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Psychosocial Integrity

368 questions

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Question 281Question →

A nurse is admitting a young adult client who sustained a severe, permanent spinal cord injury three days ago. While staring at the ceiling, the client says to the nurse, "I don't know why the paramedics even bothered to save me. Being paralyzed is worse than being dead." Which of the following is the most therapeutic response by the nurse?

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Answer: It sounds like you are experiencing a profound sense of hopelessness regarding your future.

Answer

The most therapeutic response is the one that reflects the client's feelings, stating that it sounds like they are experiencing a profound sense of hopelessness regarding their future.
The correct response utilizes the therapeutic communication technique of reflecting feelings. By stating that the client sounds hopeless, the nurse accurately identifies the underlying emotion without judgment, validates the client's distress, and leaves the door open for the client to elaborate on their feelings. This builds trust and facilitates the grieving process.

Step-by-Step Solution

1
Analyze the client's statement to determine the underlying emotion.
The client is expressing deep despair, grief, and a feeling that life is no longer worth living due to the recent paralysis.
Understanding the core emotion is necessary to select a response that directly addresses the client's psychosocial needs.
2
Evaluate the provided nursing responses for therapeutic communication techniques.
The statement reflecting hopelessness uses 'reflection of feelings', a proven therapeutic technique.
Therapeutic communication should validate emotions, show empathy, and encourage further expression without judgment or unwanted advice.
3
Identify and eliminate non-therapeutic barriers in the remaining options.
Options containing false reassurance, probing 'why' questions, and unsolicited advice are eliminated.
These techniques block open communication, invalidate the client's experience, and put the client on the defensive.

Key Concept

Therapeutic Communication
Question 282Question →

A school nurse is caring for a high school student who just witnessed a severe physical altercation between peers in the hallway. The student is pacing rapidly around the health office, demonstrating tachypnea, and shouting, "I am not safe anywhere! They are going to come after me next!" Which of the following is the priority nursing intervention?

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Answer: Remain with the student in a quiet area and provide brief, direct instructions to slow their breathing.

Answer

The priority intervention is to remain with the student in a quiet area and provide brief, direct instructions to help them slow their breathing.
During an acute situational crisis resulting in severe anxiety or panic, the client experiences heightened physiological arousal (such as tachypnea and pacing) and a severe inability to focus or process complex information. According to Maslow's hierarchy of needs, the priority is to address immediate physiological and safety needs. Remaining with the client ensures their physical safety and provides a grounding presence. Using brief, direct instructions to guide breathing helps stabilize the client's physiological response without overwhelming their currently impaired cognitive capacity.

Step-by-Step Solution

1
Assess the client's current level of anxiety and identify immediate physiological or safety needs.
The client is exhibiting signs of severe anxiety or panic, including rapid pacing, tachypnea, and catastrophic thinking.
Determining the phase of the crisis dictates the level of intervention required; acute panic necessitates immediate physiological and environmental stabilization.
2
Implement immediate de-escalation and stabilization techniques based on Maslow's hierarchy.
The nurse stays with the client to ensure safety, reduces environmental stimuli, and gives clear, concise directions for deep breathing.
A client in severe panic has a significantly narrowed perceptual field and cannot process complex information. A calm presence and direct guidance address acute physiological symptoms and restore a sense of safety.

Key Concept

Crisis Intervention: Acute Panic Management
Question 283Question →

A nurse is caring for a client hospitalized with acute pancreatitis related to heavy, daily alcohol consumption. The client reports their last alcoholic beverage was approximately 14 hours ago. During morning rounds, the client is pacing the room continuously, appears highly anxious, and repeatedly demands to leave the facility against medical advice. Current vital signs reveal a heart rate of 112 bpm, blood pressure of 148/92 mm Hg, and mild diaphoresis. Which action is the priority for the nurse to implement?

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Answer: Administer the prescribed as-needed dose of a benzodiazepine.

Answer

The priority action is to administer the prescribed as-needed dose of a benzodiazepine.
The client is exhibiting classic early manifestations of acute alcohol withdrawal, including psychomotor agitation (pacing), anxiety, tachycardia, hypertension, and diaphoresis. These symptoms typically begin 6 to 24 hours after the cessation of heavy alcohol use. The priority nursing action is to administer a cross-tolerant central nervous system depressant, such as a benzodiazepine, to manage the autonomic hyperactivity, prevent the progression to withdrawal seizures or delirium tremens, and safely reduce the client's severe agitation.

Step-by-Step Solution

1
Analyze the client's timeline and clinical history.
The client has a history of heavy, daily alcohol use and the last drink was 14 hours ago.
Establishing the timeline is critical for predicting the onset and stage of alcohol withdrawal.
2
Evaluate the current physical and behavioral manifestations.
The client exhibits pacing, anxiety, tachycardia (112 bpm), hypertension (148/92 mm Hg), and diaphoresis.
These findings must be correlated with potential complications based on the client's substance use history.
3
Synthesize the data to identify the primary clinical problem.
The findings represent early but escalating signs of acute alcohol withdrawal.
Recognizing the physiological etiology of the agitation prevents misclassifying it as purely a behavioral or psychosocial issue (e.g., just wanting to leave AMA).
4
Determine the priority nursing intervention based on physiological stability.
Pharmacological management with a cross-tolerant central nervous system depressant is required immediately.
Untreated alcohol withdrawal can rapidly progress to life-threatening seizures or delirium tremens, making physiological stabilization the highest priority.

Key Concept

Recognition and pharmacological management of acute alcohol withdrawal
Question 284Question →

A 10-year-old child with a cognitive disability is brought to the emergency department by a caregiver. The child has an actively bleeding scalp laceration, and the nurse observes patterned, defensive bruising on the child's forearms. The caregiver's explanation of the injuries is inconsistent with the physical findings. Arrange the following nursing actions in the correct order of priority from first to last.

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Answer

The correct sequence prioritizes physiological stability, then immediate safety, followed by assessment, factual documentation, and finally mandatory reporting.
Nursing prioritization follows a strict clinical hierarchy: physiological needs (circulation and bleeding control) must be addressed first, followed immediately by physical safety (separating the suspected abuser). Once the client is medically stabilized and safe, the nurse can conduct a thorough, uncoerced assessment. Objective documentation of these findings must precede external reporting to ensure accurate and factual information is provided to child protective services.

Step-by-Step Solution

1
Apply direct pressure to the actively bleeding scalp laceration.
The active hemorrhage is controlled, achieving physiological stability.
According to the ABCs of resuscitation, physiological survival (circulation) takes immediate precedence over all other interventions.
2
Separate the caregiver from the child using a facility-approved protocol.
The child is placed in a secure environment away from potential intimidation or further harm.
Once medically stable, ensuring the client's immediate physical safety and security is the next priority in Maslow's hierarchy of needs.
3
Complete a full physical assessment and interview the child privately.
Comprehensive clinical data and the client's perspective are gathered safely.
A thorough assessment can only yield accurate, uncoerced information if the suspected abuser is no longer present.
4
Document the objective characteristics of the wounds and the child's exact statements.
An objective legal medical record of the abuse suspicion is created.
Factual documentation provides the essential evidence base required before initiating external communications.
5
Report the suspected child abuse to the designated local child protective services agency.
The legal obligation as a mandated reporter is fulfilled.
External reporting relies on the objective data gathered during the assessment phase and must be completed once safety and stability are ensured.

Key Concept

Prioritization of Care in Suspected Abuse
Question 285Question →

A nurse enters the room of a client with a history of severe opioid use disorder and finds the client unresponsive, cyanotic, and exhibiting a respiratory rate of 4 breaths/min with pinpoint pupils. Arrange the following nursing interventions in the correct order of priority, from first to last.

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Answer

The correct prioritization sequence is: Activate the rapid response team -> Establish a patent airway -> Initiate rescue breathing with a BVM -> Administer intravenous naloxone -> Reassess the client's status.
The correct sequence strictly adheres to the American Heart Association (AHA) Basic Life Support (BLS) and prioritizing principles (ABCs). Upon discovering an unresponsive client, the nurse must first call for help. Next, physical airway patency must be established, immediately followed by rescue breathing to treat the severe hypoxia caused by the respiratory rate of 4. Only after oxygenation is supported should the nurse administer the pharmacological reversal agent (naloxone). Finally, because naloxone has a short half-life, continuous reassessment is necessary to detect recurrent respiratory depression.

Step-by-Step Solution

1
Activate the facility's rapid response team and request the emergency cart.
Additional clinical support and necessary resuscitation equipment are mobilized.
Basic Life Support (BLS) guidelines dictate that recognizing unresponsiveness must be immediately followed by calling for help before initiating time-intensive physical interventions.
2
Establish a patent airway using a head-tilt/chin-lift maneuver.
The airway is opened, lifting the tongue away from the posterior pharynx.
A patent airway is an absolute prerequisite for effective ventilation and oxygenation.
3
Initiate rescue breathing using a bag-valve-mask (BVM) device with 100% oxygen.
Oxygen is delivered to the client's lungs, correcting severe hypoxia.
The client's respiratory rate of 4 breaths/min is inadequate to sustain life. Immediate mechanical ventilation prevents progression to cardiac arrest.
4
Administer the prescribed dose of intravenous naloxone.
The opioid receptor antagonist begins to reverse the central nervous system and respiratory depression.
While naloxone treats the root cause, preparing and administering the medication takes time; the brain must be oxygenated manually while the drug is given.
5
Reassess the client's respiratory rate, oxygen saturation, and level of consciousness.
The nurse evaluates the effectiveness of the naloxone and the need for further intervention.
Naloxone's duration of action is short (approximately 30 to 90 minutes). The opioid effect may outlast the reversal agent, causing the client to slip back into respiratory depression.

Key Concept

Prioritization of care in opioid overdose emergencies using Basic Life Support (BLS) and Airway, Breathing, Circulation (ABC) principles.
Question 286Question →

A nurse is interacting with an older adult client who recently experienced a severe ischemic stroke and is scheduled to transfer to a long-term care facility. The client stares out the window and tearfully states, "I never imagined my life would end up this way. I am losing my home, my garden, and everything I worked for. I will just be sitting in some room waiting for the end." Which of the following responses by the nurse is the most therapeutic?

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Answer: This transition is bringing up profound feelings of grief and loss regarding your independence.

Answer

The response that acknowledges the client's profound feelings of grief and loss regarding their independence.
The correct answer utilizes the therapeutic technique of reflection. By directly naming the grief and loss the client is describing, the nurse validates their emotional experience. This approach demonstrates empathy, creates a safe environment for vulnerability, and encourages the client to continue processing the difficult transition to long-term care without feeling judged or dismissed.

Step-by-Step Solution

1
Analyze the client's statement to identify the core emotional message.
The client is expressing deep sadness, hopelessness, and anticipatory grief over the loss of their home, routine, and independence.
Understanding the underlying emotion is essential before selecting an appropriate therapeutic response.
2
Evaluate the options against principles of therapeutic communication.
Options that offer false reassurance, give advice, or change the subject act as communication barriers. The option that reflects the client's feelings directly addresses their psychological needs.
Therapeutic communication aims to validate feelings, encourage emotional exploration, and avoid judgment or minimization.
3
Select the response that best validates the client's emotional state.
The statement reflecting the client's grief and loss is the most therapeutic choice.
Reflection of feeling demonstrates active listening and empathy, which builds trust and helps the client process their grief.

Key Concept

Therapeutic Communication: Reflection and Validation
Question 287Question →

A home health nurse evaluates a client who provides full-time care for a spouse with advanced Alzheimer's disease. The client exhibits unintended weight loss, a flat affect, and reports chronic insomnia. The client states, "I am completely exhausted, but I cannot let anyone else help. If I don't do every single task myself, my spouse will suffer." Which action should the nurse take first to facilitate effective stress management?

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Answer: Explore the client's underlying beliefs regarding the delegation of caregiving tasks.

Answer

The correct action is to explore the client's underlying beliefs regarding the delegation of caregiving tasks.
The correct answer addresses the root of the client's maladaptive coping. The client's statement reveals a cognitive distortion (perfectionism/all-or-nothing thinking) that serves as a barrier to stress relief. By exploring this belief first, the nurse validates the client's feelings and begins the process of cognitive restructuring, which is a prerequisite for the client to accept practical help like respite care.

Step-by-Step Solution

1
Analyze the client's clinical presentation and verbal statements.
The client is showing physiological signs of severe stress (weight loss, insomnia) and explicitly expressing a cognitive barrier to accepting help.
Identifying both the physical impact of stress and the psychological roadblocks is essential for prioritizing effective care planning.
2
Apply the nursing process and therapeutic communication principles to the scenario.
The nurse must prioritize exploring the client's beliefs before implementing solutions or teaching new skills.
Interventions like referrals or relaxation techniques will fail if the underlying cognitive distortion preventing their use is not addressed first.
3
Evaluate the distractors against priority frameworks.
Providing resources or teaching breathing exercises skips the crucial exploration phase, while reassuring the client minimizes their severe distress.
Therapeutic communication prioritizes understanding and validating the client's specific perspective to facilitate meaningful behavioral change.

Key Concept

Cognitive Restructuring in Stress Management
Question 288Question →

A nurse at a community health center is caring for a client who presents in a state of acute situational crisis after experiencing sudden, unexpected financial ruin. The client is pacing rapidly, crying, and states, 'I have lost absolutely everything; I do not see a way out of this.' Arrange the following crisis interventions in the sequential order the nurse should implement them.

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Answer

The correct sequence for crisis intervention is to first ensure safety (lethality assessment), then build rapport (therapeutic alliance), assess the problem (precipitating event), evaluate resources (coping mechanisms), and finally plan interventions (action plan).
The established standard of care for crisis intervention follows a structured, priority-based sequence. It begins with ensuring immediate safety by assessing for lethality. Once the client is deemed safe, establishing rapport and trust is the next critical step. Following this, the nurse assesses the specific precipitating event and how the client views it. The nurse then evaluates the client's existing coping skills and support networks. Finally, utilizing these resources, the nurse and client collaboratively develop a concrete, short-term action plan to restore equilibrium.

Step-by-Step Solution

1
Prioritize physiological and psychological safety.
The nurse conducts a lethality assessment to rule out immediate risk of suicide or self-harm.
According to prioritization frameworks, immediate life-threatening risks must be addressed before any other psychological or social assessment.
2
Establish a therapeutic connection.
The nurse uses active listening and empathy to build a trusting relationship.
A safe, supportive environment is required for a client in acute distress to effectively share sensitive information and de-escalate.
3
Assess the nature of the crisis.
The nurse identifies the precipitating event and explores the client's perception of the problem.
Understanding the specific trigger and the client's subjective experience of it is necessary to tailor appropriate interventions.
4
Evaluate available resources.
The nurse explores the client's past coping skills and available social support network.
Identifying existing strengths and external help determines what tools can be leveraged in the recovery process.
5
Develop a structured intervention.
The nurse and client collaborate to create a short-term, concrete action plan.
A collaborative action plan empowers the client, reduces anxiety, and provides clear steps toward restoring pre-crisis baseline functioning.

Key Concept

Prioritization and Sequencing of Crisis Intervention
Question 289Question →

A registered nurse on a medical-surgical unit is completing an admission assessment for a 74-year-old client admitted with severe dehydration. The nurse observes bilateral, patterned bruising on the client's upper arms and back. When asked about the injuries, the client avoids eye contact and whispers, "Please do not tell my son I showed you; he gets so angry when I need help to the bathroom." Based on this interaction, the nurse suspects elder abuse but lacks conclusive evidence. Which action represents the nurse's appropriate legal and professional responsibility?

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Answer: Notify the designated state adult protective services agency immediately to report the suspected abuse.

Answer

The nurse must report the suspected abuse immediately to the designated state adult protective services agency.
The correct action is to immediately notify the designated state agency. As a mandatory reporter, a nurse is legally required to report suspected abuse, neglect, or exploitation of vulnerable populations (children, elders, and dependent adults). The threshold for reporting is 'reasonable suspicion,' which is met here by the physical assessment findings and the client's direct, fearful statement. Conclusive proof is not required by the reporter; investigating the validity of the suspicion is the role of protective services and law enforcement.

Step-by-Step Solution

1
Analyze the clinical findings and the client's verbal statements.
The patterned bruising combined with the client's fearful statement regarding their son establishes a reasonable clinical suspicion of elder physical abuse.
Identifying indicators of abuse is the first step in recognizing a vulnerable adult in danger.
2
Determine the legal obligation of the registered nurse in this scenario.
The nurse identifies that they are a mandatory reporter under state and federal law.
Nurses must understand their individual legal responsibilities to protect vulnerable populations.
3
Select the appropriate intervention based on mandatory reporting laws.
The nurse reports the suspicion to the state authorities immediately without waiting for definitive proof or internal investigations.
Mandatory reporting requires only reasonable suspicion. Delaying the report for evidence gathering or confronting the abuser severely compromises client safety.

Key Concept

Mandatory reporting requires nurses to report suspected elder abuse immediately based on reasonable suspicion, without needing conclusive proof or prior internal facility investigation.
Question 290Question →

While providing care on a maternity unit, the nurse observes that a client has consumed minimal fluids over the past eight hours. The client's relatives have brought in several thermoses of hot herbal tea and moved the hospital-provided pitcher of ice water out of reach. Which of the following is the most appropriate action by the nurse?

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Answer: Ask the client to describe their personal preferences regarding fluid temperature and the meaning of the herbal teas.

Answer

The most appropriate action is to ask the client to describe their personal preferences regarding fluid temperature and the meaning of the herbal teas.
Cultural competence requires that the nurse perform an individualized assessment of the client's health beliefs, values, and practices. By directly asking the client to describe their preferences regarding fluid temperature and the meaning of the herbal teas, the nurse demonstrates respect for the client's autonomy, avoids making assumptions based on the family's behavior, and gathers essential information to create a safe, individualized plan of care. It is common for some cultures to follow 'hot and cold' dietary theories during the postpartum period, but the nurse must verify the individual client's adherence to these practices.

Step-by-Step Solution

1
Observe the situation involving the client's fluid intake, the presence of family members, and the replacement of hospital fluids with traditional herbal teas.
The nurse identifies a potential cultural practice related to postpartum dietary restrictions (such as hot and cold theories of health).
Recognizing the clinical and cultural context is the first step in providing culturally competent care.
2
Determine the priority nursing action to address the client's minimal fluid intake while respecting cultural differences.
The nurse decides to perform an individualized assessment rather than making assumptions based on the family's behavior.
Cultural competence dictates that every client is an individual. Family practices do not necessarily equate to the individual client's beliefs.
3
Select the option that utilizes therapeutic communication to directly assess the client's wishes.
The nurse chooses to ask the client about their personal preferences and the meaning of the teas.
This approach is non-judgmental, avoids stereotyping, and establishes a therapeutic nurse-client relationship.

Key Concept

Individualized Cultural Assessment
Question 291Question →

Following a total knee arthroplasty, a 68-year-old client is recovering on the surgical unit. Review of the electronic health record reveals a home regimen of high-dose clonazepam that was inadvertently not continued postoperatively. At 48 hours post-admission, the client develops profound disorientation, coarse bilateral tremors, profuse diaphoresis, and a resting heart rate of 124 beats/min. Which action should the nurse take first?

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Answer: Implement strict seizure precautions and urgently contact the healthcare provider.

Answer

Implement strict seizure precautions and urgently contact the healthcare provider.
The client is exhibiting classic signs of acute benzodiazepine withdrawal, including profound disorientation, coarse tremors, diaphoresis, and tachycardia. Because clonazepam is a benzodiazepine, its abrupt cessation places the client at high risk for life-threatening withdrawal seizures. The nurse's immediate priority is to ensure client safety by implementing seizure precautions and contacting the healthcare provider to obtain a prescription for a benzodiazepine replacement or taper.

Step-by-Step Solution

1
Analyze the client's medication history and current clinical presentation.
The client has abruptly stopped taking high-dose clonazepam (a long-acting benzodiazepine) and is exhibiting profound autonomic hyperactivity and disorientation 48 hours later.
Identifying the timeline of medication cessation is critical to determining the underlying etiology of the new-onset symptoms.
2
Recognize the specific withdrawal syndrome.
The hyperadrenergic symptoms and altered mental status indicate severe acute benzodiazepine withdrawal.
Abrupt discontinuation of long-acting benzodiazepines classically produces severe withdrawal symptoms that peak 2 to 4 days after the last dose.
3
Determine the highest priority complication and the required nursing intervention.
The client is at imminent risk for status epilepticus, making safety and medical intervention the immediate priorities.
Life-threatening seizures are the most severe complication of benzodiazepine withdrawal, requiring immediate environmental safety measures (seizure precautions) and medical intervention (resumption of a benzodiazepine or equivalent taper).

Key Concept

Clients abruptly discontinuing benzodiazepines are at high risk for life-threatening withdrawal seizures, necessitating immediate seizure precautions and prompt medical management.
Question 292Question →

A nurse on a medical-surgical unit is caring for a client who is scheduled for a below-the-knee amputation the following morning due to severe vascular complications. The client is pacing the room, crying, and states, 'I cannot live with half a leg. I will never be able to do anything for myself again. My life is essentially over.' Which of the following responses by the nurse is the most therapeutic?

Show answer & explanation

Answer: It sounds like you are feeling devastated and deeply concerned about losing your independence.

Answer

The most therapeutic response is to reflect the client's feelings by stating that it sounds like they are feeling devastated and deeply concerned about losing their independence.
The correct response effectively uses the therapeutic communication techniques of empathy and reflection. By summarizing and stating back the client's underlying fears—feeling devastated and worried about losing independence—the nurse validates the client's emotions. This approach demonstrates active listening, encourages the client to elaborate on their feelings, and builds a trusting therapeutic relationship during a crisis.

Step-by-Step Solution

1
Analyze the client's verbal and non-verbal communication.
The client is pacing, crying, and expressing feelings of hopelessness and fear regarding a loss of independence after an upcoming amputation.
Understanding the underlying emotion is necessary to formulate an appropriate therapeutic response.
2
Evaluate the intent of a therapeutic response in this context.
The nurse needs to validate the client's emotions, encourage further expression of feelings, and avoid minimizing the profound impact of the surgery.
Therapeutic communication builds trust and helps the client process anticipatory grief and anxiety.
3
Assess each option against therapeutic communication principles.
Reflecting feelings is therapeutic. False reassurance, asking 'why', and giving personal advice are non-therapeutic barriers.
Identifying communication blocks eliminates the incorrect options.

Key Concept

Therapeutic Communication Techniques: Empathy and Reflection
Question 293Question →

A client is admitted to the neurology unit after a moderate cerebrovascular accident (CVA), resulting in right-sided hemiparesis. The client's adult child and spouse are present in the room. The child approaches the nurse privately in the hallway and states, 'My mother is completely overwhelmed and in denial about the extent of his deficits. You must tell her that he requires transfer to an inpatient rehabilitation facility instead of returning home.' Which response by the nurse demonstrates an understanding of therapeutic family dynamics?

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Answer: It sounds like you have significant concerns about his safety at home. Let us sit down together with your parents to discuss everyone's perspective on the discharge plan.

Answer

The most appropriate response is to acknowledge the adult child's concerns while proposing a joint discussion that includes both parents, thereby facilitating open and direct family communication.
The correct response demonstrates an understanding of family systems theory, specifically addressing triangulation. Triangulation occurs when one family member tries to draw a third party (in this case, the nurse) into a conflict to reduce tension or avoid direct communication. By acknowledging the child's concern and proposing a joint discussion that includes both parents, the nurse sets a therapeutic boundary, refuses to act as a secret-keeper, and facilitates open, direct communication within the family unit.

Step-by-Step Solution

1
Analyze the family dynamic presented in the clinical scenario.
The adult child is attempting to use the nurse as a go-between to communicate a difficult message to the spouse.
Identifying triangulation is essential to formulate a therapeutic nursing response.
2
Evaluate the nursing priorities regarding psychosocial integrity.
The nurse must establish therapeutic boundaries, avoid taking sides, and encourage direct communication between family members.
Nurses support healthy family dynamics by empowering families to resolve conflicts collaboratively rather than fostering dependence on staff for communication.
3
Select the option that best addresses the dysfunctional dynamic.
Suggesting a joint meeting with the parents addresses the child's anxiety while redirecting the communication back to the family unit.
This approach dismantles the triangulation and promotes functional family coping during a crisis.

Key Concept

Triangulation and Therapeutic Boundaries in Family Systems
Estimated Time:1m 30s
Question 294Question →

A 55-year-old client is admitted to the medical unit for treatment of a severe diabetic foot ulcer. The electronic health record indicates a history of alcohol use disorder, with the client's last alcoholic drink consumed approximately 60 hours ago. During the initial shift assessment, the nurse observes that the client has coarse bilateral hand tremors, profound diaphoresis, and new-onset disorientation to place. Current vital signs are: blood pressure 162/98 mmHg, heart rate 124 bpm, respiratory rate 24/min, and temperature 99.8°F (37.7°C). Which action is the highest priority for the nurse to take?

Show answer & explanation

Answer: Administer the prescribed intravenous lorazepam and immediately initiate seizure precautions.

Answer

Administer the prescribed intravenous lorazepam and immediately initiate seizure precautions.
The client is exhibiting classic signs of alcohol withdrawal delirium (delirium tremens), which typically peaks 48 to 72 hours after the last alcohol intake. Symptoms include disorientation, marked autonomic hyperactivity (hypertension, tachycardia, diaphoresis), and coarse tremors. This is a life-threatening medical emergency. The priority is to administer a prescribed benzodiazepine (e.g., lorazepam) to depress the central nervous system, control agitation, and prevent seizures, while concurrently initiating seizure precautions to ensure client physical safety.

Step-by-Step Solution

1
Analyze the client's timeline and history.
The client has a history of alcohol use disorder and had their last drink 60 hours ago.
Establishing the timeline is critical for identifying the stage of alcohol withdrawal. Delirium tremens typically peaks at 48 to 72 hours.
2
Evaluate the clinical presentation and vital signs.
The client is experiencing disorientation, severe tremors, diaphoresis, hypertension, and tachycardia.
These are classic manifestations of severe autonomic hyperactivity and central nervous system excitability characteristic of alcohol withdrawal delirium.
3
Differentiate the current symptoms from other potential medical complications, such as sepsis from the foot ulcer.
While infection is present, the specific combination of hypertension, severe tremors, and the 60-hour timeline points directly to withdrawal rather than septic shock (which often presents with hypotension).
Accurate differential assessment ensures the nurse addresses the most immediate, life-threatening neurological risk.
4
Determine the priority nursing intervention.
The nurse must administer central nervous system depressants (benzodiazepines) and protect the client from injury.
Pharmacological intervention is required to halt the progression of withdrawal symptoms and prevent fatal seizures.

Key Concept

Alcohol Withdrawal Delirium (Delirium Tremens) Management
Question 295Question →

An 82-year-old client is brought to the emergency department by their adult child. During the triage assessment, the nurse observes bilateral patterned bruising on the client's upper arms and notes signs of severe dehydration. The adult child is agitated, pacing the room, and complaining loudly about the burden of providing care for the client. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence is to first assess physiological stability, then separate the client from the suspected abuser, interview the client privately, document the objective findings, and finally file the mandatory report.
When managing a client with suspected abuse or neglect, the nurse must follow a systematic prioritization approach. First, acute physiological needs and medical stabilization (such as treating severe dehydration) take priority according to Maslow's hierarchy of needs. Second, the nurse must ensure immediate client safety by separating them from the suspected abuser. Third, once in a secure and private environment, the nurse conducts a focused assessment of the injuries by asking direct, non-judgmental questions. Fourth, all objective findings and verbatim statements must be thoroughly documented in the medical record. Finally, based on the accumulated reasonable suspicion, the nurse fulfills their individual legal obligation by reporting the suspected elder abuse to the appropriate state authorities.

Step-by-Step Solution

1
Assess the client's vital signs and intervene for dehydration.
Immediate physiological needs are addressed.
Medical stabilization always takes precedence over psychosocial assessments.
2
Escort the client to a private examination room.
The client is separated from the adult child.
A private environment ensures client safety and prevents the suspected abuser from intimidating the client during the interview.
3
Ask direct, non-judgmental questions about the bruising.
Information regarding the potential abuse is gathered directly from the client.
Direct questioning in a safe environment helps determine the origin of the suspicious injuries.
4
Document objective characteristics and verbatim quotes.
A factual, accurate medical record is created.
Objective documentation provides necessary evidence and context for the mandatory report.
5
File a report with Adult Protective Services.
The legal obligation of mandatory reporting is fulfilled.
Nurses must report reasonable suspicion of elder abuse to the appropriate state agency.

Key Concept

Prioritization of Care in Suspected Elder Abuse
Question 296Question →

A nurse is caring for a client with obsessive-compulsive disorder (OCD) on their first day of inpatient treatment. The client has a complex ritual of tapping the doorframe exactly twelve times before crossing any threshold. As lunchtime approaches, the nurse observes the client beginning this tapping sequence at the entrance to the dining hall. What is the most appropriate nursing action?

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Answer: Permit the client to finish the tapping sequence before they enter the dining hall.

Answer

The correct action is to permit the client to finish the tapping sequence before they enter the dining hall.
The correct action is to allow the client to complete the ritual. In the initial phase of treatment for a newly admitted client with OCD, compulsions should not be abruptly interrupted. The ritual serves as an essential, albeit maladaptive, coping mechanism to manage severe anxiety. Preventing the compulsion will cause the client's anxiety to escalate to a panic level. Once a therapeutic relationship is established and baseline anxiety is managed pharmacologically, the nurse will collaborate with the client to gradually set limits on the time spent performing rituals.

Step-by-Step Solution

1
Assess the client's stage of treatment and the purpose of the observed behavior.
The client is newly admitted (initial phase) and performing a compulsion to manage severe internal anxiety.
Understanding that compulsions temporarily relieve extreme anxiety dictates the immediate intervention strategy.
2
Determine the safety and immediate consequences of interrupting the behavior.
Abruptly blocking the compulsion will remove the client's only coping mechanism, leading to an immediate panic attack.
Maintaining client safety and emotional stability is the highest priority on the first day of admission.
3
Select the intervention that maintains safety while establishing trust.
Allowing the ritual to conclude prevents panic and builds the rapport necessary for future therapy.
Limit-setting on rituals is a collaborative process implemented later in the treatment plan, not abruptly on admission.

Key Concept

Management of Compulsive Behaviors in Early Treatment
Estimated Time:1m 0s
Question 297Question →

A clinical instructor and a nursing student are conducting a life-skills workshop for a small group of clients in the behavioral health dayroom. One participant continuously shifts their chair closer to the student, repeatedly demands to know the student's relationship status, and attempts to stroke the student's arm. Which actions should the clinical instructor take to reinforce milieu boundaries and maintain safety? Select all that apply.

Select all that apply

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Answer: Verbally intervene to set immediate, clear limits regarding physical contact and acceptable topics.; Attempt to redirect the participant's focus back to the ongoing life-skills activity.; Debrief the encounter privately with the nursing student afterward to process the event and review boundary management.

Answer

The correct actions are to verbally intervene to set clear limits, redirect the participant's focus back to the activity, and debrief the encounter privately with the nursing student afterward.
A therapeutic environment requires clear, consistent boundaries to ensure both physical and emotional safety. When a client violates these boundaries, the nurse must intervene promptly using the least restrictive measures possible. Verbally establishing clear limits and redirecting the client's attention to the ongoing activity are appropriate, non-restrictive first-line interventions. Additionally, a therapeutic milieu involves supporting the healthcare team; therefore, processing the event afterward with the student nurse is a crucial component of maintaining staff well-being and clinical development.

Step-by-Step Solution

1
Evaluate the client's behavior and its impact on the therapeutic milieu.
The behavior is identified as a boundary violation that compromises the safety and structure of the educational group.
A therapeutic environment requires physical and emotional safety, as well as clear interpersonal boundaries.
2
Determine the least restrictive interventions to manage the inappropriate behavior.
Verbal limit setting and redirection are selected as the initial, non-restrictive interventions.
Nursing interventions must always begin with the least restrictive measures before escalating to more restrictive options like seclusion or restraint.
3
Identify post-incident nursing responsibilities to support the unit staff.
The instructor plans to debrief with the student nurse after the group concludes.
Debriefing supports staff development, helps process stressful events, and maintains a supportive professional milieu.

Key Concept

Managing boundary violations in a therapeutic environment using least restrictive measures.
Question 298Question →

A charge nurse on an inpatient clinical unit observes a staff registered nurse (RN) returning from a scheduled break. The staff RN is exhibiting an unsteady gait, slurred speech, and noticeably constricted pupils. Over the past several weeks, the charge nurse has noted that this specific RN frequently volunteers to administer intravenous pain medications for other nurses' clients. Which of the following is the priority action for the charge nurse to take?

Show answer & explanation

Answer: Relieve the staff RN of all client care responsibilities immediately and escort them to the nursing supervisor.

Answer

The priority action is to immediately relieve the impaired staff RN of all client care responsibilities and escort them to nursing administration.
When a nurse exhibits signs of acute intoxication or impairment, such as constricted pupils, slurred speech, and ataxia, they pose an immediate and severe risk to client safety. The absolute highest priority is to remove the impaired professional from the clinical setting to prevent client harm. Once the nurse is removed, the charge nurse must involve nursing administration, such as the nursing supervisor, to manage the substance use violation according to facility policy.

Step-by-Step Solution

1
Analyze the clinical presentation of the staff RN.
The combination of constricted pupils, slurred speech, ataxia, and a history of volunteering to give narcotics strongly indicates opioid intoxication and potential drug diversion.
Recognizing the signs of chemical dependency in peers is a critical professional responsibility.
2
Determine the highest priority need based on the assessment.
An actively impaired nurse providing direct care poses a severe, immediate threat to client safety.
According to Maslow's hierarchy and basic safety principles, protecting clients from immediate physical harm takes precedence over all other actions.
3
Select the intervention that immediately mitigates the safety risk.
Removing the nurse from the unit and involving the nursing supervisor ensures clients are protected and facility protocols for suspected substance use are followed.
Administrative intervention is required to manage workplace impairment safely and legally.

Key Concept

Impaired Professional and Workplace Substance Use Disorders
Question 299Question →

A public health nurse is preparing to conduct a comprehensive health history for a newly enrolled community member who does not speak the local dominant language. In which order should the nurse perform the following actions to facilitate a culturally competent and legally sound encounter? Arrange the actions in chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First determine the language, then secure a certified interpreter, brief the interpreter, arrange the seating for direct eye contact, and finally direct questions directly to the client.
Establishing culturally competent communication requires a systematic approach. The nurse must first identify the specific language needs before obtaining a qualified, facility-approved interpreter to ensure medical accuracy. Briefing the interpreter prior to the encounter ensures mutual understanding of clinical goals. Arranging the seating to maintain eye contact with the client (rather than the interpreter) must happen before the dialogue begins. Finally, conducting the interview by speaking directly to the client in short segments ensures accurate translation and builds therapeutic trust.

Step-by-Step Solution

1
Determine the client's preferred spoken language and specific dialect.
The exact language requirement is identified.
Accurate identification prevents the dangerous assumption of a language based on nationality or appearance.
2
Obtain the services of a facility-approved certified medical interpreter.
A qualified professional is secured for the translation.
Using certified medical interpreters ensures medical accuracy and protects client privacy, which untrained family members cannot guarantee.
3
Brief the interpreter regarding the clinical objectives and potential cultural sensitivities.
The interpreter understands the context and goals of the upcoming conversation.
Pre-session briefing allows the nurse to set expectations and plan for culturally sensitive topics before entering the room.
4
Position the seating to maintain direct visual contact between the nurse and the client.
The physical environment promotes a nurse-client connection.
Placing the interpreter slightly behind or next to the client forces the nurse to maintain eye contact with the client, honoring their autonomy.
5
Direct questions straight to the client using short, manageable segments.
The interview is conducted successfully and accurately.
Speaking directly to the client (e.g., 'How are you feeling?') rather than the interpreter (e.g., 'Ask him how he is feeling') validates the client and builds trust.

Key Concept

Culturally Competent Communication via Interpreters
Question 300Question →

A nurse is caring for a client who was recently diagnosed with hypertension. The client refuses the prescribed morning dose of an oral antihypertensive medication, stating, "My body is currently too cold, and this Western medicine is a cold treatment. It will disrupt my balance and make my condition worse." Which of the following is the most appropriate response by the nurse?

Show answer & explanation

Answer: Can you tell me more about how you balance hot and cold in your health practices?

Answer

The nurse should ask the client to explain more about how they balance hot and cold in their health practices.
The correct response utilizes an open-ended statement that respects the client's cultural framework regarding the balance of hot and cold. This approach validates the client's concerns, builds trust, and allows the nurse to gather more information to adapt the care plan to the client's preferences.

Step-by-Step Solution

1
Analyze the client's statement regarding their refusal of medication.
The client's refusal is based on a specific cultural belief regarding the balance of "hot" and "cold" energies in the body.
Identifying the root cause of the medication refusal is necessary before intervening.
2
Evaluate the nursing responses based on principles of therapeutic communication and cultural competence.
Responses using "why," fear tactics, or stereotyping must be eliminated as they are non-therapeutic.
Culturally competent care requires respecting the client's beliefs without judgment or generalization.
3
Select the response that promotes individualized assessment and collaboration.
Asking the client to elaborate on their hot and cold health practices is the most appropriate action.
Open-ended exploration allows the nurse to understand the client's worldview and eventually negotiate a care plan (e.g., taking the "cold" medication with a "hot" herbal tea).

Key Concept

Cultural Competence and Therapeutic Communication
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