Psychosocial Integrity

A nurse in an inpatient psychiatric unit is caring for a client with schizophrenia who is actively experiencing distressing auditory hallucinations. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

A nurse is caring for a young adult client who has just received a diagnosis of HIV. The client is staring at the floor and states in a quiet voice, "I cannot tell my family about this. If they find out, they will completely disown me and I will have no one left." Which of the following is the most therapeutic response by the nurse?

A nurse is initiating a therapeutic interaction with a newly admitted client who has major depressive disorder. The client is sitting alone in the dayroom, appearing withdrawn, and avoiding eye contact. Arrange the following therapeutic communication interventions in the most appropriate sequence, from first to last.

A young adult client recently admitted with a diagnosis of anorexia nervosa is observed pacing rapidly up and down the unit hallway. The client appears severely anxious and tells the nurse, "I had to eat that entire sandwich at lunch, and I can literally feel the fat forming on my thighs. I have to keep moving." Which action should the nurse take?

A 22-year-old client with severe right lower quadrant abdominal pain arrives at the emergency department accompanied by a parent. The parent states, "My child understands very little English, so I will translate. In our culture, we prefer to endure pain and use traditional herbal teas rather than taking Western narcotics." The client is grimacing, guarding the abdomen, and avoiding eye contact. Which of the following is the most appropriate action by the nurse?

A client with a history of aggressive behavior becomes visibly agitated in the dayroom, pacing rapidly with clenched fists and shouting profanities at peers. Arrange the following nursing interventions in order from the least restrictive to the most restrictive approach.

A nurse in a surgical intensive care unit is responding to a spouse who just learned their partner sustained a severe traumatic brain injury. The spouse is pacing the hallway, crying uncontrollably, and states, "I do not know what to do. I cannot live without them." Arrange the following nursing interventions in the correct order of priority according to the principles of crisis intervention. (Place the first action at the top and the last action at the bottom.)

The healthcare provider has just informed a client with end-stage renal disease about the immediate need to begin hemodialysis. After the provider leaves the room, the client angrily yells at the nurse, "I absolutely refuse to do it! Being tied to a machine three days a week isn't living. I would rather just let nature take its course!" Which of the following responses by the nurse is the most therapeutic?

An emergency department nurse is caring for an 8-year-old client who presents with a spiral fracture of the left humerus. The parent states the child fell off a bicycle. During the physical examination, the nurse observes fading, varied-colored bruises on the child's torso. The child is unusually withdrawn and constantly looks at the parent before answering any questions. Which of the following is the priority nursing action?

During a shift on the behavioral health unit, a client diagnosed with acute mania begins pacing aggressively, clenching their fists, and shouting threats at peers. Place the following nursing interventions in the correct sequence from first action to last action, prioritizing milieu safety and the principle of least restrictive care.

While working the evening shift at a behavioral health facility, the registered nurse observes an individual in the manic phase of bipolar disorder wandering into the bedrooms of peers, taking their personal items, and singing loudly. Other individuals on the unit are expressing visible anger, and one peer explicitly threatens to physically retaliate against the hyperactive client. Which action should the nurse implement first to restore safety and maintain a therapeutic environment?

Match each client statement or behavioral scenario with the most appropriate therapeutic nursing response.

A client with advanced dementia is admitted to the medical-surgical unit with severe aspiration pneumonia. The client lacks decision-making capacity and is rapidly declining. The adult children are arguing at the bedside regarding whether to insert a percutaneous endoscopic gastrostomy (PEG) tube or transition exclusively to comfort measures. Arrange the following nursing actions in the most appropriate sequence to address this end-of-life conflict.

A client was admitted to the behavioral health unit three days ago after experiencing a severe situational crisis involving an unexpected divorce and the immediate loss of a career. Initially, the client exhibited extreme agitation, cried continuously, and expressed feelings of profound hopelessness. During morning rounds today, the nurse observes the client sitting calmly, smiling, and giving a valued wristwatch to another client. The client states, 'I have finally figured everything out, and I will not be a burden to anyone anymore.' Which of the following is the priority nursing action?

A client with a history of borderline personality disorder is receiving care on an orthopedic unit following surgical repair of a fractured tibia. The client tells the evening nurse, 'You are the only person who actually cares about me; the day nurses are terrible and ignored my pain.' Later, the client begins shouting in the corridor because a requested snack was unavailable. Which behavioral interventions should the evening nurse implement? Select all that apply.

A client diagnosed with borderline personality disorder frequently interrupts unit meetings, monopolizes conversations, and attempts to engage other clients in arguments regarding facility rules. The registered nurse is developing a plan of care to maintain a safe and therapeutic milieu. Which interventions should the nurse include in the plan of care? Select all that apply.

A pediatric client is admitted to the intensive care unit with a severe traumatic brain injury following a motor vehicle collision. The client's parent is crying at the bedside and states, 'If only I had taken our usual route to school instead of the shortcut, this never would have happened. It is completely my fault.' Which of the following is the most therapeutic response by the nurse?

While completing evening rounds, the nurse is approached by a client with borderline personality disorder. The client states, "You are the only person working here who actually understands me. The day shift nurse was completely heartless and refused to let me make a phone call." Which of the following is the most appropriate response by the nurse?

A 74-year-old client with mobility impairment is brought to an outpatient wound care clinic by a family caregiver. The client appears disheveled, has poor oral hygiene, and exhibits a new, unstageable sacral pressure injury. The caregiver loudly states, "I cannot deal with cleaning up these messes anymore; it is disgusting." The client avoids eye contact and remains silent. Which of the following nursing actions are appropriate? Select all that apply.

An older adult client with a history of mild neurocognitive disorder is admitted to a bustling medical-surgical unit. During the chaotic shift change, the client becomes acutely agitated, yells that "strangers are attacking," and attempts to climb over the raised bed rails. The nurse recognizes the client is experiencing acute delirium exacerbated by sensory overload. Arrange the following nursing actions in the chronological priority order they should be performed.