Examkin

Psychosocial Integrity

346 soru

Tüm türler346Çoktan seçmeli178Çoklu seçim89Eşleştirme19Sıralama60
Soru 301Soru →

A nurse on a rehabilitation unit is providing morning care for a client who is recovering from a recent surgical procedure. The client's adult child died unexpectedly two weeks ago. While being assisted with hygiene, the client begins to cry and states, "I just realized that I will never hear her voice call my name again." Which response by the nurse is most therapeutic?

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Cevap: I can sit here with you for a while if you would like to talk about her.

Cevap

The most therapeutic response is to offer a supportive presence and give the client the opportunity to talk about the deceased child.
Offering self by stating a willingness to sit with the client is a highly effective therapeutic communication technique. It demonstrates care, provides a supportive presence, and encourages the client to share their feelings without feeling pressured or judged.

Adım Adım Çözüm

1
Analyze the client's statement and current emotional state.
The client is expressing acute grief, sadness, and a realization of the permanence of their loss during a vulnerable moment of care.
Understanding the emotional context is necessary to select a response that validates the client's feelings and provides appropriate support.
2
Evaluate each option based on the principles of therapeutic communication.
Offering to sit and listen is the only therapeutic choice, whereas the other options use communication blocks or rigidly label the grieving process.
Effective grief support requires active listening, empathy, and presence rather than giving advice, probing, or placing expectations on the client's grief trajectory.

Anahtar Kavram

Therapeutic Communication in Acute Grief
Soru 302Soru →

A client recovering from surgery has an established diagnosis of post-traumatic stress disorder. Suddenly, a heavy equipment cart crashes loudly in the adjacent hallway. The client immediately drops to the floor, curls into a tight position, and begins hyperventilating. Which action is the priority for the practical nurse (PN) to take?

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Cevap: Stay in the room, keep a non-threatening stance, and calmly orient the client to the current setting

Cevap

The priority action is to remain in the room, maintain a non-threatening posture, and use a calm voice to orient the client to their current surroundings.
During an acute flashback or severe panic episode, the client's psychological grounding is the immediate priority. By remaining in the room, maintaining a safe posture, and calmly orienting the client to the present, the nurse provides a safe environment. This therapeutic approach helps the client regain a sense of reality without introducing physical touch, which could be misinterpreted as a threat, and establishes trust without invalidating their intense emotional experience.

Adım Adım Çözüm

1
Assess the client's immediate behavioral and physiological response to the trigger.
The client is exhibiting signs of an acute flashback and severe anxiety, indicated by dropping to the floor and hyperventilating.
Identifying the severity of the stress reaction determines the level of intervention required.
2
Determine the safest and most therapeutic initial nursing intervention.
The nurse must prioritize psychological grounding and safety over investigation, logic, or physical contact.
Clients experiencing acute trauma responses may perceive sudden movements, logical reasoning, or physical touch as an active threat.
3
Select the option that provides presence and reality orientation.
Staying in the room with a non-threatening stance and orienting the client to the present environment is the correct choice.
This approach uses the therapeutic technique of offering self and reality grounding without forcing rationalization or minimizing the client's feelings.

Anahtar Kavram

Crisis Intervention and Grounding Techniques in PTSD
Soru 303Soru →

A client receives a new diagnosis of advanced pancreatic cancer from the healthcare provider. Later that afternoon, the client presents the practical nurse (PN) with a binder of medical research articles and spends the interaction calmly asking highly technical questions about the cellular mechanisms of various chemotherapy agents. Which of the following is the most appropriate action by the PN?

Cevabı ve açıklamayı göster

Cevap: Acknowledge the client's need for information and offer to document their specific questions for the healthcare provider.

Cevap

Acknowledge the client's need for information and offer to document their specific questions for the healthcare provider.
The correct action acknowledges the client's emotional state by safely supporting their current coping strategy (intellectualization). By offering to write down the questions for the healthcare provider, the nurse acts as a patient advocate while strictly remaining within the legal scope of practice for a practical nurse, which excludes initial, complex education on new treatment modalities.

Adım Adım Çözüm

1
Analyze the client's behavior and identify the underlying coping strategy.
The client is focusing entirely on complex, factual data rather than the emotional impact of a terminal diagnosis. This indicates the use of the defense mechanism known as intellectualization.
Recognizing the defense mechanism helps the nurse understand that the behavior is currently protecting the client from overwhelming emotional distress.
2
Determine the appropriate therapeutic communication approach.
The nurse should support the client by validating their need for information without aggressively stripping away their emotional defense or offering false reassurance.
Challenging a defense mechanism too early can increase severe anxiety, while false reassurance blocks therapeutic trust.
3
Evaluate the options against the practical nurse (PN) scope of practice.
Teaching complex new pharmacology is outside the PN scope. The PN should facilitate communication by gathering the questions for the provider.
Maintaining safe delegation and scope of practice boundaries is a critical component of every client interaction.

Anahtar Kavram

Coping Mechanisms (Intellectualization) and PN Scope of Practice
Soru 304Soru →

A practical nurse (PN) enters the room of a client who was recently admitted to a hospice facility. The client's sibling is sitting at the bedside crying and states, "I do not know what I am going to do without them. We have lived together for over 60 years." Arrange the PN's actions in the most appropriate therapeutic sequence. All options must be used.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The most appropriate therapeutic sequence begins with establishing a supportive presence, followed by validating the sibling's feelings, actively listening to their stories, assessing for personal support systems, and finally offering interdisciplinary resources.
In psychosocial interventions involving acute anticipatory grief, the nursing process prioritizes immediate emotional safety and therapeutic presence. Nonverbal communication (offering tissues, sitting quietly) establishes trust and a safe environment. Next, verbal validation (using reflection) acknowledges the significance of the relationship and encourages the expression of feelings. Active listening allows the individual to process their grief. Only after the immediate emotional peak has stabilized and feelings have been expressed should the nurse transition to assessing personal support systems (family or friends) and offering interdisciplinary interventions (chaplain or bereavement counselor).

Adım Adım Çözüm

1
Provide a box of tissues and sit quietly at the bedside.
Establishes a therapeutic, non-judgmental presence.
Immediate nonverbal support and therapeutic silence take priority in an acute emotional crisis.
2
State, "It sounds like you and your sibling share a very deep bond."
Validates the sibling's feelings and acknowledges their pain.
Reflection encourages the individual to open up and establishes trust.
3
Utilize active listening while the sibling shares stories about their shared life.
Facilitates the expression of anticipatory grief.
Allowing the client to verbalize memories helps them process the impending loss without interruption.
4
Ask the sibling if there are other family members or friends they would like to call.
Assesses personal support networks.
Once the immediate emotional need is addressed, practical and personal support systems should be evaluated.
5
Offer to arrange a visit from the facility's chaplain or bereavement counselor.
Provides long-term interdisciplinary resources.
Connecting the family with specialized professionals ensures ongoing psychosocial support as part of the care plan.

Anahtar Kavram

Therapeutic Communication Sequence in Anticipatory Grief
Tahmini Süre:1m 30s
Soru 305Soru →

A client with advanced diabetic retinopathy is hospitalized for a systemic infection. In the middle of the night, while the hospital room is entirely dark, the client becomes intensely agitated, attempts to climb over the side rails, and shouts, 'The room is flooding with water, I need to swim out!' Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Illuminate the room, state the nurse's name clearly, and reassure the client of their immediate safety

Cevap

The correct priority action is to illuminate the room, state the nurse's name clearly, and reassure the client of their immediate safety.
The client is experiencing a perceptual alteration likely caused by a combination of acute delirium (from the systemic infection) and severe sensory deprivation (from the dark room and underlying diabetic retinopathy). The priority nursing action is to implement the least restrictive intervention that ensures safety and addresses the sensory deficit. Illuminating the room removes the sensory deprivation and ambiguity that contributes to illusions or hallucinations. Stating the nurse's name and offering reassurance immediately reorients the client to reality and decreases severe anxiety.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a severe visual impairment and is in a dark room, creating intense sensory deprivation. The systemic infection increases the risk for acute delirium, manifesting here as a severe perceptual alteration (hallucination or illusion).
Identifying the root cause of the perceptual alteration guides the appropriate and most effective nursing intervention.
2
Prioritize interventions based on safety and the least restrictive alternative.
Environmental modification (turning on the lights) directly addresses the sensory deprivation by maximizing remaining vision, while verbal reassurance provides immediate reorientation.
Client safety must be achieved using the least restrictive alternatives before considering physical restraints or escalation.

Anahtar Kavram

Sensory and Perceptual Alterations
Soru 306Soru →

A practical nurse (PN) is co-leading a group activity on an inpatient psychiatric unit. A client suddenly stands up, begins hyperventilating, grips their chest, and says, "I am having a heart attack and I am going to die!" Medical causes have been previously ruled out, and the PN recognizes an acute panic attack. In what order should the PN perform the following actions? Arrange the interventions in the correct sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence of actions is: 1) Remain with the client, 2) Escort to a quiet environment, 3) Communicate with short phrases, 4) Coach deep breathing, and 5) Document the event.
When managing an acute panic attack, prioritizing safety and immediate presence is paramount. The nurse first stays with the client to ensure safety, then alters the environment by removing them from high stimuli. Next, communication is adjusted to short, simple phrases because the client's perceptual field is severely narrowed. This clear communication paves the way to successfully coach physical interventions like deep breathing. Finally, post-crisis documentation is completed once the client is stable.

Adım Adım Çözüm

1
Remain with the client.
The client's immediate safety is ensured.
Clients in panic states should never be left alone due to extreme fear and risk of injury.
2
Move the client to a quiet area.
Environmental triggers are minimized.
Decreasing sensory input helps lower the client's overall anxiety level.
3
Use short, simple sentences.
The client comprehends the nurse's instructions.
Severe anxiety narrows the perceptual field, making complex sentences impossible to process.
4
Coach deep breathing.
Hyperventilation is corrected.
Physiological symptoms of panic must be managed with direct, guided interventions once the client can focus.
5
Document the incident.
The healthcare team is informed.
Post-crisis documentation is required by nursing standards of practice.

Anahtar Kavram

Nursing Management of Acute Panic Attacks
Soru 307Soru →

A practical nurse (PN) is assisting a facilitator during a community support group for bereaved families. A parent expresses concern about their 16-year-old child following the sudden death of the child's other parent eight months ago. The parent states, "My teenager seemed to have accepted the loss a few months ago, but lately, they are lashing out in anger and refusing to talk. Aren't they supposed to be past the anger stage by now?"

Which response by the PN is most appropriate?

Cevabı ve açıklamayı göster

Cevap: People often cycle back and forth through different emotions of grief over time; it is rarely a straight line.

Cevap

The most appropriate response is to explain that people often cycle back and forth through different emotions of grief over time, as it is rarely a straight line.
The correct response accurately reflects that grief is an individualized, dynamic process rather than a strict sequence of stages. It is normal for individuals, particularly adolescents, to revisit emotions such as anger long after a loss. This response provides necessary education while therapeutically supporting the parent.

Adım Adım Çözüm

1
Analyze the parent's statement and underlying concern.
The parent incorrectly believes that the grief process is a linear timeline and expects their teenager to be permanently in the 'acceptance' stage after eight months.
Identifying the knowledge gap helps determine the most therapeutic and educational response.
2
Recall the characteristics of normal and complicated grief, particularly in adolescents.
Grief is a highly individualized, dynamic process. Individuals often revisit stages such as anger or denial, especially around milestones, holidays, or subsequent life changes.
Accurate clinical knowledge is required to provide correct reinforcement of teaching to the family.
3
Evaluate the response options against principles of therapeutic communication.
The correct response addresses the misconception about linear grief stages without being dismissive, giving unwanted advice, or providing false reassurance.
The PN must use communication techniques that encourage coping and provide accurate psychosocial education.

Anahtar Kavram

Non-linear progression of the grieving process
Soru 308Soru →

A practical nurse (PN) is assisting with the admission of a client to an inpatient mental health unit. The client is acutely intoxicated with methamphetamine and experiencing paranoid delusions. The client is diaphoretic, pacing rapidly around the dayroom, and stating, "They followed me here, I know they are waiting right outside the window." Which of the following actions should the PN include in the client's immediate care? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Monitor the client's vital signs frequently for severe hypertension and tachycardia.; Decrease environmental stimuli by maintaining low unit lighting and minimizing noise.; Maintain a safe physical distance and ensure a clear exit path during all interactions.

Cevap

The correct actions include monitoring vital signs frequently for hypertension and tachycardia, decreasing environmental stimuli, and maintaining a safe physical distance with a clear exit path.
Clients experiencing acute methamphetamine intoxication and active paranoia require interventions that prioritize physical safety, physiologic stability, and de-escalation. Frequent vital sign monitoring is critical due to the risk of sympathetic nervous system overstimulation, which can cause hypertensive crisis, severe tachycardia, and hyperthermia. Decreasing environmental stimuli (dimming lights, reducing noise) helps lower sensory overload that feeds paranoid delusions. Furthermore, maintaining a safe physical distance and a clear exit path protects the nurse while preventing the client from feeling trapped, which could otherwise trigger an aggressive 'fight or flight' response.

Adım Adım Çözüm

1
Analyze the client's presentation and substance involved.
The client is intoxicated with methamphetamine (a powerful central nervous system stimulant) and is exhibiting paranoia, agitation (pacing), and sympathetic overactivation (diaphoresis).
Identifying the physiological and psychological effects of the specific substance guides immediate safety and medical priorities.
2
Determine physiological safety priorities.
Stimulant toxicity carries a high risk of cardiovascular collapse, hypertensive crisis, and hyperthermia, requiring frequent vital sign monitoring.
Airway, breathing, and circulation (including blood pressure and heart rate) remain the highest priority in acute toxicity.
3
Determine psychological and environmental safety priorities.
The nurse must reduce stimuli to avoid worsening the paranoia, maintain a safe distance so the client does not feel cornered, and avoid arguing with the delusions or offering false reassurance.
Proper de-escalation techniques and environmental management prevent the escalation of agitation into physical violence.

Anahtar Kavram

Nursing Management of Acute Stimulant Intoxication and Paranoia
Soru 309Soru →

A licensed practical nurse (LPN) in a pediatric clinic is reinforcing teaching with the parents of an 8-year-old child whose sibling recently died. Which of the following behaviors or statements by the child should the LPN explain are expected developmental responses to grief for this age group? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Asking specific questions about what happens to a person's physical body after they die; Displaying sudden aggressive behaviors and experiencing a drop in academic performance; Expressing intense anxiety and fear that their parents might also become sick and die

Cevap

The expected developmental responses for an 8-year-old include asking specific questions about physical body changes, displaying aggressive behaviors with a drop in academic performance, and expressing fear that their parents might also die.
School-age children (ages 6 to 12) have developed the cognitive ability to understand that death is permanent, irreversible, and universal. Because they recognize the finality of death, they often fear that other loved ones, such as their parents, might also become sick and die. Their growing logical thought process leads to a factual curiosity about the biological and physical aspects of what happens to the body after death. Additionally, children in this age group may have difficulty verbalizing their complex emotions, often expressing their grief through behavioral changes, such as aggression, acting out, or experiencing a sudden decline in academic performance.

Adım Adım Çözüm

1
Identify the developmental stage of the client's child.
The child is 8 years old, which falls into the school-age developmental stage.
Understanding of death evolves with cognitive development, making chronological age a critical factor in assessing normal grief responses.
2
Recall the characteristics of a school-age child's understanding of death.
School-age children understand that death is permanent, universal, and irreversible. They often display curiosity about the physical aspects of death and may act out their grief behaviorally rather than verbally.
This knowledge allows the nurse to differentiate normal developmental grief from regressive behaviors or prolonged complications.
3
Evaluate each option against school-age developmental milestones.
Interest in the physical body, fear of others dying, and behavioral changes are expected at this age. Magical thinking and believing death is temporary are preschool concepts.
Selecting the expected behaviors ensures the LPN reinforces accurate, developmentally appropriate information to the grieving parents.

Anahtar Kavram

Developmental understanding of grief in school-age children
Tahmini Süre:1m 30s
Soru 310Soru →

A practical nurse is caring for an Orthodox Jewish client who is observing the Sabbath (Shabbat) and requires assistance with activities of daily living. Knowing that the client's religious practices prohibit the use of electrical devices during this time, which action should the nurse take?

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Cevap: Perform frequent, scheduled rounding to anticipate the client's needs without requiring the use of the electronic call light.

Cevap

The nurse should perform frequent, scheduled rounding to anticipate the client's needs without requiring the use of the electronic call light.
During the Sabbath (Shabbat), which lasts from sunset on Friday to sunset on Saturday, Orthodox Jewish clients strictly refrain from activities considered 'work', which includes operating electrical devices like televisions, motorized beds, and electronic call lights. Because the client cannot summon help using the standard call bell system for routine needs, the most appropriate and culturally competent nursing action is to perform frequent, scheduled rounding. This proactive approach ensures the client's safety, hygiene, and comfort needs are met without forcing them to compromise their spiritual beliefs.

Adım Adım Çözüm

1
Identify the cultural and religious restrictions of the client during the Sabbath (Shabbat).
The nurse recognizes that Orthodox Jewish clients abstain from using electrical devices, including call lights, from sunset Friday to sunset Saturday.
Understanding specific religious prohibitions is necessary to plan culturally competent care.
2
Determine how the restriction impacts the client's safety and ability to communicate needs.
The client cannot use the standard electronic call bell to request help for activities of daily living.
Safety is a primary nursing priority, and alternative communication or monitoring methods must be established.
3
Implement an appropriate nursing intervention that accommodates the belief while maintaining safety.
The nurse initiates frequent, proactive rounding to check on the client.
Frequent rounding ensures the client's needs are met promptly without forcing them to violate their religious principles by operating a device.

Anahtar Kavram

Culturally Competent Care: Sabbath Observance
Soru 311Soru →

A practical nurse (PN) is reviewing documentation for several clients in a community health setting. Match each client statement or behavior to the corresponding defense mechanism.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

"I skipped my physical therapy session today because the hospital parking lot is always too crowded."
A client who is devastated by a recent amputation screams at the dietary aide for bringing the wrong flavor of juice.
A caregiver who previously expressed deep resentment about their duties tells the nurse, "I am so wonderfully blessed to spend every waking moment caring for my sick husband."
A client who struggles with intense feelings of hostility joins a community martial arts program to channel their anger.

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The correct matches are: the parking excuse aligns with Rationalization, yelling at the aide aligns with Displacement, expressing extreme joy to mask resentment aligns with Reaction formation, and joining martial arts aligns with Sublimation.
Each scenario accurately illustrates a distinct defense mechanism: rationalization involves making excuses to protect self-esteem, displacement redirects strong emotions to a safer target, reaction formation expresses the exact opposite of true feelings to mask them, and sublimation channels unacceptable impulses into constructive, productive activities.

Adım Adım Çözüm

1
Analyze the first scenario where the client makes excuses about the parking lot.
Matches with rationalization.
The client is using a socially acceptable reason to justify non-compliance with the treatment plan.
2
Evaluate the second scenario involving the client yelling at the dietary aide.
Matches with displacement.
The client transfers anger from a significant stressor onto a safer, secondary target.
3
Assess the third scenario where the caregiver expresses extreme joy despite known resentment.
Matches with reaction formation.
The caregiver is displaying outward emotions that directly contradict their true, unacceptable internal feelings.
4
Examine the fourth scenario regarding the client joining a martial arts program.
Matches with sublimation.
The client is channeling negative energy into a positive, socially acceptable outlet.

Anahtar Kavram

Ego Defense Mechanisms
Soru 312Soru →

A practical nurse is planning care for a newly admitted client who is a devout member of the Church of Jesus Christ of Latter-day Saints. Which of the following nursing actions are appropriate to support the client's spiritual and cultural needs? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Ensure that coffee and black tea are omitted from the client's meal tray.; Seek the client's permission before removing their sacred undergarments for a physical examination.; Provide a private space when church elders arrive to administer a blessing of the sick.

Cevap

The correct actions are omitting coffee and black tea from the meal tray, seeking permission before removing sacred undergarments, and providing privacy for a blessing of the sick.
Members of the Church of Jesus Christ of Latter-day Saints observe the Word of Wisdom, which prohibits coffee and black tea. Devout members often wear sacred temple garments that should be treated with deep respect and removed only when medically necessary, ideally with the client's permission. Additionally, receiving a priesthood blessing from church elders is a core spiritual practice during illness, requiring the nurse to facilitate privacy and respect.

Adım Adım Çözüm

1
Identify the client's specific religious affiliation and associated practices.
The client is a member of the Church of Jesus Christ of Latter-day Saints. Key practices include the Word of Wisdom (no coffee or black tea), wearing temple garments, and receiving priesthood blessings.
Accurate identification of spiritual needs prevents the application of incorrect cultural stereotypes.
2
Evaluate each nursing intervention against the client's religious practices and the practical nurse scope of practice.
Omitting coffee and tea, respecting sacred garments, and allowing priesthood blessings align directly with the client's faith and the nurse's role.
Culturally competent care requires accommodating specific religious practices when they do not interfere with medical safety.
3
Identify and exclude interventions that represent nursing errors or fall outside the PN scope of practice.
Providing false reassurance, ordering a kosher diet (which is for Judaism), and explaining surgical risks (which is the provider's role) must be excluded.
Safe and effective care requires therapeutic communication, accurate dietary accommodations, and strict adherence to legal scope of practice.

Anahtar Kavram

Culturally competent care and spiritual support for Latter-day Saint clients within the practical nursing scope of practice.
Soru 313Soru →

During rounds on the behavioral health unit, a client recovering from amphetamine toxicity suddenly backs into the corner of the dayroom. The client is heavily diaphoretic, glaring at the ceiling, and shouting, "The drones are dropping poison on me!" Which action is the priority for the nurse to implement?

Cevabı ve açıklamayı göster

Cevap: Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.

Cevap

Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.
The priority when managing a client experiencing stimulant-induced psychosis and paranoia is establishing physical safety. By maintaining a safe distance and ensuring an unobstructed exit, the nurse protects themselves and prevents the client from feeling trapped, which reduces the immediate risk of violence.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is exhibiting symptoms of severe stimulant-induced psychosis, including paranoia, visual hallucinations, and backing into a corner.
Recognizing the signs of a psychotic break allows the nurse to anticipate unpredictable or defensive behavior.
2
Evaluate the priority of care based on the scenario.
Immediate physical safety for both the client and the nursing staff is the absolute highest priority.
A cornered, terrified client experiencing hallucinations may resort to violence in an attempt to protect themselves from perceived threats.
3
Select the safest initial nursing intervention.
The nurse must secure the environment by keeping a safe physical distance and ensuring an unblocked escape route.
This strategy de-escalates the immediate environmental tension and provides the nurse with a safe way out if the client becomes physically aggressive.

Anahtar Kavram

Crisis Intervention and Safety in Substance-Induced Psychosis
Soru 314Soru →

A practical nurse (PN) is reinforcing discharge instructions for a client who had a permanent pacemaker implanted the previous day. The client laughs and states, 'I do not need to check my pulse or go to those follow-up appointments. This little machine is a magic fix, and my heart is completely bulletproof now.' Which therapeutic response should the PN provide?

Cevabı ve açıklamayı göster

Cevap: I understand you are feeling relieved, but checking your pulse daily is still a necessary part of your care.

Cevap

The response stating that the nurse understands the client is feeling relieved, but checking the pulse daily is still a necessary part of care.
The correct response is therapeutic because it validates the client's positive feelings ('I understand you are feeling relieved') while gently but firmly presenting reality ('checking your pulse daily is still a necessary part of your care'). This technique addresses the client's denial without being confrontational and ensures that critical safety information is reinforced.

Adım Adım Çözüm

1
Identify the client's behavior and underlying coping mechanism.
The client is demonstrating denial by ignoring the reality of needing ongoing cardiac monitoring and follow-up care.
Recognizing the defense mechanism is essential to formulating a therapeutic response.
2
Determine the appropriate practical nurse (PN) intervention.
The PN must use therapeutic communication to acknowledge the client's emotional state while gently orienting them to reality and reinforcing the established teaching plan.
Validating feelings builds trust, while presenting reality ensures client safety and compliance with the medical regimen.
3
Evaluate the options against communication principles and the PN scope of practice.
Eliminate options that use non-therapeutic blocks (like 'why' questions or false reassurance) and options that require RN-level assessment or care plan modification.
This leaves only the therapeutic response that safely reinforces adaptive coping and required health maintenance.

Anahtar Kavram

Therapeutic Communication and Adaptive Coping
Soru 315Soru →

A practical nurse (PN) in a long-term care facility is talking with an older adult client whose spouse died three months ago. The client tearfully states, "Sometimes I still hear his footsteps in the hallway and think he is coming into the room. I feel like I am going crazy." Which of the following is the most therapeutic response by the PN?

Cevabı ve açıklamayı göster

Cevap: It is very common for people to experience the sensation of hearing or seeing their loved one while grieving.

Cevap

The most therapeutic response is to validate that experiencing the sensation of hearing or seeing a deceased loved one is a common and normal part of the grieving process.
The correct answer utilizes the therapeutic technique of providing information and validation. By reassuring the client that sensory experiences of the deceased are a common, normal aspect of the grieving process, the nurse alleviates the client's fear of losing their mind and encourages further expression of feelings.

Adım Adım Çözüm

1
Analyze the client's statement and current emotional state.
The client is experiencing brief sensory illusions related to their deceased spouse and feels distressed, fearing they are 'going crazy.'
Understanding the client's experience is necessary to formulate a therapeutic and supportive response.
2
Evaluate the clinical significance of the client's experience.
Brief auditory or visual sensations of a recently deceased loved one are a normal manifestation of acute grief, not a sign of psychosis.
Differentiating normal grief manifestations from pathological conditions guides the nurse's intervention.
3
Select the response that utilizes therapeutic communication techniques.
The response that normalizes the experience provides empathy and validation, avoiding non-therapeutic blocks like advice-giving, false reassurance, or rigid expectations.
Therapeutic communication fosters trust and helps the client process their grief.

Anahtar Kavram

Therapeutic Communication in Normal Grief
Soru 316Soru →

A practical nurse (PN) is caring for a client who is a devout Roman Catholic. It is a Friday during the season of Lent, and the PN is delivering the client's lunch tray, which contains a pork chop, mashed potatoes, and green beans. The client looks at the tray and appears distressed. Which action is the most appropriate for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Ask the client if they prefer a meatless meal and contact dietary services to request a replacement tray.

Cevap

Ask the client if they prefer a meatless meal and contact dietary services to request a replacement tray.
Many Roman Catholics abstain from eating meat on Fridays during the season of Lent. By acknowledging the client's distress, clarifying their preference, and proactively contacting dietary services for a meatless alternative, the practical nurse demonstrates cultural competence and supports the client's psychosocial and spiritual well-being.

Adım Adım Çözüm

1
Analyze the client's reaction and the cultural context of the situation.
The client is distressed by the presence of meat on a Friday during Lent, a time when many Roman Catholics observe abstinence from meat.
Recognizing spiritual and religious influences is essential for providing culturally competent and holistic care.
2
Determine the appropriate, therapeutic nursing intervention.
The PN validates the client's concern, verifies their dietary preference, and coordinates with dietary services for a proper replacement meal.
This action supports the client's psychosocial integrity, ensures nutritional needs are safely met without cross-contamination, and demonstrates respect for their spiritual practices.

Anahtar Kavram

Accommodating religious and spiritual dietary practices in the healthcare setting
Tahmini Süre:1m 0s
Soru 317Soru →

A client with suspected acute cocaine toxicity is brought to the emergency department. The client is profoundly restless, diaphoretic, and reports severe, crushing chest pain. In what order should the practical nurse (PN) prioritize the following actions? Arrange the actions from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence is to first verify airway patency, then attach cardiac monitoring, obtain complete vital signs, decrease environmental stimuli, and finally assist with administering the prescribed benzodiazepine.
In acute substance toxicity emergencies, care is prioritized using Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation). The nurse must first ensure an open airway and adequate breathing. Next, because cocaine toxicity severely compromises the cardiovascular system, continuous cardiac monitoring is established to detect life-threatening dysrhythmias. Following this, completing the primary data collection with full vital signs (including temperature to check for hyperthermia) is essential. Once physiological stability is assessed, the nurse implements environmental safety measures by decreasing stimuli to reduce agitation. Finally, the nurse assists the RN with pharmacological interventions, such as benzodiazepines, which are the treatment of choice for cocaine-induced agitation and cardiovascular toxicity.

Adım Adım Çözüm

1
Assess airway and breathing.
Ensures the client has adequate oxygenation.
Airway and breathing (ABCs) are the highest priority in any physiological emergency to sustain life.
2
Initiate cardiac monitoring.
Allows for immediate detection of lethal arrhythmias.
Cocaine causes severe vasoconstriction and tachycardia, making myocardial infarction or arrhythmias the most immediate life-threatening complications.
3
Obtain full vital signs.
Completes the primary data collection.
Vital signs, especially temperature, are critical to detect hyperthermia, a common complication of stimulant overdose.
4
Modify the environment.
Reduces external triggers.
A low-stimulus environment decreases sympathetic nervous system activation and cardiac workload.
5
Assist with medication preparation.
Prepares for pharmacological intervention.
Medications are administered only after immediate physiological assessments and safety measures are established.

Anahtar Kavram

Prioritization of Care in Substance Toxicity (ABCs and Nursing Process)
Soru 318Soru →

A client is recovering in the surgical unit 3 days after a permanent colostomy placement. The client refuses to look at the stoma, turns their head away during pouch changes, and states, "Just do what you have to do so I can go to sleep." Which actions by the practical nurse (PN) are appropriate to support the client's coping? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Provide a supportive, non-judgmental environment by actively listening if the client chooses to express their feelings.; Ensure the client's privacy by closing the door and drawing the curtains during ostomy care.; Introduce small, manageable aspects of care, such as having the client simply hold a clean pouch.

Cevap

The appropriate actions are providing a supportive environment, ensuring privacy during care, and introducing small, manageable aspects of care.
The correct actions reflect therapeutic communication and appropriately paced nursing care. Providing a non-judgmental environment encourages the expression of feelings when the client feels ready. Ensuring privacy minimizes embarrassment and promotes dignity during a vulnerable time. Introducing small, manageable steps respects the client's current use of denial as a protective coping mechanism while gently moving them toward eventual adaptation and self-care.

Adım Adım Çözüm

1
Analyze the client's behavior and statements.
The client is demonstrating avoidance and denial regarding the body image change caused by the new colostomy.
Recognizing the current coping mechanism (denial) is essential for selecting appropriate, paced therapeutic interventions.
2
Evaluate the nursing actions for therapeutic value.
Listening actively, ensuring privacy, and introducing care in small steps support the client without forcing immediate confrontation with the stoma.
These actions promote dignity, build trust, and gently guide the client toward acceptance at a pace they can handle.
3
Identify and eliminate non-therapeutic actions.
Providing false reassurance, asking "why" questions, and enforcing rigid grief stages are identified as inappropriate.
These actions block communication, increase the client's anxiety, and fail to recognize the highly individual nature of coping with a body image change.

Anahtar Kavram

Coping Mechanisms and Therapeutic Communication
Soru 319Soru →

A practical nurse is providing care for a hospitalized client who observes traditional Orthodox Jewish practices and is scheduled for surgery the next morning. Which of the following actions by the practical nurse are appropriate? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Accommodating the client's request to wear a yarmulke continuously, provided it does not compromise a sterile field or medical procedure.; Ensuring the client's meals are served on single-use, disposable plates with plastic utensils if a certified Kosher kitchen is unavailable.; Facilitating a quiet environment and providing uninterrupted time for the client to perform their daily prayers.

Cevap

The appropriate actions are accommodating the yarmulke, using disposable plates and utensils for meals, and facilitating a quiet environment for daily prayers.
The correct actions reflect an integration of cultural sensitivity and spiritual support within the practical nurse's scope of practice. Kosher dietary laws mandate the strict separation of meat and dairy products; therefore, utilizing disposable plates and utensils prevents cross-contamination with non-Kosher food items in a standard hospital kitchen. Furthermore, accommodating the client's desire to wear a yarmulke and providing uninterrupted time for prayer are vital interventions for maintaining the client's psychosocial integrity and spiritual well-being during the stress of hospitalization.

Adım Adım Çözüm

1
Identify the client's specific cultural and spiritual needs.
The client observes Orthodox Jewish practices, which commonly include wearing a yarmulke, adhering to a Kosher diet (no mixing of meat/dairy, specific food preparation), and daily prayer.
Understanding the core tenets of the client's faith guides individualized nursing interventions.
2
Evaluate the procedural and communication options against nursing standards.
Explaining surgical risks exceeds the practical nurse's scope of practice, and offering guarantees of safety constitutes non-therapeutic false reassurance.
Culturally competent care must still align with legal scopes of practice and therapeutic communication principles.
3
Evaluate the dietary and supportive options for cultural appropriateness.
Using disposable utensils prevents cross-contamination in non-Kosher kitchens, and allowing the yarmulke and prayer time supports spiritual health. Serving meat and dairy together is a violation of Kosher laws.
Nurses must actively prevent dietary violations and advocate for the patient's spiritual routines during hospitalization.

Anahtar Kavram

Culturally Competent Care: Orthodox Judaism
Soru 320Soru →

A client on an oncology unit has just been informed by the provider that their cancer is no longer responding to treatment. The client's partner begins pacing the public hallway, breathing rapidly, and loudly stating, "This cannot be happening!" In which order should the licensed practical nurse (LPN) prioritize the following actions? (Arrange the actions from first to last.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first secure privacy (escort to a private area), second establish therapeutic presence (sit silently), third provide verbal validation (acknowledge the news is overwhelming), fourth mobilize resources (inquire about a support person), and finally perform administrative duties (document).
In psychosocial crises, the nursing process dictates prioritizing immediate safety and milieu management first (privacy), followed by nonverbal therapeutic techniques (presence), then verbal therapeutic techniques (validation), followed by mobilizing coping resources (support persons), and ending with administrative requirements (documentation).

Adım Adım Çözüm

1
Ensure privacy and dignity by moving the partner out of the hallway.
The partner is in a safe, controlled environment away from other clients.
Milieu management and client/family dignity are foundational first steps during an acute emotional crisis.
2
Provide a silent, calming presence.
The partner has time and space to process the initial shock without pressure to communicate.
Offering self is a primary therapeutic communication technique that establishes trust when an individual is too overwhelmed for conversation.
3
Use verbal therapeutic communication to acknowledge the distress.
The partner's feelings of grief and disbelief are validated.
Stating that the news is overwhelming acknowledges the reality of the loss and opens the door for further expression of feelings.
4
Offer to contact external support systems.
The partner is connected with family, friends, or spiritual care.
The nurse assists with coping by integrating the family's preferred support network once the immediate panic has subsided.
5
Document the event in the medical record.
The health care team has an accurate record of the psychosocial event.
Documentation must always follow the completion of direct, immediate client or family care.

Anahtar Kavram

Nursing Management of Acute Grief and Loss
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