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Psychosocial Integrity

368 questions

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Question 361Question →

A home hospice nurse arrives for a scheduled visit to a client with end-stage amyotrophic lateral sclerosis (ALS). The client's spouse, who is the primary caregiver, is crying and states, "I just cannot do this anymore." The client's sibling, who recently arrived from out of town, is standing in the room arguing loudly, "You are completely neglecting my brother!" The client is awake in bed and visibly distressed by the interaction. Which of the following is the priority nursing action?

Show answer & explanation

Answer: Request that the spouse and sibling step into another room, then acknowledge the emotional stress both are experiencing.

Answer

The priority action is to ask the family members to step into another room and then acknowledge their emotional stress.
The correct action prioritizes the client's immediate emotional and physical safety by removing the loud conflict from the client's presence. Validating the feelings of both family members without taking sides establishes a therapeutic environment, addresses caregiver strain, and initiates neutral conflict resolution.

Step-by-Step Solution

1
Assess the immediate environment and identify the primary threat to the client.
The loud argument is identified as an acute psychological stressor causing visible distress to the client.
Protecting the client from environmental and psychological harm is the nurse's first priority.
2
Intervene to separate the conflict from the client.
The spouse and sibling are directed to move their conversation to a different room.
This immediately resolves the environmental hazard for the client.
3
Utilize therapeutic communication to de-escalate the family members.
The nurse neutrally acknowledges the severe emotional strain both individuals are experiencing without taking sides.
Validation of feelings reduces defensiveness and opens the door for a collaborative discussion about caregiver strain and the client's care needs.

Key Concept

Family Dynamics and Conflict De-escalation
Question 362Question →

A home health nurse is conducting an initial assessment of a family providing full-time care for a 5-year-old child who requires continuous mechanical ventilation via a tracheostomy. Which findings indicate to the nurse that the parents are experiencing caregiver role strain? Select all that apply.

Select all that apply

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Answer: The primary caregiver reports chronic fatigue and has canceled their own routine medical appointments.; The primary caregiver exhibits a flat affect and states they no longer enjoy previously pleasurable activities.; The parents state they have stopped communicating with friends because no one understands their situation.

Answer

The findings indicating caregiver role strain include self-neglect (canceling personal medical appointments), signs of depression (flat affect and anhedonia), and social isolation (withdrawing from friends).
Caregiver role strain occurs when the demands of providing care compromise the caregiver's physical, emotional, or social well-being. Canceling personal medical appointments indicates physical self-neglect. A flat affect and loss of interest in activities are signs of clinical depression and emotional exhaustion. Stopping communication with friends demonstrates severe social isolation. All of these are maladaptive responses signaling that the caregivers are overwhelmed and require additional support interventions.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary nursing concern.
The nurse must evaluate for caregiver role strain in a high-stress home care environment involving a technology-dependent child.
Families caring for children with complex medical needs are at high risk for physical, emotional, and social exhaustion.
2
Differentiate between adaptive coping mechanisms and maladaptive signs of burnout.
Identify actions that promote family functioning versus actions that compromise the caregiver's well-being.
Accurate assessment guides appropriate nursing interventions and referrals.
3
Select the options that represent maladaptive responses to chronic stress.
Self-neglect, depressive symptoms, and social withdrawal are identified as clear indicators of strain.
These findings require immediate nursing intervention to support the family system and ensure continued safe care for the child.

Key Concept

Caregiver Role Strain and Maladaptive Coping
Question 363Question →

A 38-year-old client is admitted to the medical-surgical unit for treatment of acute pancreatitis. The health history reveals chronic daily consumption of liquor. The client states their last alcoholic beverage was approximately 14 hours ago. During the initial shift assessment, the nurse notes the client is restless, has a heart rate of 112 beats per minute, and exhibits fine bilateral hand tremors. Which nursing action is most appropriate?

Show answer & explanation

Answer: Initiate the prescribed withdrawal medication protocol and implement strict seizure precautions.

Answer

Initiate the prescribed withdrawal medication protocol and implement strict seizure precautions.
The client is exhibiting classic early signs of alcohol withdrawal, which include tachycardia, restlessness, and fine tremors, typically beginning 6 to 24 hours after the last drink. Initiating a withdrawal protocol (often involving benzodiazepines) and establishing seizure precautions are the priority actions to prevent the condition from progressing to severe, life-threatening complications like delirium tremens or withdrawal seizures.

Step-by-Step Solution

1
Analyze the client's history and current clinical presentation.
The client has a history of chronic alcohol use, stopped drinking 14 hours ago, and presents with restlessness, tachycardia, and fine tremors.
Identifying the timeline of last substance use is essential to anticipate withdrawal syndromes.
2
Correlate the assessment findings with potential complications.
The onset of tremors, elevated heart rate, and agitation 6 to 24 hours after the last drink are hallmark early signs of alcohol withdrawal.
Early recognition prevents progression to life-threatening complications such as seizures or delirium tremens.
3
Determine the highest priority nursing intervention.
The nurse must provide immediate medical intervention (administering withdrawal protocol medications like benzodiazepines) and ensure client safety (seizure precautions).
Patient safety and physiological stabilization take precedence over routine care or delegation.

Key Concept

Early Recognition and Management of Alcohol Withdrawal
Estimated Time:1m 0s
Question 364Question →

A nurse is caring for an older adult client who recently began experiencing mild confusion. The client's two adult children are arguing loudly at the bedside about long-term care plans. One child turns to the nurse and asks, 'Don't you agree that our parent needs to go to a nursing home immediately because of this decline?' What is the most appropriate response by the nurse?

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Answer: It sounds like you both are very concerned about your parent's safety. Let's arrange a family meeting with the care team to discuss all available options.

Answer

The most appropriate response acknowledges the family's underlying emotions, avoids taking sides in their conflict, and suggests an interdisciplinary family meeting.
This response is highly therapeutic because it uses empathy and reflection to validate the family's underlying emotional distress ('concerned about your parent's safety') without taking a side in their argument. By suggesting a family meeting, the nurse establishes professional boundaries, avoids being triangulated into the conflict, and guides the family toward a safe, interdisciplinary approach to decision-making.

Step-by-Step Solution

1
Analyze the family dynamic and the client's situation.
The family is exhibiting conflict and attempting to triangulate the nurse by asking the nurse to take a side regarding the client's placement.
Identifying triangulation is critical to avoiding non-therapeutic engagement.
2
Evaluate the nurse's role in the family conflict.
The nurse must remain neutral, establish boundaries, and address the underlying emotion (concern for safety) rather than answering the direct, polarizing question.
Taking sides escalates family conflict and breaks therapeutic boundaries.
3
Select the response that promotes therapeutic communication and collaborative care.
Suggesting a family meeting with the interdisciplinary team provides a structured, supportive environment for decision-making.
Complex discharge planning and family disagreements are best managed collaboratively with social services, case management, and the provider.

Key Concept

Family Triangulation and Therapeutic Boundaries
Question 365Question →

A nurse is conducting hourly rounds on an inpatient dual-diagnosis unit and discovers a client unresponsive with cyanotic lips, pinpoint pupils, and a respiratory rate of 6 breaths per minute. The client has a documented history of severe opioid use disorder. Arrange the following nursing actions in the correct order of priority.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to first determine unresponsiveness and call for help, then check the pulse and breathing, initiate ventilations to correct hypoxia, administer naloxone to reverse the overdose, and finally monitor for recurrent respiratory depression.
According to basic life support and emergency guidelines for a suspected opioid overdose, the absolute first priority is to assess responsiveness and call for help to activate the emergency response system. Next, the nurse must simultaneously check for a pulse and breathing. Upon identifying severe respiratory depression (6 breaths per minute) with a likely pulse, the immediate physiological need is oxygenation; therefore, the nurse must open the airway and provide ventilations. Once breathing is mechanically supported, the nurse administers naloxone to reverse the opioid effects. Finally, continuous reassessment is critical because the half-life of naloxone is often shorter than the opioid ingested, putting the client at high risk for a recurrence of respiratory depression.

Step-by-Step Solution

1
Determine unresponsiveness and call for immediate help.
Activates the emergency response team.
Ensures adequate personnel and equipment (such as a crash cart) are en route before beginning physical interventions.
2
Simultaneously check the carotid pulse and observe for breathing.
Identifies whether the client requires full CPR or solely respiratory support.
Guides the appropriate progression of the basic life support algorithm based on circulatory status.
3
Open the airway and initiate bag-valve-mask ventilations.
Provides immediate oxygenation to the client.
Reversing severe hypoxia is the primary physiological priority. Interventions for oxygenation must not be delayed.
4
Administer the prescribed dose of intravenous naloxone.
Reverses the opioid-induced central nervous system and respiratory depression.
Treats the underlying toxicological cause of the respiratory failure once the airway is supported.
5
Reassess the client continuously for recurrent respiratory depression.
Monitors the sustained effectiveness of the reversal agent.
Naloxone has a shorter half-life than many opioids, meaning the client could slip back into a comatose, apneic state.

Key Concept

Priority Management of Acute Opioid Overdose
Estimated Time:1m 30s
Question 366Question →

A 52-year-old client is recovering on the medical-surgical unit 48 hours after an elective orthopedic surgery. The client suddenly becomes highly agitated, visibly diaphoretic, and exhibits a coarse bilateral hand tremor. Current vital signs reveal a heart rate of 124 bpm, blood pressure of 168/98 mm Hg, and temperature of 100.2°F (37.9°C). The client's spouse arrives and states, "I forgot to bring the home pill bottles, including the clonazepam that my spouse takes three times every day." Which of the following is the priority nursing action?

Show answer & explanation

Answer: Initiate seizure precautions and contact the healthcare provider to obtain a prescription for a withdrawal management protocol.

Answer

The priority action is to initiate seizure precautions and contact the healthcare provider for a withdrawal management protocol.
The client is exhibiting classic signs of acute sedative-hypnotic (benzodiazepine) withdrawal, which typically begins 24 to 72 hours after the last dose. Because abrupt cessation of benzodiazepines can rapidly progress to life-threatening status epilepticus and delirium, the absolute priority is to ensure client safety by implementing seizure precautions and promptly obtaining medical treatment (such as a benzodiazepine taper) to manage the physiological withdrawal.

Step-by-Step Solution

1
Analyze the client's clinical presentation and timeline.
The client is 48 hours post-admission and exhibiting tachycardia, hypertension, agitation, diaphoresis, and coarse tremors.
Establishing the timeline and symptoms helps differentiate between normal surgical recovery and acute complications.
2
Incorporate the collateral information provided by the spouse.
The spouse indicates the client missed their daily scheduled doses of clonazepam (a benzodiazepine).
Missing daily sedative-hypnotic medication aligns with the onset of acute withdrawal symptoms.
3
Determine the highest safety priority for this specific withdrawal syndrome.
Benzodiazepine withdrawal carries a high risk for life-threatening seizures and delirium tremens.
According to Maslow's hierarchy and the ABCs (Airway, Breathing, Circulation, Safety), preventing physiological harm from seizures is the immediate priority.

Key Concept

Recognition and emergency management of sedative-hypnotic withdrawal
Question 367Question →

A client attending a community-based addiction recovery program states to the nurse, "I know I slipped up and used cocaine this weekend, but my partner has been arguing with me constantly, and I just could not handle the stress." Which response by the nurse is the most therapeutic?

Show answer & explanation

Answer: It sounds like you are saying your partner's arguing is the reason you decided to use cocaine.

Answer

The most therapeutic response is to reflect the client's statement back to them, indicating that they are attributing their substance use to their partner's actions.
The correct answer uses the therapeutic technique of reflection. By restating the client's rationalization in a non-judgmental manner, the nurse encourages the client to examine their own statement and begin taking accountability for their relapse without feeling attacked or judged.

Step-by-Step Solution

1
Identify the client's underlying behavior or defense mechanism.
The client is using rationalization and projection (blaming the partner and stress) to excuse the relapse.
Understanding the psychological mechanism helps the nurse choose the most effective communication strategy.
2
Evaluate the given responses against therapeutic communication principles.
Asking 'why', giving advice, judging, and offering false reassurance are non-therapeutic approaches.
These responses block open communication and prevent the client from exploring their own feelings and behaviors.
3
Select the response that encourages self-reflection without judgment.
The reflective statement allows the client to hear their own rationalization objectively.
Reflection promotes self-awareness and accountability while maintaining a supportive therapeutic environment.

Key Concept

Therapeutic Communication in Substance Use Disorders
Question 368Question →

An adult client is brought to the emergency department by friends after consuming large amounts of alcohol over the past few days. The client is lethargic, exhibits severe ataxia, and has slurred speech. The healthcare provider has prescribed several interventions. Order the nursing actions from first to last to ensure safe and effective care.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: 1) Evaluate airway and respiratory status, 2) Perform a capillary blood glucose test, 3) Establish peripheral IV access, 4) Administer intravenous thiamine, and 5) Initiate the dextrose fluid infusion.
The priority of care for an intoxicated, lethargic client begins with the ABCs. Airway and respiratory status must be evaluated first due to the risk of respiratory depression. Next, a bedside capillary blood glucose test is essential because alcohol intoxication can cause severe hypoglycemia, which mimics worsening neurological decline. Following assessment, the nurse establishes IV access to deliver treatments. Crucially, intravenous thiamine must be administered before any dextrose-containing fluids to prevent the precipitation of Wernicke's encephalopathy, a severe neurological complication caused by thiamine depletion during glucose metabolism.

Step-by-Step Solution

1
Evaluate the client's airway patency and respiratory status.
Ensures the client has adequate oxygenation and ventilation.
Lethargic clients with acute alcohol intoxication are at high risk for respiratory depression and airway compromise, making this the highest priority.
2
Perform a bedside capillary blood glucose test.
Identifies if the client is experiencing hypoglycemia.
Alcohol severely impairs the liver's ability to produce glucose. Hypoglycemia mimics worsening intoxication and requires immediate detection.
3
Establish peripheral intravenous (IV) access.
Provides a direct route for medications and fluids.
Venous access is necessary before prescribed emergency medications and intravenous hydration can be administered.
4
Administer the prescribed dose of intravenous thiamine.
Replenishes essential vitamin B1 levels.
Thiamine must be given prior to any glucose load in clients with chronic alcohol use to prevent Wernicke's encephalopathy.
5
Initiate the prescribed infusion of dextrose-containing intravenous fluids.
Corrects dehydration and low blood sugar.
Administered safely only after thiamine has been supplied, treating the underlying metabolic and fluid deficits without risking brain injury.

Key Concept

In clients with severe alcohol intoxication or chronic use, intravenous thiamine must be administered before or simultaneously with intravenous glucose to prevent Wernicke's encephalopathy.
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