoulders.
The correct sequence for post-mortem care prioritizes legal requirements and time-sensitive physiological changes. First, the nurse must verify the autopsy status, as tubes and lines must remain in place if an autopsy or medical examiner review is required. Second, elevating the head of the bed must be done quickly to prevent livor mortis from discoloring the face, and closing the eyelids is easiest before rigor mortis sets in. Third, once autopsy is ruled out, invasive tubes and lines are safely removed. Fourth, the body is washed, absorbent pads are placed to catch any relaxing sphincter output, and a clean gown is applied. Finally, the client is positioned naturally with the sheet drawn up to the shoulders to create a peaceful, dignified viewing environment for the arriving family.

Step-by-Step Solution

1
Verify the client's medical record to confirm that an autopsy is not required.
Legal and medical examiner requirements are safely confirmed.
If an autopsy is required, all tubes and lines must be left exactly as they were at the time of death to avoid destroying medical evidence.
2
Elevate the head of the bed slightly and gently close the client's eyelids.
The client's facial appearance is preserved.
Elevating the head prevents livor mortis (blood pooling) from causing irreversible purplish discoloration in the face. Closing eyelids must be done early before rigor mortis sets in.
3
Remove the client's indwelling urinary catheter and peripheral intravenous line.
The body is freed of medical equipment.
Since no autopsy is required, devices can be removed to make the body look more natural and comfortable for the family's viewing.
4
Wash any soiled areas of the body, place an absorbent pad under the buttocks, and apply a clean gown.
The client is hygienic and dressed properly.
Sphincters relax after death, often causing incontinence. Bathing the body and placing an absorbent pad manages this, and applying a clean gown restores dignity.
5
Position the client supine with arms resting at the sides and draw the top sheet up to the shoulders.
The environment is prepared for the family's arrival.
Creating a peaceful, organized, and dignified presentation helps ease the psychological distress of the family members when they enter the room.

Key Concept

Post-Mortem Care Sequencing
Question 218Question →

A pediatric client is admitted with a new diagnosis of type 1 diabetes mellitus. The client's parent is visibly distressed, clenching their hands, and says to the practical nurse, "We have no family history of this. I cooked healthy meals every single day. I failed my child." Which response by the practical nurse is most therapeutic?

Show answer & explanation

Answer: You are feeling responsible for the diagnosis despite providing a healthy lifestyle.

Answer

The response that reflects the parent's feelings of responsibility and guilt.
The correct answer utilizes reflection and empathy, which validates the parent's feelings of guilt and encourages further exploration of their emotions without judgment or minimizing their distress.

Step-by-Step Solution

1
Analyze the parent's statement.
The parent is expressing significant guilt and taking direct responsibility for the child's new diagnosis.
Understanding the core emotion helps determine what type of support the parent needs at this moment.
2
Evaluate the communication techniques used in each option.
Identify which response uses a therapeutic technique (e.g., reflection, empathy) versus non-therapeutic communication blocks (e.g., giving advice, false reassurance, asking 'why').
The correct response must align with validated therapeutic communication principles.
3
Select the best response.
The response reflecting the parent's feelings of responsibility directly addresses their stated concerns.
Reflection validates the parent's distress and promotes a trusting nurse-client relationship.

Key Concept

Therapeutic Communication
Question 219Question →

During the evening shift on a behavioral health unit, a client with a history of borderline personality disorder begins yelling at the nursing staff and demanding immediate discharge. The client starts throwing magazines across the dayroom. Arrange the following nursing interventions in the correct sequence from least restrictive to most restrictive. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence from least to most restrictive is: verbal de-escalation, environmental modification, oral pharmacological intervention, and finally physical restraints.
In psychiatric and behavioral health nursing, the principle of the least restrictive intervention dictates the sequence of actions when managing an escalating client. The nurse must begin with the least invasive method, which is verbal de-escalation and active listening. If this fails, the next step is environmental modification, such as moving the client to a low-stimulation area. If non-pharmacological methods are insufficient, a chemical intervention (like an oral PRN medication) is offered. Physical restraints are the absolute most restrictive measure and are reserved only for situations where there is an imminent threat to life or safety.

Step-by-Step Solution

1
Identify the least restrictive intervention.
Approaching the client calmly to acknowledge their frustration.
Verbal techniques are the first step in de-escalation and preserve the highest level of client autonomy.
2
Determine the next least restrictive non-pharmacological measure.
Escorting the client to a quiet area.
Removing the client from a stimulating environment helps reduce agitation without the use of medication or physical force.
3
Evaluate the restrictiveness of the remaining options.
Offering a prescribed PRN oral medication.
Chemical interventions are more restrictive than environmental changes. However, voluntary oral medication is less restrictive than physical restraints.
4
Identify the most restrictive measure of last resort.
Applying physical restraints.
Physical restraints severely limit a client's freedom of movement and are strictly a last resort when immediate safety is compromised.

Key Concept

Least Restrictive Environment and Behavioral Interventions
Estimated Time:1m 15s
Question 220Question →

At an oncology clinic, a client with newly diagnosed stage IV pancreatic cancer is sitting with arms crossed, staring at the floor. The client suddenly looks up and states, 'My spouse keeps planning our vacation for next year like nothing is happening. I feel completely invisible when those plans are mentioned.' Which response by the nurse represents the most effective application of therapeutic communication?

Show answer & explanation

Answer: Hearing about those future plans leaves you feeling unheard in this moment.

Answer

The most effective therapeutic response is to state, 'Hearing about those future plans leaves you feeling unheard in this moment.'
The correct answer utilizes the therapeutic technique of reflection (or restatement). By mirroring the client's emotional experience (feeling 'invisible' translated to 'unheard'), the nurse validates the client's distress and creates a safe space for the client to elaborate on their feelings. It remains entirely focused on the client without introducing outside judgments.

Step-by-Step Solution

1
Analyze the client's statement to identify the core emotional message.
The client is expressing profound feelings of isolation and being 'invisible' due to the spouse's avoidance of the terminal reality.
Understanding the underlying emotion is necessary to select an empathetic, validating response.
2
Evaluate the nurse's options against established therapeutic and non-therapeutic communication techniques.
Defending the spouse, giving advice, and asking closed-ended, presumptive questions are identified as non-therapeutic barriers.
Eliminating communication blocks ensures the chosen response maintains a client-centered approach.
3
Select the option that utilizes a valid therapeutic technique.
The response that reflects the client's feelings of being 'unheard' acts as a mirror, encouraging further exploration.
Reflection demonstrates empathy, validates the client's emotional state, and keeps the conversation focused on the client's immediate needs.

Key Concept

Therapeutic Communication
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