Psychosocial Integrity

A client recovering from a recent colostomy placement turns away during a dressing change and states, "I feel like a monster. My body is completely ruined." Which statement by the nurse demonstrates the most therapeutic communication?

A client diagnosed with borderline personality disorder approaches the nurse's station with several fresh, superficial horizontal lacerations on their left forearm. The client appears calm and states, "I just felt so empty inside; I needed to do this to feel something real." What is the nurse's priority and most therapeutic intervention?

A psychiatric-mental health nurse is formulating verbal interventions for several clients with complex clinical presentations. Pair each client's specific behavior or statement with the most therapeutic and clinically appropriate nursing response.

A home health nurse is evaluating the support system of a client with newly diagnosed end-stage heart failure who was recently discharged to live with their adult child. The client requires assistance with activities of daily living (ADLs) and complex medication management. Which of the following nursing actions are appropriate to promote a safe and effective support system? Select all that apply.

A 45-year-old client in the emergency department is informed that their spouse has died unexpectedly following a severe motor vehicle crash. The client begins pacing rapidly, shouting at the healthcare team, "You are all lying! We just had breakfast together! You let this happen because you didn't work fast enough!" Which of the following nursing interventions are most appropriate to include in the immediate plan of care? Select all that apply.

A 72-year-old client with end-stage heart failure is receiving mechanical ventilation in the intensive care unit. The client's family, acting as the designated healthcare proxy, has decided to transition to comfort measures only and requests a compassionate terminal extubation. Which of the following nursing interventions should the nurse include in the plan of care? Select all that apply.

An agitated client on the psychiatric acute care unit begins pacing rapidly, shouting at staff, and clenching their fists. To ensure safety while adhering to the principle of least restrictive intervention, arrange the following nursing actions in the order they should be implemented, starting with the least restrictive action first.

A triage nurse in a community urgent care center is caring for an older adult client who just received a phone call stating that their spouse of 40 years was killed in a motor vehicle collision. The client is pacing the waiting room, breathing rapidly, and repeatedly stating, "I need to go to the grocery store. He will be expecting dinner soon." Which of the following nursing interventions are appropriate at this time? (Select all that apply.)

While conducting morning rounds on an inpatient behavioral health unit, the nurse observes a client who was admitted six days ago for severe depression and suicidal ideation. The client, who previously stayed in bed most of the day, is now suddenly energetic, smiling broadly, and handing out their favorite jewelry to other clients in the dayroom. Which action should the nurse take first?

A healthcare provider has just informed a 45-year-old client that their progressive illness is now considered terminal. After the provider exits the room, the client sits motionless in bed, staring blankly at the wall without speaking. Which of the following is the most appropriate initial nursing action?

A nurse is caring for a client who was admitted to the psychiatric unit following a severe situational crisis and a subsequent suicide attempt. For the first few days, the client was profoundly depressed, tearful, and withdrawn. Today, the client suddenly appears remarkably peaceful, is smiling, and begins giving away prized personal belongings to other clients on the unit. Which action is the nurse's priority?

A pediatric oncology nurse is caring for a 7-year-old child who was recently diagnosed with acute lymphoblastic leukemia. The child's parent is observed meticulously organizing the child's hospital room, creating detailed spreadsheets of daily laboratory values, and reading advanced medical journals about chemotherapy protocols. When the unit social worker attempts to discuss the emotional impact of the diagnosis, the parent abruptly changes the subject, stating, "We just need to focus on the statistical probabilities and the pharmacokinetics of the treatment plan right now." Which defense mechanism is the parent primarily demonstrating, and what is the most appropriate initial nursing action?

A hospice nurse is interacting with the 5-year-old grandchild of a client who recently died. The child states, 'Grandpa is just sleeping because I was too loud playing my games yesterday. I will be very quiet now so he can wake up.' Which response by the nurse is the most therapeutic?

The nurse is caring for a 28-year-old client on a surgical trauma unit, two days following a traumatic below-the-knee amputation.

Objective cues: The client is lying in bed, staring out the window, and has consistently refused to look at the surgical site during dressing changes.
Client statement: "Just leave the discharge instructions on the bedside table. My partner can read them and do the wound care. I don't want to deal with it."

Based on the client's use of avoidance as a coping mechanism, what is the most therapeutic response by the nurse?

A client whose expected hospital discharge was just canceled due to a low hemoglobin level turns away from the nurse and begins to cry silently. Arrange the following nursing actions in the most appropriate therapeutic sequence, from first to last.

An interdisciplinary care team is planning the transition to home for a 78-year-old client who recently underwent a total hip arthroplasty. The client lives in a multi-level home with a spouse who has moderate Alzheimer's disease. Their extended family lives internationally. Which of the following interventions should the nurse recommend to ensure a safe support system? (Select all that apply.)

A nurse in a pediatric clinic is assessing a 3-year-old child who has multiple small, circular burn marks on their back. The parent states, "The child accidentally backed into a hot radiator." The nurse recognizes that the physical injuries are highly inconsistent with the parent's explanation and suspects child physical abuse. Which of the following is the nurse's priority action?

A client whose newborn infant was just pronounced dead in the neonatal intensive care unit is sitting in a rocking chair, staring blankly at the empty isolette. The client is not crying and has not spoken for the last 20 minutes. The nurse enters the room. Which of the following is the most therapeutic nursing action?

A client is resting in the postpartum unit following a vaginal delivery. The newborn was transferred to the neonatal intensive care unit (NICU) two hours ago due to sudden respiratory distress. The client is crying quietly and states, "This is all my fault. If I had taken better care of myself during the pregnancy, my baby would be here with me." Which of the following is the most therapeutic response by the nurse?

A nurse is teaching a client experiencing acute stress how to perform diaphragmatic breathing. Arrange the steps of this stress management technique in the correct chronological order.