Psychosocial Integrity

A nurse on an acute psychiatric unit is reviewing the protocol for managing clients who exhibit escalating, aggressive behavior. According to the principle of least restrictive intervention, arrange the following nursing actions in the correct sequence from least restrictive to most restrictive.

A client voluntarily admitted to the behavioral health unit becomes visibly upset after a phone call, throws a plastic cup against the wall, and begins shouting angrily at the nursing staff. To maintain a therapeutic environment and ensure safety, which of the following is the most appropriate initial action by the nurse?

An older adult Roman Catholic client who recently received a terminal prognosis is experiencing severe bone pain and acute spiritual distress. The client is crying and states, "This illness is a punishment from God for my past mistakes. I feel completely abandoned." Which of the following nursing actions are appropriate? Select all that apply.

A nurse is caring for a client in the active phase of dying. The client begins to exhibit loud, gurgling respiratory secretions. The client's family members are at the bedside, visibly distressed, and state, "Please help, they are choking!" Arrange the following nursing actions in the priority order they should be performed.

A young adult client arrives at an outpatient primary care clinic. While in the reception area, the client begins pacing rapidly, hyperventilating, and clutching their chest. Suddenly, the client attempts to push through the staff-only doors, shouting, "I need help right now, I am suffocating!" What is the priority nursing action?

A nurse is managing the care of a client on a physical rehabilitation unit who has a history of substance use disorder. Over the past two days, the client has exhibited manipulative behaviors, such as attempting to pit nursing staff against each other to obtain early doses of PRN analgesics and frequently arguing about unit visitation rules. The nurse is updating the client's care plan to address these behaviors. Which of the following behavioral interventions should the nurse include? Select all that apply.

A pediatric oncology unit is providing palliative care to a 15-year-old client with relapsed, refractory leukemia. The client's parents have explicitly requested that the healthcare team withhold the terminal prognosis from their child. During a routine assessment, the adolescent looks directly at the nurse and asks, "Am I dying?" What is the most appropriate initial action by the nurse?

A nurse is admitting a client who is a practicing Seventh-day Adventist for an elective surgical procedure. During the admission assessment, the client appears visibly anxious and states, "I just realized my surgery is scheduled for this Saturday morning." Which of the following is the priority nursing action?

A nurse is caring for a client with acute delirium who is experiencing severe sensory overload. The client is highly agitated, attempting to climb over the bed rails, and shouting at shadows on the wall while the room's television is blaring. In what order should the nurse prioritize the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).

A nurse is caring for an older adult client with end-stage heart failure who has recently transitioned to comfort measures only. The client is minimally responsive, exhibits Cheyne-Stokes respirations, and has mottling of the lower extremities. The client's family is at the bedside and expresses distress about the breathing pattern. Which nursing actions are appropriate? Select all that apply.

A client has recently passed away on a medical-surgical unit. The provider has pronounced the death and confirmed that an autopsy is not indicated. The family is currently waiting in the lounge to view the body. Arrange the following post-mortem care actions in the correct chronological sequence.

While completing evening rounds on a behavioral health unit, a nurse observes a client clenching their fists, breathing rapidly, and shouting obscenities at another staff member. The nurse recognizes that the client is experiencing acute agitation. In what order should the nurse implement the following interventions? Arrange the actions from first to last.

A client who recently experienced sudden and total vision loss following a traumatic injury is admitted to a surgical step-down unit. During the first night, the client becomes acutely agitated, attempts to remove the intravenous (IV) catheter, and shouts, "Who is in here? What are you doing to me?" Which action should the nurse take first?

A nurse is caring for a client in the final stages of terminal lung cancer. The client is unresponsive and exhibiting a Cheyne-Stokes respiratory pattern. The client's spouse is crying at the bedside and asks the nurse, "I know he is dying, but I just want him to wake up and talk to me one last time. Should I try to wake him?" Which of the following is the most appropriate response by the nurse?

A nurse provides care for a client hospitalized with a severe respiratory infection. During the shift, the client repeatedly activates the call bell for minor demands, attempts to touch the nurse's arm, and makes sexually explicit remarks regarding the nurse's appearance. Which of the following is the priority behavioral intervention for the nurse to implement?

A client on a busy cardiovascular step-down unit becomes increasingly agitated. The client's room is brightly lit, and multiple monitor alarms are continuously sounding. The client points frantically at the electrocardiogram (ECG) lead wires on their chest and shouts, 'Get these worms off of me!' Which of the following nursing interventions should the nurse implement to manage this perceptual alteration? Select all that apply.

A nurse is establishing a plan of care for an older adult client who requires bilateral eye patches and strict bed rest following complex ophthalmic surgery. The client reports feeling highly anxious and "disconnected from reality." Which interventions should the nurse include in the plan of care to address the client's sensory and perceptual alterations? Select all that apply.

During a mealtime on a secure mental health unit, a client becomes suddenly hostile, throws a food tray across the room, points aggressively at the wall, and yells about the food being poisoned by spies. Which of the following initial actions should the nurse implement? (Select all that apply.)

A client arrives at the behavioral health center for inpatient treatment of major depressive disorder. During the intake interview, the individual mentions consuming a 'couple of drinks' nightly to manage insomnia, with the most recent beverage consumed approximately 12 hours prior. The client currently exhibits restlessness, continuous pacing, and complains of nausea along with a mild headache. What is the priority nursing action at this time?

A client with end-stage renal disease has made the decision to discontinue hemodialysis and transition to hospice care. The client's parent is visibly distraught, approaches the nurse in the hallway, and states, "You have to talk some sense into them! They cannot just give up and die." Which response by the nurse is the most therapeutic?