Psychosocial Integrity

A triage nurse in the emergency department is evaluating four clients, each with a history of substance use. Based on the presenting clinical findings, which client should the nurse identify as the highest priority for immediate medical intervention?

A client is brought to the emergency department by law enforcement due to severe agitation, paranoia, and physical aggression after ingesting synthetic cathinones ('bath salts'). Arrange the following nursing actions in the prioritized order of execution.

An occupational health nurse is called to the human resources department to assist an employee who was just informed of their unexpected, immediate termination after 20 years with the company. The employee is sitting rigidly in a chair, hyperventilating, staring blankly, and repeating, "This cannot be happening. How will I feed my children?" Which of the following is the priority nursing action?

An ambulatory care nurse is speaking with a client who was just informed they have early-stage Alzheimer's disease. The client laughs and says, "The doctor doesn't know what he's talking about. I just have a little trouble remembering names sometimes, like anyone my age." Which of the following is the most therapeutic response by the nurse?

During an intake assessment at a community behavioral health clinic, a client seeking treatment for alcohol dependence states, "I do not understand why everyone is making such a big deal. I can stop drinking whenever I choose." Which response by the nurse is most appropriate?

A 28-year-old client is visiting her mother, who has terminal ovarian cancer and has just been transitioned to comfort care. The daughter begins to cry and says to the nurse, "I do not know how I am going to survive without her." Which response by the nurse is the most therapeutic?

During a group therapy session in the main lounge, a client with acute mania abruptly stands up, overturns a table, and begins aggressively threatening the facilitator with a clenched fist. Place the following psychiatric emergency interventions in the correct chronological sequence, prioritizing immediate safety and adhering to the least restrictive environment doctrine. (Arrange from first action to last action.)

A 45-year-old client on the oncology unit has just been informed that their chemotherapy was ineffective and the tumor has metastasized. The client stares out the window and quietly states, "I did everything the doctors told me to do. I changed my diet, I took the treatments, and it didn't even matter." Which of the following is the most therapeutic response by the nurse?

A home health nurse is evaluating a client recently diagnosed with a chronic, progressive neurological disorder. The client states, "The clinic mixed up my laboratory reports. There is absolutely nothing wrong with me, and I am not taking any of those new medications." Which actions by the nurse are appropriate at this time? Select all that apply.

A nurse is caring for a client who is preparing for discharge to a skilled nursing facility following a complex cerebrovascular accident. The client pushes their food tray away, begins crying softly, and says to the nurse, "I am just a useless burden to everyone. My children are sending me away because they are tired of dealing with me." Which of the following statements by the nurse demonstrate appropriate therapeutic communication? (Select all that apply.)

A nurse is caring for a client admitted with end-stage heart failure who was just informed by the healthcare provider that they are no longer a candidate for a heart transplant. After the provider leaves the room, the client stares blankly at the wall and says in a flat tone, "Well, I guess that is it then. All this fighting for nothing." Which of the following is the most therapeutic response by the nurse?

A nurse is caring for a client on a medical-surgical unit who suddenly begins pacing rapidly, clenching their fists, and glaring at staff members. The client is visibly agitated and their behavior is escalating. Arrange the following nursing interventions in the order they should be implemented, prioritizing from the least restrictive approach to the most restrictive.

An ambulatory care nurse is assessing a caregiver who arrived with a 4-week-old infant for a scheduled immunization visit. The caregiver is trembling, crying profusely, and states, 'I cannot handle this. I have not slept in almost a week, the baby will not stop screaming, and I am a complete failure.' Which of the following initial interventions by the nurse are appropriate? Select all that apply.

A hospice nurse is caring for a client with end-stage liver disease who acutely develops severe terminal delirium, characterized by distressing hallucinations and physical agitation. The client's family is present and extremely frightened by the sudden change in behavior. Arrange the following nursing actions in the correct priority sequence.

A nurse in a pediatric rehabilitation unit is caring for a 15-year-old client who is recovering from a severe traumatic brain injury. The client's separated parents are arguing loudly at the bedside regarding the discharge plan. The mother insists on home care with a private aide, while the father demands placement in a residential facility. Both parents turn to the nurse and ask, "What do you think is the best choice for our child?" The client begins to cry, becomes restless, and the cardiac monitor shows a heart rate increase from 88 to 128 beats/min. Which action is the nurse's priority?

A nurse is caring for a client who was admitted 72 hours ago for a severe respiratory infection. The client suddenly becomes extremely agitated, exhibits profuse diaphoresis, and frantically states, "There are spiders crawling all over the walls!" The client's spouse reports that the client usually drinks a pint of vodka daily but abruptly stopped on the day of admission. Arrange the following nursing actions in the correct prioritized sequence from first to last.

A client with end-stage chronic obstructive pulmonary disease (COPD) is admitted to the palliative care unit. The client is experiencing severe dyspnea at rest, anxiety, and reports feeling "like I cannot get enough air." The goal of care has shifted entirely to comfort measures. Which nursing actions are appropriate to include in the plan of care? Select all that apply.

A client is admitted to the inpatient psychiatric unit with major depressive disorder and active suicidal ideation. After five days of refusing meals, isolating in their room, and avoiding staff interactions, the client suddenly emerges into the dayroom smiling. The client hands a cherished watch to a peer and states, "The heavy cloud has finally lifted. I know exactly what I have to do now, and everything will be at peace." Which of the following is the priority nursing action?

A 15-year-old client is receiving treatment in the emergency department for injuries sustained in a sports accident. The client's divorced parents are arguing loudly in the hallway outside the room regarding the proposed treatment plan, which is visibly upsetting the conscious client. In what order should the nurse perform the following actions to de-escalate the family crisis and establish boundaries? Arrange the nursing actions from first to last.

A client arrives at a community health clinic reporting severe muscle aches, insomnia, stomach cramps, and a constantly runny nose that began early in the morning. During the interview, the nurse observes that the client is highly restless, yawning frequently, and has noticeably dilated pupils. The client insists on receiving a strong antibiotic to treat these "severe flu symptoms." Which response or action by the nurse is the priority?