Psychosocial Integrity

A practical nurse (PN) is caring for a client on a mental health unit who becomes increasingly agitated, begins pacing the hallway, and shouts at the nursing staff. Arrange the following behavioral interventions in order of priority, from the least restrictive to the most restrictive.

A practical nurse (PN) is caring for a client with schizophrenia in an inpatient behavioral health unit. The client, who has been quietly pacing the hallway, suddenly stops, clenches their fists, picks up a heavy wooden chair, and begins screaming that the other clients are "demons." The client's gaze is fixed on a group of clients watching television nearby. Which of the following actions should the PN take first?

During a home health visit for an older adult client diagnosed with moderate dementia, a practical nurse (PN) notes that the client's bed linens are soiled with dried urine and feces. The refrigerator contains no edible food, and the client is exhibiting signs of severe dehydration. The family caregiver, who lives in the home, tells the PN, 'I just haven't had the time to deal with any of this lately.' Which action should the PN take?

The dietary department delivers a lunch tray containing beef stew to the room of a client who practices Hinduism. What is the best immediate action for the practical nurse to take?

An older adult client with mild dementia is hospitalized for pneumonia and is observed repeatedly pulling at their peripheral intravenous (IV) catheter. The practical nurse (PN) must implement safety measures to prevent the removal of the device without using physical restraints. Place the following non-pharmacological interventions in the correct order of implementation, starting with the initial nursing action to the most restrictive alternative.

An eight-year-old client is evaluated in a community urgent care center for a twisted ankle. While preparing the client for an X-ray, the practical nurse observes several small, perfectly circular burns in various stages of healing across the client's posterior torso. The guardian states the client accidentally bumped into a hot radiator. The client exhibits a flat affect and flinches when the guardian approaches the exam table. Which action is the priority for the practical nurse?

A client diagnosed with major depressive disorder has remained in their room all morning and refused to attend the scheduled unit activity. When the practical nurse (PN) enters the room, the client is staring out the window and ignoring the breakfast tray. Which statement by the PN is most therapeutic?

A practical nurse (PN) is assigned to a client with a history of severe anxiety on a general medical unit. Upon entering the room, the PN finds the client pacing rapidly, breathing heavily, and shouting aggressively at a television news program. An unlicensed assistive personnel (UAP) is standing near the client's bed and appears frightened. In what order should the PN perform the following interventions? Arrange the actions from first to last.

During a shift on an inpatient mental health unit, a practical nurse observes a client suddenly stand up, clench their fists, and begin shouting aggressively at a peer in the dayroom. Which action should the nurse take first?

A practical nurse is providing support to the spouse of a client who recently received a terminal diagnosis and was placed on hospice care. The spouse is crying and states, 'I do not understand why he is so angry with me. I am just trying to help.' Which of the following responses by the nurse are therapeutic and appropriate? Select all that apply.

While working in a community pediatric clinic, a practical nurse observes multiple contusions in varying stages of healing on the torso and back of a 5-year-old client. The caregiver attributes the injuries to the child being uncoordinated and frequently falling. Place the following practical nursing actions in the correct priority sequence from first to last.

Family members are waiting in the surgical center lobby when one of them suddenly begins pacing rapidly, shouting profanities, and throwing magazines across the room. The practical nurse (PN) is the first staff member to arrive on the scene. Which initial actions should the PN take? (Select all that apply.)

While working in a residential step-down facility, a practical nurse observes a client who has just received a distressing telephone call from relatives. The client hurls the phone across the room, begins pacing frantically, hyperventilating, and striking a padded wall repeatedly with closed fists. Which action should the nurse prioritize?

An LPN/LVN is preparing to serve a lunch tray to a client who observes a strict kosher diet. The dietary department delivers a tray containing roast beef, gravy, green beans, and a carton of whole milk. What is the most appropriate action for the nurse to take?

A client on the inpatient mental health unit with generalized anxiety disorder is observed pacing rapidly, breathing heavily, and wringing their hands. The client tells the practical nurse (PN), 'I feel like something terrible is going to happen.' Which actions should the PN take? Select all that apply.

An older adult client is admitted to a subacute rehabilitation center following a surgical hip repair. While assisting with morning hygiene, the practical nurse (PN) observes bilateral, symmetrical bruising resembling handprints on the client's upper arms. The client's primary caregiver, who is visiting, immediately states, "Their skin is just so thin, they bruise from simply being touched." The client remains completely silent, avoids eye contact, and visibly trembles. What is the priority action for the PN?

A practical nurse (PN) is planning care for a client who is a devout Seventh-Day Adventist and is recovering from a bowel resection. The client is advancing to a regular diet and preparing for discharge. Which of the following actions should the PN include in the client's care plan? Select all that apply.

During a group meeting on a psychiatric unit, a young adult client abruptly stands up, clenches their fists, and begins yelling aggressively at another participant. What are the priority behavioral interventions the practical nurse (PN) should implement? (Select all that apply.)

A practical nurse is caring for a client who is actively dying in a long-term care facility. The client's adult child is crying and states, "A few days ago I was completely at peace with this, but today I am just so furious that this is happening!" Which response by the nurse is most appropriate?

A 32-year-old client is admitted to the rehabilitation unit following a traumatic amputation of the left arm. During morning care, the client suddenly yells at the Practical Nurse (PN), "Get out! You have no idea what it's like to be a freak! I don't want to see anyone." The client then begins to cry. Which of the following nursing actions by the PN are appropriate to support the client's coping? (Select all that apply.)