Psychosocial Integrity

An adolescent client hospitalized for major depressive disorder has displayed severe anhedonia and psychomotor retardation for the past two weeks. Today, the client emerges from their room smiling, exhibiting unusually high energy, and gives a cherished guitar pick to another client. Which action is the priority for the nurse?

A nurse is completing the preoperative checklist for an adult client scheduled for a bilateral mastectomy the following morning. The client is crying quietly and states, "I do not know who I am going to be after this surgery. My partner says it does not matter, but I just cannot believe them."

Which response by the nurse is the most therapeutic?

A home hospice nurse is managing the care of a client in the final days of life. The client is unresponsive with Cheyne-Stokes respirations and peripheral mottling. The client's spouse is visibly distressed and demands, 'You must start an IV line for hydration. It is cruel to let him dehydrate to death.' Which of the following actions are appropriate for the nurse to take? Select all that apply.

A client is brought to the emergency department by law enforcement exhibiting extreme agitation, paranoia, severe diaphoresis, and aggressive behavior after a suspected ingestion of a synthetic stimulant. The client's initial tympanic temperature is 104.2°F (40.1°C). Arrange the following nursing actions in the most appropriate order of priority from first to last.

A nurse is developing a plan of care for an older adult client admitted to a specialized burn unit with extensive facial and upper torso burns. The client's eyes and ears are covered with bulky antimicrobial dressings, resulting in acute sensory deprivation. The client has begun reporting feeling bugs crawling under their skin and hearing unfamiliar voices. Which of the following nursing interventions should be included in the plan of care to address these sensory and perceptual alterations? Select all that apply.

An emergency department nurse is caring for a client who recently experienced a devastating house fire. The client is trembling, disorganized, and repeatedly states, "Everything is gone. I should have just stayed in the house." Arrange the following crisis intervention steps in the correct order from first to last.

A nurse is responding to a client on an inpatient psychiatric unit who is pacing the hallway, speaking loudly, and visibly clenching their fists. Arrange the following therapeutic communication and de-escalation interventions in the correct chronological order from first to last.

A rapid response code is called in the psychiatric emergency department for a client demonstrating imminent physical violence. The provider verbally orders immediate four-point mechanical restraints. Arrange the following nursing actions in the correct chronological sequence of implementation.

A registered nurse in a pediatric clinic is evaluating a 4-year-old child during a routine visit. The nurse observes symmetric, well-demarcated burn marks on both of the child's calves. The parent states, 'He was running around and accidentally backed into our space heater.' Which of the following is the priority nursing action?

A 54-year-old client is admitted to the medical unit with an acute exacerbation of heart failure. The client's current vital signs are blood pressure 158/96 mm Hg, heart rate 108/min, and temperature 37.6°C (99.7°F). The client appears mildly agitated and is frequently picking at the bed linens. During the admission assessment, the client states, "I drink a half-liter of vodka every day, but I haven't had a drink since yesterday morning. Please do not tell my healthcare provider; I do not want them to judge me." Which action is the most appropriate for the nurse to take?

During a night shift on a medical-surgical unit, an 82-year-old client with profound presbycusis and dense bilateral cataracts suddenly becomes highly agitated. The client, who is in a private room with the door closed for contact precautions, points to a dark corner and insists, 'Those men in the shadows are whispering and planning to hurt me!' The client's vital signs are within normal limits, and oxygen saturation is 97% on room air. Based on principles of sensory and perceptual alterations, which nursing action is the most appropriate priority?

A public health nurse is conducting a home visit for an older adult client who is the sole caregiver for a spouse with late-stage Alzheimer's disease. The client appears disheveled, paces the room rapidly, and states, 'I am so exhausted I cannot think straight. I left the stove on twice yesterday. I just want to go to sleep and never wake up.' Which action is the nurse's priority?

A community health nurse conducts a home visit for a 45-year-old client with advanced multiple sclerosis who is wheelchair-bound and completely dependent on their spouse for activities of daily living. The nurse observes that the client is wearing soiled clothing, has a strong odor of urine, and has developed unstageable pressure injuries on the sacrum. The spouse states, "I just cannot keep up with all the cleaning and turning anymore; it is entirely too much work." Which actions are appropriate for the nurse to take? Select all that apply.

A client on an inpatient psychiatric unit receives a phone call regarding the sudden death of a family member. The client drops the phone, begins pacing the hallway rapidly, hyperventilating, and shouting, "I can't breathe, I'm going to die!" Arrange the following nursing interventions in the correct order of priority. All options must be used.

A nurse in an ambulatory care clinic is communicating with clients who are experiencing various emotional responses to their health conditions. Match each of the nurse's statements to the specific evidence-based therapeutic communication technique it represents.

A nurse in a prenatal clinic is assessing a 26-year-old client at 28 weeks of gestation. The nurse observes yellow and purple bruising on the client's upper arms and neck. The client's partner is present in the examination room, sits between the client and the door, and repeatedly answers questions that the nurse directs at the client. Which of the following is the priority nursing action?

A nurse is caring for a young adult client who was recently diagnosed with multiple sclerosis. The client refuses to participate in physical therapy and tearfully states, "What is the point of trying? My body is just going to completely betray me anyway, and I will end up being a burden to my family." Which of the following nursing responses or actions demonstrate effective therapeutic communication? Select all that apply.

An inpatient psychiatric nurse approaches a client diagnosed with schizophrenia. The client is pacing rapidly in the dayroom, staring intently at an empty corner, and looking terrified. The client points to the corner and shouts, "The demons are telling me that the food here is poisoned! Tell them to be quiet! You can hear them, right?" Which of the following is the most therapeutic response by the nurse?

A pediatric intensive care nurse is caring for a child who sustained a severe head injury three weeks ago. The child's parent, who has remained continuously at the bedside, suddenly stands up, forcefully knocks a chair over, and shouts, "You are all doing nothing! I cannot take another second of watching my child like this!" The parent is visibly trembling and pacing rapidly near the client's life-sustaining equipment. Which of the following is the priority nursing action?

A client is admitted to the behavioral health unit exhibiting symptoms of acute mania, including rapid pacing, loud and pressured speech, and impulsivity. The client continuously attempts to interrupt group sessions and intrudes on other clients' personal space. Which of the following nursing interventions should be included in the initial plan of care? Select all that apply.