Psychosocial Integrity

A client with a history of post-traumatic stress disorder is brought to the emergency department experiencing a severe flashback. The client is currently in a treatment room, pacing aggressively, shouting at unseen individuals, and throwing medical supplies at the wall. In accordance with the least restrictive alternative doctrine, arrange the following nursing actions in the correct sequential order from first to last.

A community health nurse is evaluating a client who survived a catastrophic wildfire 48 hours ago, which destroyed their entire home and neighborhood. The client is pacing the examination room, wringing their hands, and breathing at a rate of 28 breaths per minute. The client repeatedly states, "Everything is ashes. There is absolutely no way to keep going." Which nursing interventions are priority during this acute phase of crisis? Select all that apply.

A nurse in the emergency department is caring for a family whose 6-year-old child has unexpectedly died following a severe acute asthma exacerbation. The parents are at the bedside visibly grieving, and the deceased child's 4-year-old sibling is sitting quietly nearby. Which of the following actions by the nurse is most appropriate?

A 28-year-old client with a recent diagnosis of Huntington's disease is preparing for discharge to a long-term care facility. While the nurse is reviewing the transfer documents, the client suddenly tears the papers in half, throws them on the floor, and shouts, "I am not going to some facility to wait to lose my mind! You all just want to get rid of me!" Which of the following is the most therapeutic nursing response?

A nurse is working on an inpatient psychiatric unit. A newly admitted client becomes visibly agitated, pacing rapidly in the hallway and speaking loudly to staff members. Which of the following is the most appropriate initial nursing intervention to maintain a safe therapeutic environment?

An alert and oriented older adult client from a collectivistic culture is hospitalized for diagnostic testing. The client's adult children intercept the healthcare team in the hallway, requesting that a newly confirmed terminal cancer diagnosis be completely withheld from the client. They explain that in their culture, discussing a fatal prognosis destroys hope and accelerates physical decline. Shortly after, the client directly asks the nurse, "Did the doctor find out what is wrong with my scans?" Which action by the nurse represents the most appropriate integration of cultural competence and ethical practice?

A client in the inpatient mental health unit abruptly stands up in the communal dayroom, clenching their fists and shouting that the nursing staff is deliberately ignoring their needs. Arrange the nurse's therapeutic communication and de-escalation interventions in the most appropriate order from first to last.

A nurse is preparing to conduct an initial admission assessment and obtain informed consent for a client who speaks limited English. The client's bilingual adolescent child is present and offers to translate. The nurse politely declines the child's offer to ensure accuracy and confidentiality. Arrange the following subsequent nursing actions in the correct chronological order to provide culturally competent and legally sound care.

A registered nurse needs to complete an initial clinical intake for a newly admitted client who does not speak the local language. To ensure safe and culturally sensitive care, in what sequence should the nurse complete the following actions? Arrange the steps in the correct chronological order from first to last.

A young adult client who sustained a complete T4 spinal cord injury one month ago is participating in an inpatient rehabilitation program. While the nurse is setting up supplies for morning hygiene, the client suddenly sweeps the washbasin onto the floor and shouts, "Just leave me alone! I can't even hold a washcloth properly. There is absolutely no point to any of this rehabilitation!" Which response by the nurse is the most therapeutic?

Match each religious tradition with the specific clinical care consideration or health practice that the nurse must incorporate into the client's plan of care.

A nurse is initiating a therapeutic interaction with a newly admitted client who recently received a terminal prognosis. The client is sitting alone in a darkened room, staring at the wall, and has not touched their meal. Arrange the following therapeutic communication actions in the most appropriate progressive sequence from first to last to establish trust and explore the client's feelings.

A nurse is caring for an observant Muslim client who is on strict bed rest. The client expresses distress about being unable to go to the bathroom to perform the ritual washing (Wudu) required before daily prayers. Which nursing action is most appropriate to support the client's spiritual needs?

A triage nurse at an urgent care center evaluates a 9-year-old client who presents with a laceration to the forehead. The client's stepparent provides a mechanism of injury that is highly inconsistent with the physical findings and becomes verbally hostile when the nurse asks clarifying questions. Place the following nursing actions in the correct order of priority, from first to last.

A nurse is caring for a client who recently underwent a total colectomy with the creation of a permanent ileostomy. During the first ostomy teaching session, the client abruptly pushes the supplies away, crosses their arms, and states, "I am never going to touch that disgusting thing. I would rather die than live with this bag attached to me." Which of the following is the most therapeutic response by the nurse?

A client diagnosed with paranoid schizophrenia is watching television in the psychiatric unit dayroom. Suddenly, the client stands up, points at the screen, and shouts, "The broadcaster is sending the activation signals! They are coming to take me away!" The client begins pacing rapidly, clenching their fists, and breathing heavily. Which of the following is the most appropriate initial nursing action?

A nurse is caring for a client of the Islamic faith who is receiving palliative care and is in the active phase of dying. The family is attempting to reposition the client's bed so the client rests on their right side facing northeast (towards Mecca). During the movement, the client's oxygen saturation drops from 92% to 84% on room air, and the cardiac monitor displays frequent premature ventricular contractions. The client's respirations remain unlabored, and their facial expression is relaxed. Which of the following is the priority nursing action?

Match each client scenario or statement with the most appropriate therapeutic communication technique the nurse should utilize.

A charge nurse is managing the milieu of an acute behavioral health unit. A client diagnosed with schizophrenia is experiencing severe command hallucinations, pacing aggressively in the main corridor, and loudly accusing peers of being 'undercover agents.' Several other clients are visibly frightened and are gathering nearby to watch the situation. Which immediate environmental management strategies are most appropriate for the nurse to implement? (Select all that apply.)

The nurse is caring for a client on the inpatient psychiatric unit who is actively experiencing auditory hallucinations. Which actions should the nurse implement? Select all that apply.