Psychosocial Integrity

A 35-year-old client is admitted to the trauma unit following a motor vehicle collision. The electronic health record notes a history of daily, heavy consumption of both opioids and alcohol, though the client's family reports the client has not used any substances for the past 36 hours. The client suddenly becomes intensely restless, exhibits coarse bilateral hand tremors, profuse diaphoresis, and attempts to pull out their peripheral intravenous (IV) line, shouting, "You are pumping poison into my veins!" Current vital signs are a heart rate of 128 bpm, blood pressure of 172/98 mmHg, and respiratory rate of 22 breaths/min. The registered nurse (RN) is coordinating care with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which action should the RN take FIRST?

The nurse is developing a discharge plan for a 7-year-old client with newly diagnosed end-stage renal disease who will require home peritoneal dialysis. The client's parents are divorced, share joint legal and medical custody, and have a known history of severe interpersonal conflict. Which of the following nursing actions are appropriate to establish an effective support system for this client and family? Select all that apply.

A home health nurse is visiting a 68-year-old client whose spouse died unexpectedly 6 weeks ago. The client was recently diagnosed with complicated grief and major depressive disorder, and was started on fluoxetine 3 weeks ago. Previously, the client exhibited profound psychomotor retardation, severe insomnia, and an inability to complete activities of daily living. Today, the client is fully dressed, appears noticeably energetic and calm, and states, 'I finally see things clearly now. I gave my prized vintage car to my nephew this morning because I won't be needing it anymore.' Which action is the nurse's priority?

A pediatric oncology nurse is caring for a 7-year-old client who is transitioning to the actively dying phase. The client's parents and 4-year-old sibling are present at the bedside. Which of the following nursing actions are most appropriate to support the family through the anticipatory grief process? Select all that apply.

A nurse is caring for a client whose spouse died unexpectedly 3 days ago. The client is pacing the room, crying, and states, 'I do not know how I am going to survive without him. Everything is ruined, and it is my fault for not making him go to the hospital sooner.' Which of the following is the most therapeutic response by the nurse?

A nurse is preparing to discharge an older adult client who recently had a stroke. The client's spouse, who will be the primary caregiver, states, 'I am terrified. I do not know how I will be able to provide care 24 hours a day by myself.' Which response by the nurse best identifies and utilizes an appropriate support system?

During the evening shift, a client admitted for osteomyelitis returns from an unescorted pass off the unit. The nurse immediately notes that the client is exhibiting severe psychomotor agitation, profound diaphoresis, and pupillary dilation. The client is rapidly pacing the hallway and shouting about hidden cameras. Current vital signs include a heart rate of 128 beats per minute and a blood pressure of 188/110 mm Hg. Based on these manifestations of suspected acute stimulant intoxication, which nursing actions should be prioritized? Select all that apply.

A nurse is providing support to the parents of a 4-year-old child whose grandfather recently passed away. The parents ask for guidance on how to discuss the loss with their child. Which of the following statements by the nurse is the most appropriate?

A hospice nurse is evaluating the home support system for a client with terminal cancer. The client is alert, oriented, and has explicitly stated a wish to remain at home. The client's spouse is the primary caregiver but suffers from severe rheumatoid arthritis, which causes difficulty opening medication bottles and drawing up oral syringes. The couple's estranged adult child recently moved in to assist, but the spouse refuses to let the child administer liquid morphine, stating, 'I do not trust them with narcotics, so I struggle to do it myself.' The adult child privately reports to the nurse that the spouse often delays the client's scheduled doses by over an hour because of severe hand pain. Which action by the nurse is the priority?

Match each client scenario or statement to the correct defense mechanism it demonstrates.

A home health nurse is visiting a client with early-onset Alzheimer's disease who is being cared for at home by their spouse. The spouse appears fatigued, tearful, and states, "I feel completely isolated. My friends have stopped visiting, and I have to do everything myself. I do not know how much longer I can handle this alone." Which of the following is the priority nursing intervention?

A 28-year-old client is admitted to the oncology unit after receiving a new diagnosis of acute leukemia. The client sits quietly, staring out the window, and states, "Everything happens for a reason. I'm sure this is just a minor infection, and I'll be home by the weekend." The nurse observes that the client's lunch tray is untouched. Which nursing intervention is the most appropriate priority action based on the client's current coping mechanism?

A home health nurse is evaluating the support system of a family. A 35-year-old client with advanced multiple sclerosis is completely dependent for activities of daily living. The client's 65-year-old parent is the sole caregiver. During the visit, the parent appears disheveled, exhibits a flat affect, and states, 'I almost gave them a double dose of muscle relaxers last night because I was so exhausted I could not read the label.' The nurse assesses the client and finds them to be physically stable. Which intervention regarding the family's support system is the priority?

A critical care nurse is caring for a client who has just been pronounced brain dead following a severe traumatic brain injury. The client is a registered organ donor, and mechanical ventilation is being maintained. The client's 16-year-old child enters the room, becomes highly agitated, and shouts, "You are killing him! His heart is still beating and his skin is warm! Stop trying to take his organs!" Which of the following is the most appropriate initial nursing action?

A nurse is preparing to perform post-mortem care for a client who has just passed away. Place the following nursing actions in the correct chronological sequence.

A nurse is preparing to perform post-mortem care for a client who has just passed away. The client's family has temporarily stepped out of the room but wishes to return to view the body before it is transported. Arrange the following nursing actions in the correct chronological sequence.

A pediatric nurse is caring for a 5-year-old client who was recently diagnosed with acute lymphoblastic leukemia. The client's single parent is visibly overwhelmed and states, 'I do not know how I will manage my full-time job, caring for my 3-year-old at home, and being here at the hospital.' Which of the following nursing interventions are appropriate to assess and strengthen the parent's support systems? Select all that apply.

A nurse is evaluating the psychosocial responses of several clients on a medical-surgical unit. Pair each documented clinical observation or client statement with the specific defense mechanism it best demonstrates.

A client who is scheduled for surgery the next morning tells the nurse, "I am really terrified of being put to sleep. What if I do not wake up?" Which of the following is the most therapeutic response by the nurse?

While making morning rounds on the pediatric unit, the nurse encounters a frustrated parent. The parent's 8-year-old child, who was admitted yesterday for acute respiratory distress, has wet the hospital bed overnight despite being completely toilet trained for several years. The parent asks, "Why is my child acting like a baby again?" What is the most therapeutic response by the nurse?