Psychosocial Integrity

A 24-year-old client suffered a traumatic amputation of their right dominant hand in an industrial accident earlier today. After recovering from anesthesia, the client points to their backpack and says to the nurse, "Could you hand me my sketchbook and pencils? I need to finish a portrait for my gallery show tomorrow." Which of the following is the most therapeutic nursing response?

A client in an acute psychiatric unit becomes increasingly agitated, pacing the hallway, clenching their fists, and speaking loudly. The nurse plans to intervene using verbal de-escalation techniques. Arrange the following nursing actions in the correct progressive order from first to last.

A client is brought to a mental health triage center by a family member after experiencing a sudden, catastrophic financial loss. The client is pacing the waiting room rapidly, hyperventilating, wringing their hands, and shouting, "I can't even think! Everything is ruined! My life is completely over!" Which of the following is the priority nursing intervention?

An individual arrives at the community health clinic seeking help for alcohol dependence. To establish a safe monitoring timeline and anticipate physiological risks, which assessment question is the highest priority for the clinic nurse to ask first?

A nurse at an outpatient clinic is interacting with a client who is awaiting the results of a biopsy for a suspicious breast mass. The client is pacing the room and states, "If this is cancer, I do not know how I will tell my children. They are still in school, and they need their mother." Which of the following is the most therapeutic response by the nurse?

The nurse is observing various clients in an outpatient behavioral health clinic. Match each client behavior or statement to the specific defense mechanism it represents.

A nurse on a locked behavioral health unit is caring for an adult client. The client approaches the nurses' station with a raised voice, tightly clenched fists, and demands immediate access to a restricted personal item. When the nurse explains the unit safety policy, the client becomes abruptly escalated, begins aggressively striking the reinforced glass, and shouts threats at the staff. Which of the following initial interventions should the nurse implement? Select all that apply.

While working in a hospice unit, a nurse is caring for a client with metastatic bone cancer who is experiencing periods of severe breakthrough pain. The client's adult child approaches the nurse in the hallway, crying, and states, 'I cannot stand seeing my parent suffer like this anymore. The provider said there are only a few days left. Can't you just give an extra-large dose of morphine to make this end faster?' What is the most therapeutic response by the nurse?

A client is brought to the emergency department with severe acute alcohol intoxication. The client is lethargic and suddenly begins to vomit. Arrange the following nursing actions in the correct order of priority from first to last.

A nurse at a disaster relief shelter is caring for an individual whose neighborhood was completely destroyed by a severe tornado three days ago. Since arriving at the shelter, the individual has been intensely agitated and sobbing inconsolably. This morning, the nurse observes that the individual appears suddenly serene, hands a cherished piece of family jewelry to a shelter volunteer, and states, 'I have finally figured out how to solve all my problems permanently.' What is the priority nursing intervention at this time?

A nurse is caring for a client with severe obsessive-compulsive disorder on a behavioral health unit. The client is tearful and states, 'I spent three hours washing my hands this morning. I feel like my mind is completely broken, and I am never going to get better.' Which of the following responses by the nurse demonstrate the appropriate use of therapeutic communication? (Select all that apply.)

A community psychiatric nurse is conducting an initial assessment at the home of a client with severe obsessive-compulsive disorder (OCD). The client's spouse reports that the client must arrange all living room furniture in specific geometric patterns before sitting down, a process that takes hours and causes extreme exhaustion. As the nurse and spouse are talking, the client begins moving a heavy armchair to start the ritual. Which nursing action is most appropriate at this early stage of the therapeutic relationship?

A college student rushes into the university health clinic, visibly trembling and crying hysterically. The student shouts, "I was just abruptly evicted from my apartment and I have absolutely nowhere to go!" The nurse notes the student is hyperventilating with a respiratory rate of 34 breaths per minute. Which of the following is the priority nursing intervention?

A palliative care nurse conducts a home visit for an older adult client with end-stage heart failure. The client's adult daughter, who serves as the primary caregiver, appears tearful and profoundly fatigued. The daughter's spouse privately states to the nurse, "She refuses to leave her father's side, even to sleep or eat with our children. Our family is falling apart." When approached by the nurse, the daughter states, "Nobody else can care for him correctly. If he dies while I am resting, I will never forgive myself." Which of the following is the priority nursing action?

A home health nurse is conducting an initial evaluation for an older adult client with newly diagnosed heart failure. The client recently immigrated and speaks limited English. The client's adult children, who are fluent in English, answer all the nurse's questions and state, "We will manage all the medications, cooking, and medical decisions for our parent, as is our cultural tradition." Which action is the priority for the nurse to take?

A client is receiving cardiac monitoring on a telemetry unit three days after an intentional medication overdose. During the first two days of admission, the client was withdrawn, tearful, and refused to eat. On the morning of the third day, the nurse notes the client is fully dressed, appears highly energized, and exhibits a bright affect. The client approaches the nurse, offers a valuable piece of personal jewelry, and states, "Thank you for everything; I finally know exactly how to fix all my problems." Which behavioral intervention should the nurse implement first?

A nurse is interacting with several clients across different clinical settings and utilizes various therapeutic communication techniques to facilitate psychosocial care. Match each nursing statement with the specific therapeutic communication technique it demonstrates.

A palliative care nurse is caring for an alert and oriented client with end-stage liver disease. The client's extended family privately requests that the nurse avoid discussing the poor prognosis with the client, stating that in their culture, discussing death brings bad luck and destroys hope. Shortly after, the client asks the nurse, "Am I dying?" Which of the following are appropriate nursing actions? Select all that apply.

A nurse is caring for a Native American client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). The client is receiving continuous oxygen therapy via nasal cannula. The client's family arrives and requests to perform a traditional smudging ceremony in the client's room, which involves burning small amounts of dried sage for spiritual purification. Which of the following is the most appropriate action by the nurse?

A client presents to the primary care clinic pacing rapidly, wringing their hands, and hyperventilating. The client states, "My business partner just stole everything we had and vanished! I'm completely ruined. I can't think, I don't know how I'm going to tell my family." Which of the following initial nursing interventions are appropriate for this client? Select all that apply.