Examkin

Psychosocial Integrity

368 questions

All types368Multiple choice190Multiple select86Matching19Ordering73
Question 181Question →

A young adult client is brought to the emergency department via police after being found wandering in traffic. The client is currently in an examination room, highly agitated, hyperventilating, and throwing medical supplies onto the floor. When staff approach, the client screams, 'They are coming to take me away!' Which of the following initial actions by the nurse are appropriate? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Approach the client from a 45-degree angle while maintaining a distance of at least two arm lengths.; Remove non-essential medical equipment from the immediate area and ensure other individuals are cleared.; Speak using short, concrete sentences such as 'You are safe in the hospital, and I am here to help you.'

Answer

The correct actions are approaching from a 45-degree angle at a safe distance, removing non-essential equipment and clearing the area, and using short, concrete sentences to communicate safety.
The correct interventions prioritize safety and utilize the least restrictive measures for an acutely agitated and paranoid client. Approaching from a 45-degree angle at a safe distance is non-threatening and respects personal space boundaries. Removing objects that can be thrown and clearing the immediate area ensures physical safety for everyone while simultaneously reducing environmental stimulation. Using short, concrete sentences is essential because severe anxiety and paranoia impair a client's cognitive ability to process complex information.

Step-by-Step Solution

1
Assess the client's clinical presentation and identify safety risks.
The client is highly agitated, experiencing paranoia, and demonstrating physical escalation by throwing objects.
An accurate behavioral assessment dictates the appropriate level of intervention, ensuring safety for both the client and the healthcare team.
2
Select interventions that follow the principle of the least restrictive environment.
The nurse utilizes non-threatening body positioning (45-degree angle, ample distance) and clear, concrete verbal reassurance.
These techniques de-escalate the situation by reducing the client's perceived threat without imposing unnecessary physical boundaries.
3
Modify the physical environment to mitigate immediate hazards.
Medical equipment is removed from the room, and unnecessary personnel are cleared.
Removing potential projectiles minimizes injury risk, while decreasing environmental stimuli helps lower the client's severe panic.
4
Evaluate and reject unsafe or overly restrictive interventions.
Options involving delegating to a UAP, physically blocking the exit, and jumping directly to physical restraints are eliminated.
These actions violate safety protocols, inappropriate delegation rules, and the legal mandate to exhaust all less restrictive alternatives first.

Key Concept

Prioritizing least restrictive de-escalation techniques, milieu safety, and appropriate nursing delegation during acute behavioral crises.
Question 182Question →

A client on the inpatient psychiatric unit is experiencing severe anxiety. They are pacing rapidly, hyperventilating, and frantically stating, "I feel like I am going to die!" Which of the following is the priority nursing action?

Show answer & explanation

Answer: Remain with the client and speak using a calm, reassuring voice.

Answer

Remain with the client and speak using a calm, reassuring voice.
The correct action provides immediate support and safety. A client with severe anxiety may feel out of control and extremely fearful. The physical presence of a nurse who remains calm helps to ground the client, reduce isolation, and prevent further escalation of panic. This represents the least restrictive and most therapeutic initial behavioral intervention.

Step-by-Step Solution

1
Assess the client's current behavioral and emotional state.
The client is experiencing severe panic-level anxiety, demonstrated by rapid pacing, hyperventilation, and feelings of impending doom.
Understanding the severity of the anxiety dictates the most appropriate and immediate intervention.
2
Determine the least restrictive, most therapeutic initial intervention to ensure safety.
Providing a physical presence and maintaining a calm demeanor are selected as the first-line strategies.
A client in severe panic cannot process complex information or answer probing questions; a calm, grounding presence is the priority.

Key Concept

During severe panic or anxiety, the nurse's primary behavioral intervention is to provide a safe environment by remaining with the client and using a calm, directive approach.
Question 183Question →

A nurse is caring for an older adult client who is actively dying in a hospice unit. The client is unresponsive, experiencing noisy respiratory secretions, and exhibiting restlessness. Which actions should the nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Administer a prescribed anticholinergic medication to reduce respiratory secretions.; Turn the client to a side-lying position to facilitate the drainage of oral fluids.; Provide gentle mouth care using moistened swabs to maintain oral comfort.

Answer

The nurse should administer prescribed anticholinergic medications, turn the client to a side-lying position, and provide gentle mouth care.
End-of-life care focuses on promoting comfort, dignity, and symptom management. Turning the client to a side-lying position allows gravity to drain pooled secretions, naturally reducing noisy breathing. Anticholinergic medications are medically appropriate to dry up excessive respiratory secretions. Frequent mouth care prevents the severe discomfort of dry, cracked mucous membranes, which is common in dying clients due to mouth breathing and decreased fluid intake.

Step-by-Step Solution

1
Assess the client's presenting symptoms and physiological needs.
The client is actively dying, unresponsive, and experiencing noisy secretions and restlessness.
Identifying symptoms allows the nurse to prioritize appropriate palliative care interventions over aggressive or non-therapeutic measures.
2
Select interventions that directly alleviate the client's physical discomfort.
The nurse chooses to reposition the client, administer secretion-drying medications, and perform oral care.
These actions address the 'death rattle' and maintain mucous membrane integrity without causing harm.
3
Ensure safe delegation and therapeutic communication principles are maintained.
The nurse retains the responsibility of assessing pain and avoids giving the family false reassurance.
Nursing assessments cannot be delegated, and therapeutic communication requires honesty and active listening rather than dismissive clichés.

Key Concept

End of Life Comfort Measures and Palliative Care
Question 184Question →

A client receives a new diagnosis of amyotrophic lateral sclerosis (ALS) from the neurologist. Shortly after the discussion, the nurse enters the room and the client says, "The doctor is just being overly dramatic. I just have a pinched nerve from working in the garden, and it will heal on its own with some rest." Which initial response by the nurse is the most therapeutic?

Show answer & explanation

Answer: You are thinking this might just be a pinched nerve. How are you feeling about the conversation you just had with the doctor?

Answer

The most therapeutic response is to use reflection and an open-ended question, stating, "You are thinking this might just be a pinched nerve. How are you feeling about the conversation you just had with the doctor?"
The client is exhibiting denial, a common and protective initial defense mechanism when faced with a devastating diagnosis. The most therapeutic nursing response utilizes reflection to gently acknowledge what the client has said without reinforcing the denial, paired with an open-ended question to invite the client to share their feelings when they are ready. This approach keeps communication open while respecting the client's current coping limits.

Step-by-Step Solution

1
Analyze the client's statement and behavior.
The client is minimizing a severe diagnosis (ALS) by attributing symptoms to a minor issue (a pinched nerve).
This identifies the defense mechanism being used, which is denial.
2
Evaluate the purpose of the identified defense mechanism.
Denial acts as a temporary protective barrier against the overwhelming anxiety of a terminal or severe illness diagnosis.
Understanding that denial is a normal initial stage of grief guides the selection of a supportive, non-confrontational intervention.
3
Select the most therapeutic communication technique.
The correct response uses reflection to acknowledge the client's current perception without validating the delusion, followed by an open-ended question to explore feelings.
This approach maintains the therapeutic relationship, allows the client to process the trauma at their own pace, and avoids non-therapeutic blocks like confrontation or false reassurance.

Key Concept

Therapeutic Communication and Coping Mechanisms (Denial)
Question 185Question →

A nurse on the maternity unit is caring for a couple who just experienced an unexpected stillbirth at 38 weeks of gestation. The parents are crying softly and averting their gaze from the delivery area. Which action should the nurse take to best facilitate the initial stages of the grieving process?

Show answer & explanation

Answer: Clean and swaddle the infant, then gently offer the parents the opportunity to see and hold their baby when they are ready.

Answer

The correct action is to clean and swaddle the infant, then gently offer the parents the opportunity to see and hold their baby when they feel ready.
The correct answer supports the parents by validating the existence of their infant and gently offering them the opportunity to create memories. Cleaning and swaddling the baby presents the infant in a dignified, less traumatic manner. Allowing the parents to decide when they are ready to see and hold the baby respects their autonomy and individual coping timelines, which is a foundational component of healthy bereavement in perinatal loss.

Step-by-Step Solution

1
Assess the clinical situation and the parents' immediate psychosocial needs following a perinatal loss.
The parents are experiencing acute grief, crying quietly, and avoiding looking at the delivery area.
Understanding the parents' emotional state and readiness is essential for selecting a therapeutic, patient-centered intervention.
2
Evaluate the nursing interventions based on evidence-based principles of perinatal grief and loss.
The most therapeutic approach involves acknowledging the infant's existence, preparing the baby for presentation, and allowing the parents to control the pace of their interaction.
Creating memories and physically interacting with the baby helps parents ground the reality of the loss, which facilitates a healthy mourning process.
3
Select the option that offers compassionate support without forcing interaction, making assumptions, or using communication blocks.
Offering the parents the opportunity to see and hold their swaddled baby when they are ready is the best initial nursing action.
This intervention respects the parents' autonomy, avoids non-therapeutic platitudes, and establishes a foundation of trust and support.

Key Concept

Perinatal Grief and Therapeutic Nursing Interventions
Question 186Question →

An older adult client is admitted to the intensive care unit (ICU) following major surgery. The client is continuously exposed to monitor alarms, bright overhead lights, and frequent staff interactions. On the second day, the client becomes severely agitated, disoriented to time and place, and begins pulling at their intravenous (IV) lines. Which action should the nurse take first to address the client's current condition?

Show answer & explanation

Answer: Cluster nursing activities and dim the overhead lights to provide uninterrupted rest periods.

Answer

The nurse should first decrease sensory stimuli by clustering nursing activities and dimming the overhead lights.
The client is experiencing sensory overload (often referred to as ICU psychosis or delirium) resulting from the continuous barrage of excessive environmental stimuli. The most effective and least restrictive initial nursing action is to decrease the sensory input. By dimming the lights, lowering alarm volumes to safe levels, and clustering care, the nurse provides long, uninterrupted blocks of time for rest, which directly mitigates the sensory overload.

Step-by-Step Solution

1
Identify the primary cause of the client's agitation and disorientation.
The environment of continuous alarms, bright lights, and frequent interruptions indicates that the client is experiencing sensory overload (ICU delirium).
Recognizing the environmental etiology of the sudden behavioral change directs the nurse toward the most appropriate, non-pharmacological intervention.
2
Determine the least restrictive and most direct nursing intervention to address the root cause.
Modifying the environment by grouping nursing tasks and dimming the room lights reduces excessive stimulation.
Environmental modification treats the root cause of the sensory overload directly, avoiding inappropriate use of physical restraints or improper delegation.

Key Concept

Management of sensory overload in critical care environments.
Estimated Time:1m 0s
Question 187Question →

During a morning assessment, a client with newly diagnosed end-stage liver disease refuses their prescribed oral medications. The client crosses their arms, looks away, and states, "I am not swallowing another pill. My body is shutting down anyway, so delaying the inevitable is just a waste of everyone's time." Which response by the nurse demonstrates the most appropriate therapeutic communication technique?

Show answer & explanation

Answer: You feel that taking these medications is pointless because of the progression of your illness.

Answer

The response that restates the client's feeling that taking the medications is pointless due to the illness progression.
The correct response utilizes reflection, a powerful therapeutic technique that directs the client's ideas, feelings, and thoughts back to them. By restating the client's core message without adding new information or judgment, the nurse validates the client's feelings of hopelessness and encourages them to continue sharing their emotional experience.

Step-by-Step Solution

1
Analyze the client's statement to identify the core emotional message.
The client is expressing feelings of hopelessness, despair, and powerlessness regarding their terminal prognosis.
Recognizing the underlying emotional context is essential for selecting a response that addresses the client's actual psychological needs.
2
Evaluate the nursing responses for therapeutic communication techniques.
The reflective statement accurately mirrors the client's expressed feelings of pointlessness back to them.
Reflection validates the client's emotional state, demonstrates active listening, and opens the door for further exploration of their feelings.
3
Identify non-therapeutic communication barriers in the remaining options.
The other options use non-therapeutic techniques such as providing logical explanations (ignoring feelings), asking 'why' (causing defensiveness), or highlighting negative consequences (subtle threatening).
Eliminating responses that block communication ensures the selection of the most therapeutic approach.

Key Concept

Therapeutic Communication
Question 188Question →

A client in an outpatient neurology clinic has just been informed of a progressive, life-altering neurological diagnosis. The client sits rigidly in the chair, staring blankly at the wall, and states in a flat tone, 'My future is gone. There is no point in trying to go on anymore.' Which action is the priority for the nurse to take?

Show answer & explanation

Answer: Ask the client explicitly if they are thinking about ending their life.

Answer

Ask the client explicitly if they are thinking about ending their life.
During an acute situational crisis, ensuring client safety is the paramount concern. The statement about having 'no point in trying to go on' is a strong, covert indicator of hopelessness and potential suicidal ideation. According to the nursing process and safety prioritization principles, the nurse must immediately and directly assess the client's risk for self-harm before proceeding to other supportive, empathetic, or educational interventions.

Step-by-Step Solution

1
Analyze the client's presentation and verbal statements.
The client is exhibiting signs of an acute situational crisis with a statement ('no point in trying to go on anymore') that suggests hopelessness and potential self-harm.
Identifying covert or overt threats is the first step in psychiatric triage.
2
Apply prioritization frameworks (e.g., Maslow's Hierarchy, Safety/Risk Reduction).
Psychological and physical safety must be secured before addressing self-esteem, coping, or educational needs.
A client cannot successfully process grief or learn about treatments if their immediate survival is at risk.
3
Select the intervention that most directly addresses the highest priority need.
Directly assessing for suicidal ideation addresses the immediate safety risk.
Direct questioning is the standard of care for evaluating self-harm risk in a crisis.

Key Concept

Prioritizing Safety and Lethality Assessment in Crisis Intervention
Question 189Question →

An older adult client is admitted to the intensive care unit (ICU) for the management of severe sepsis and requires mechanical ventilation. On the third day of admission, the client develops acute, fluctuating confusion, severe inattention, and psychomotor agitation. The client appears terrified of the ventilator sounds and makes repeated attempts to remove the endotracheal tube. Based on the client's acute sensory and perceptual alterations, which nursing interventions are most appropriate? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Consolidate nursing assessments and interventions to promote restorative sleep cycles and minimize continuous sensory overload.; Provide consistent, low-stimulus reality orientation by clearly identifying oneself and explaining all procedures before initiating physical contact.; Implement non-pharmacological safety measures, such as a bedside sitter or family presence, to mitigate the risk of device removal.

Answer

The appropriate interventions are to consolidate nursing care to reduce sensory overload, provide consistent reality orientation before touching the client, and utilize a sitter or family member as a less restrictive safety measure.
Clients in intensive care settings frequently develop acute delirium due to sensory overload, disrupted sleep-wake cycles, and underlying critical illness. Evidence-based management prioritizes reducing excessive environmental stimuli by consolidating care, promoting restorative sleep, and providing simple, consistent reality orientation. Because the client is at high risk for removing life-sustaining equipment, ensuring safety is paramount; however, the standard of nursing practice dictates implementing the least restrictive measures first. Utilizing a bedside sitter or encouraging family presence serves to calm the client, provide continuous monitoring, and prevent self-harm without the adverse psychological and physical effects of restraints.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client is experiencing acute delirium, characterized by fluctuating confusion, inattention, and agitation, likely secondary to sensory overload in the ICU environment.
Identifying the root cause of the behavior dictates the appropriate environmental and therapeutic interventions.
2
Prioritize safety through the least restrictive means.
Selected interventions that use non-pharmacological methods (like a sitter) before resorting to physical restraints.
Nursing standards of care mandate that restraint alternatives must be exhausted prior to applying physical restraints, even when there is a risk of medical device removal.
3
Determine appropriate delegation boundaries.
Excluded the option that assigns neurological and cognitive assessments to the UAP.
Evaluating delirium requires complex clinical judgment, which is strictly within the scope of practice of the registered nurse.
4
Select evidence-based therapeutic communication strategies.
Chose simple, clear, and calming orientation over complex logical explanations or confrontational 'why' questions.
Clients with acute perceptual alterations cannot process complex logic; simplified communication reduces anxiety and paranoia.

Key Concept

Management of Sensory Overload and Acute Delirium
Question 190Question →

A nurse is preparing a client's body for family viewing following an expected death from end-stage heart failure. The family is waiting in a nearby consultation room. Place the following nursing actions for post-mortem care in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first verify the pronouncement of death, then determine autopsy or donor status, next remove medical equipment, subsequently bathe and dress the body, and finally cover the client and tidy the environment.
Appropriate post-mortem care requires strict adherence to legal and facility protocols followed by compassionate preparation of the body. Verification of death is the absolute first step. Following this, the nurse must ensure no autopsy is required before altering the body by removing lines. Once cleared, the nurse removes medical equipment, cleanses and dresses the body, and finally prepares the physical environment to support the grieving family during their initial viewing.

Step-by-Step Solution

1
Verify the formal pronouncement of death in the client's medical record.
Legal confirmation of death is established.
Post-mortem care cannot legally commence until a provider has officially pronounced the time of death.
2
Determine whether the client requires an autopsy or is an organ donor.
The nurse knows whether lines and tubes must be retained.
If an autopsy is required, all lines, tubes, and medical equipment must be left in place to preserve forensic evidence.
3
Remove all intravenous lines, indwelling catheters, and medical equipment.
The body is free of medical devices.
Once an autopsy is ruled out, removing equipment helps normalize the client's appearance for the family.
4
Bathe the client's body, apply a clean gown, and place a pillow under the head.
The body is clean and positioned to prevent blood pooling.
Bathing provides dignity, and placing a pillow under the head prevents livor mortis (discoloration) in the face.
5
Cover the client with a clean sheet up to the shoulders and tidy the room.
The environment is prepared for the family's visit.
A clean, calm environment reduces trauma for the family and supports the initial stages of the grieving process.

Key Concept

Post-Mortem Care Sequence
Question 191Question →

The nurse is reviewing the interdisciplinary notes of four adult clients recovering on a severe trauma and burn step-down unit. Match each documented client statement or behavioral cue to the specific defense mechanism being demonstrated.

Click a left item, then click its matching right item

Items

A client harboring intense anger toward the driver who caused their accident channels this energy into organizing a community chapter for impaired driving awareness.
An adult client who was previously independent begins whining, exhibiting nocturnal enuresis, and demanding the nurse feed them.
A client who ignored workplace safety protocols causing their burn injury states, 'The equipment was outdated anyway, so it was bound to happen eventually.'
A client who secretly resents their spouse for escaping the house fire unharmed is excessively affectionate and constantly tells staff, 'My spouse is an absolute angel.'

Matches

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Answer

The correct pairings are: channeling anger into community awareness matches with Sublimation, reverting to whining and enuresis matches with Regression, justifying the accident on outdated equipment matches with Rationalization, and displaying excessive affection to hide resentment matches with Reaction Formation.
Defense mechanisms are unconscious psychological strategies used to protect a person from anxiety arising from unacceptable thoughts or feelings. Sublimation is an adaptive mechanism where negative energy is redirected into positive, socially acceptable endeavors. Regression is a maladaptive response characterized by returning to an earlier, more comfortable developmental stage. Rationalization involves creating self-justifying explanations to hide the true underlying motives or guilt. Reaction formation occurs when a person outwardly exhibits the exact opposite of their true, unacceptable internal feelings.

Step-by-Step Solution

1
Analyze the first cue involving channeling anger into a community chapter.
Recognize this as an adaptive replacement of unacceptable anger into a socially constructive activity, which defines Sublimation.
Identifying the positive societal outcome helps distinguish this highly adaptive coping mechanism.
2
Analyze the second cue involving an adult exhibiting enuresis and whining.
Identify this as a retreat to a previous developmental level of functioning due to high anxiety and trauma, which defines Regression.
Noting the childlike behavior in an adult highlights the maladaptive attempt to seek comfort and avoid present stressors.
3
Analyze the third cue involving a client blaming the equipment to justify ignoring safety rules.
Understand this as formulating logical but false reasons to protect the ego from guilt, which defines Rationalization.
Recognizing the self-serving excuse helps differentiate this from simply lying or projecting.
4
Analyze the fourth cue involving a client showing excessive affection to cover up resentment.
Identify this as overcompensating or demonstrating behavior opposite to true unacceptable feelings, which defines Reaction Formation.
Spotting the extreme polarity between the internal feeling (resentment) and external display (excessive affection) is key to this mechanism.

Key Concept

Defense Mechanisms in Psychosocial Adaptation
Question 192Question →

A nurse is providing psychosocial care to clients across multiple units. Pair each client's presentation or statement with the most therapeutic nursing response.

Click a left item, then click its matching right item

Items

"The physician said my tumor is growing, but I know they mixed up my scan with another patient's. I feel perfectly fine."
A client on the inpatient psychiatric unit sits motionless in the dayroom, avoids all eye contact, and has remained completely mute for several hours.
"The shadow creatures are crawling out of the television! They are coming to take me away right now!"
"My family never visits me. Nobody cares if I live or die in this place. You staff are all just here to collect a paycheck."
"I am absolutely terrified of having this open-heart surgery tomorrow. What if I never wake up from the anesthesia?"

Matches

Show answer & explanation

Answer

1) The client in denial matches with reflecting their belief without arguing. 2) The mute client matches with offering silent presence. 3) The hallucinating client matches with validating fear while presenting reality. 4) The angry, projecting client matches with translating hostile words into feelings of isolation. 5) The anxious preoperative client matches with exploring their fears via open-ended prompts.
The correct pairings apply foundational therapeutic communication principles to specific clinical vignettes. When a client experiences profound denial (tumor growth), the nurse restates and reflects to validate their current emotional state without forcing an aggressive reality confrontation. For a mute client, 'offering self' provides patient, non-demanding support. When addressing acute hallucinations, the nurse must present reality while acknowledging the client's genuine fear. For the angry, projecting client, translating their hostile words into the underlying feelings of abandonment de-escalates the emotional crisis. Finally, using open-ended exploration helps the preoperative client process their specific anxieties rather than shutting them down with false reassurance.

Step-by-Step Solution

1
Analyze the presentations involving altered perception or reality (the tumor denial and the visual hallucinations).
The client in denial requires a reflection of their belief, while the hallucinating client requires the nurse to present reality.
Therapeutic communication mandates validating the emotional experience without reinforcing a false belief.
2
Evaluate the presentations involving intense mood alterations (the mute client and the aggressively projecting client).
The mute client benefits from 'offering self' (sitting quietly), while the angry client needs their hostility translated into the underlying feeling of isolation.
Severely depressed clients cannot process verbal demands, and angry clients need the root cause of their acting out addressed safely.
3
Assess the presentation of the client with severe preoperative anxiety.
The most therapeutic approach is to use open-ended exploration to prompt further discussion.
Exploring allows the client to verbalize and process their specific fears, whereas false reassurance would minimize their acute distress.

Key Concept

Therapeutic Communication Techniques and Principles
Question 193Question →

A client arrives at a community health clinic in a state of acute panic, stating, "My partner just found out I'm trying to leave. They are looking for me and said they will kill me." The client is hyperventilating, pacing rapidly, and unable to focus. Arrange the following nursing actions in the correct priority order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first secure physical safety, then address acute physiological symptoms like hyperventilation, establish psychological safety and rapport, assess the precipitating event, and finally develop a concrete safety plan.
In crisis intervention, prioritizing care follows Maslow's hierarchy of needs and the nursing process. The absolute first priority is physical safety, which requires moving the client to a secure area and notifying security due to the active threat. Second, physiological stability must be achieved; hyperventilation prevents the client from processing information, making breathing exercises the next immediate action. Third, once the client can breathe and hear the nurse, psychological safety is established through therapeutic reassurance. Fourth, with the client stabilized and grounded, the nurse assesses the specific details of the crisis. Finally, based on the assessment, the nurse collaborates with the client and interdisciplinary team to formulate a concrete, short-term safety plan.

Step-by-Step Solution

1
Ensure physical safety by escorting the client to a secure room and notifying security.
The immediate threat of harm from the abuser is mitigated.
According to Maslow's hierarchy, physical safety must be secured before any other interventions can be effective.
2
Address the client's hyperventilation with breathing exercises.
The client's acute physiological arousal and panic are reduced.
A hyperventilating client cannot process verbal reassurance or participate in an assessment due to a severely narrowed perceptual field.
3
Provide clear, calming reassurance of safety.
Psychological safety and therapeutic rapport are established.
Once the client is physically safe and able to breathe normally, verbal reassurance helps ground them in reality and builds trust.
4
Assess the client's perception of the threat and the events of the day.
The nurse gathers necessary information about the crisis.
Assessment follows basic stabilization. The nurse must understand the specific situational crisis to plan appropriate interventions.
5
Collaborate on an immediate safety plan, such as shelter placement.
A concrete, short-term resolution to the crisis is implemented.
Planning and implementation occur after a thorough assessment, providing the client with a safe disposition.

Key Concept

Prioritization in Crisis Intervention
Question 194Question →

An adolescent client is admitted to an inpatient eating disorder unit for the treatment of severe anorexia nervosa. During the client's first supervised lunch, the nurse observes the client cutting a piece of chicken into minuscule pieces, continuously rearranging them on the plate, and hiding small portions under a napkin. After the allotted 30-minute meal period, the client has consumed less than 15% of the food and states, 'I cannot eat another bite, this food is saturated in grease and makes me nauseous.' Which of the following is the most appropriate nursing response?

Show answer & explanation

Answer: Your meal time has ended. I will take your tray now and provide the prescribed liquid nutritional supplement to replace the remaining calories.

Answer

The most appropriate response is to inform the client that meal time has ended, remove the tray, and provide the prescribed liquid nutritional supplement.
The correct response adheres to established milieu therapy protocols for anorexia nervosa. Clients with eating disorders often utilize stalling tactics, food manipulation, and complaints about food quality to avoid caloric intake. The nurse must maintain strict, unemotional boundaries regarding meal time limits and objectively implement the prescribed alternative (such as a liquid supplement) without engaging in a debate, offering threats, or coaxing the client.

Step-by-Step Solution

1
Analyze the client's behavior and diagnosis.
The client has anorexia nervosa and is exhibiting classic food-avoidance rituals (cutting food into tiny pieces, rearranging, hiding food) and utilizing stalling tactics.
Understanding the pathology behind the behavior is required to choose an intervention that does not reinforce the eating disorder.
2
Evaluate the nursing priorities for inpatient eating disorder protocols.
The primary goals are physiological stabilization through adequate caloric intake and the establishment of a highly structured therapeutic milieu.
Clients with anorexia require strict, consistent boundaries to prevent manipulation of the environment and to separate their self-worth from their eating behaviors.
3
Select the response that enforces the protocol without hostility or negotiation.
Removing the tray exactly at the end of the 30-minute limit and objectively offering the liquid supplement is the correct action.
This prevents power struggles, avoids debates about the food's quality, and ensures the physiological need for calories is met in a clinical, matter-of-fact manner.

Key Concept

Therapeutic Milieu and Limit Setting for Eating Disorders
Question 195Question →

An occupational health nurse is evaluating an adult client who recently experienced a traumatic workplace injury resulting in a lower limb amputation. The client stares at the floor and states, "My life is completely over. There is no point in trying to do anything anymore." Which of the following responses by the nurse is the most therapeutic?

Show answer & explanation

Answer: It sounds like you are feeling completely overwhelmed and hopeless about your future right now.

Answer

It sounds like you are feeling completely overwhelmed and hopeless about your future right now.
The correct response utilizes the therapeutic communication technique of reflection. By restating the client's expressed feelings in a gentle, non-judgmental way, the nurse validates the client's emotional pain, demonstrates active listening, and creates a safe space for the client to explore their feelings of hopelessness.

Step-by-Step Solution

1
Identify the client's current emotional state and psychosocial needs.
The client is expressing profound hopelessness, grief, and a sense of loss following a life-altering amputation.
Understanding the client's emotional baseline is required to choose an appropriate communication strategy.
2
Evaluate the primary goal of the nurse-client interaction at this moment.
The goal is to establish trust, validate the client's emotional pain, and encourage them to express their feelings.
Before problem-solving or education can occur, the client must feel heard and emotionally supported.
3
Analyze the options to eliminate non-therapeutic communication blocks.
Eliminate options that offer false reassurance, ask demanding 'why' questions, or give unprompted advice, as these block further emotional expression.
Non-therapeutic techniques invalidate the client's experience and create barriers in the therapeutic relationship.
4
Select the response that utilizes a recognized therapeutic communication technique.
The option utilizing reflection and empathy is selected.
Reflection acknowledges the client's stated feelings and opens the door for deeper therapeutic dialogue.

Key Concept

Therapeutic Communication Techniques in Grief and Loss
Question 196Question →

A client waiting for a biopsy procedure is wringing their hands, pacing the hallway, and tells the nurse, "I am so stressed and terrified about what they might find today." Which initial nursing action is the priority to help the client manage their acute stress?

Show answer & explanation

Answer: Say to the client, "It sounds like you are very concerned. Tell me more about what you are feeling right now."

Answer

The most appropriate action is to validate the client's concerns and encourage them to express their feelings by saying, "It sounds like you are very concerned. Tell me more about what you are feeling right now."
The correct response utilizes active listening, validation, and open-ended questioning. By stating, "It sounds like you are very concerned," the nurse validates the client's emotional state. Adding, "Tell me more..." provides a broad opening that empowers the client to verbalize their specific fears, which is the crucial first step in reducing acute situational stress.

Step-by-Step Solution

1
Assess the client's current behavioral and verbal cues.
The client is pacing, wringing hands, and verbally expressing intense fear about an impending procedure.
Identifying the severity of the stress response guides the choice of intervention.
2
Identify the priority nursing intervention for acute situational stress.
The nurse must use therapeutic communication to establish trust and allow the client to explore their fears.
Before teaching coping mechanisms or administering medications, the nurse must assess the specific cause of the anxiety through open-ended exploration.
3
Evaluate the available options against principles of therapeutic communication.
The option offering a broad opening and reflecting feelings is selected over options using false reassurance, "why" questions, or premature pharmacological interventions.
Therapeutic communication is the foundational independent nursing action for stress management.

Key Concept

Therapeutic Communication in Stress Management
Estimated Time:45s
Question 197Question →

A client in an outpatient clinic waiting area is becoming visibly frustrated due to a prolonged appointment delay. The client begins pacing rapidly, sighing loudly, and complaining to other visitors about the wait. Which action should the nurse take first?

Show answer & explanation

Answer: Calmly approach the client and offer to discuss their concerns in a quiet, private room.

Answer

Calmly approach the client and offer to discuss their concerns in a quiet, private room.
The correct answer emphasizes using the least restrictive alternative and verbal de-escalation. By approaching the client calmly and offering a quiet space, the nurse validates the client's frustration while removing them from an audience, which is an effective behavioral intervention to prevent further escalation.

Step-by-Step Solution

1
Analyze the client's behavior and the clinical environment.
The client is exhibiting early, non-violent signs of agitation (pacing, loud sighing, complaining) in a public setting.
Recognizing early signs of escalation allows the nurse to intervene proactively before the behavior becomes dangerous.
2
Identify the safest, least restrictive nursing intervention.
Verbal de-escalation and moving the client to a less stimulating area are prioritized over restrictive measures.
Nursing standards mandate using the least restrictive alternative first. A private room addresses the client's needs while protecting the safety of the milieu.

Key Concept

Least Restrictive Behavioral Interventions
Question 198Question →

A nurse is providing post-mortem care for a client who recently passed away. The provider has pronounced the death, and no autopsy is required. Arrange the following nursing actions in the appropriate sequential order to prepare the body for family viewing.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: assess cultural preferences, close the eyes and position the head, remove medical tubes, cleanse and dress the body, and finally invite the family back into the room.
The correct sequence prioritizes psychosocial needs first by assessing family cultural preferences. Next, the nurse addresses physiological changes by elevating the head and closing the eyes to prevent facial discoloration. Afterward, the nurse removes medical equipment and performs hygiene care to restore a natural appearance. Finally, the family is invited to view the deceased in a prepared, peaceful environment.

Step-by-Step Solution

1
Assess cultural and religious preferences.
The nurse determines how the family wishes the body to be handled.
Cultural beliefs dictate the approach to post-mortem care and must be respected before touching the body.
2
Close the eyes and elevate the head.
The face is protected from livor mortis.
Elevating the head prevents blood pooling and discoloration in the face.
3
Remove medical tubes and lines.
The body is freed from medical equipment.
Removing invasive devices normalizes the client's appearance, provided an autopsy is not required.
4
Cleanse the body and apply a clean gown.
The client is presented cleanly and with dignity.
Hygiene measures remove fluids or odors before the family visits.
5
Invite the family to view the body.
The family can begin grieving in a peaceful setting.
This is the final step once the physical preparation is complete.

Key Concept

Post-Mortem Care Sequential Priorities
Question 199Question →

A 79-year-old client with a history of stroke and vascular dementia is directly admitted to the medical-surgical unit from home. During the initial admission process, the nurse observes that the client is visibly malnourished, wearing urine-soaked clothing, and has bilateral heel ulcers covered in purulent drainage. The client's adult child, who is the primary caregiver, remarks, 'Taking care of them is just too overwhelming these days.' Which of the following actions should the nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Document the clinical findings objectively and record the caregiver's remarks using direct quotes.; Interview and examine the client privately, separate from the adult child.; Report the suspected elder neglect to the designated adult protective services agency.

Answer

The correct actions are to objectively document the findings with direct quotes, separate the client from the caregiver for a private assessment, and report the suspected neglect to adult protective services.
Nurses are mandated reporters who must immediately report suspected abuse or neglect based on reasonable suspicion, without waiting for definitive proof. Client safety is the paramount priority, requiring the nurse to separate the client from the suspected perpetrator to conduct a thorough, private assessment. Additionally, accurate and objective documentation of physical findings and verbatim quotes is essential for preserving evidence in the legal and clinical record.

Step-by-Step Solution

1
Analyze the clinical scenario and recognize indicators of neglect.
The client presents with severe malnutrition, poor hygiene, and untreated pressure injuries, strongly indicating elder neglect by the primary caregiver.
Recognizing indicators of abuse or neglect is the necessary first step to initiate safety protocols and legal responsibilities.
2
Determine immediate priority safety interventions.
The nurse must separate the client from the adult child to ensure physical safety and to conduct an accurate, private assessment.
Clients are often fearful or unable to disclose abuse or neglect in the presence of the suspected perpetrator.
3
Identify legal reporting responsibilities.
The nurse must report the suspected neglect to adult protective services immediately.
Nurses are mandated reporters and are required by law to report reasonable suspicion of abuse or neglect without waiting for definitive proof.
4
Apply correct principles of documentation and delegation.
The nurse must document objective findings and exact quotes from the caregiver, while retaining the initial wound assessment rather than delegating it to a UAP.
Objective documentation preserves factual evidence, and initial clinical assessments strictly require the clinical judgment of a registered nurse.

Key Concept

Mandatory Reporting and Immediate Safety in Suspected Elder Neglect
Question 200Question →

A client who recently received a diagnosis of multiple sclerosis pushes their breakfast tray aside and stares blankly out the window. When the nurse enters the room, the client sighs heavily and states, "What is the point of eating or taking these pills? I am just going to end up a helpless burden to my spouse anyway." Which response by the nurse is the most therapeutic?

Show answer & explanation

Answer: You are feeling overwhelmed and worried about how this illness will impact your family.

Answer

The most therapeutic response is to reflect and validate the client's feelings by acknowledging their feelings of being overwhelmed and worried about the impact of the illness on their family.
The correct response directly addresses the client's emotional state by reflecting their feelings of fear and concern about their spouse. This technique, known as reflection or empathetic validation, acknowledges the client's current emotional reality and creates a safe, non-judgmental space for them to further explore and process their grief and anxiety.

Step-by-Step Solution

1
Analyze the client's statement and nonverbal behavior.
The client is expressing feelings of hopelessness, fear of the future, and deep concern about becoming a burden due to a new chronic illness diagnosis.
Identifying the underlying emotion and psychosocial need is the first step in formulating an effective therapeutic response.
2
Evaluate the provided response options against therapeutic communication principles.
Options that offer false reassurance, ask 'why', or lecture the client must be eliminated as they block therapeutic engagement.
Therapeutic communication should validate feelings, build trust, and encourage exploration, rather than dismiss emotions with advice or judgment.
3
Select the response that utilizes reflection and empathy.
The statement acknowledging the client's worry about their family directly addresses the expressed emotion.
Reflection demonstrates active listening and allows the client to feel heard and understood without feeling pressured.

Key Concept

Therapeutic Communication: Empathy, Validation, and Reflection
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