Psychosocial Integrity

A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "The laboratory must have mixed up my test results with someone else's. I feel perfectly healthy and I am returning to work tomorrow." Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who had a permanent colostomy placed two days ago following emergency bowel surgery. When the nurse approaches to empty the ostomy pouch, the client turns away and states, 'I cannot even look at it. I feel like my body is completely ruined.' Which of the following is the most therapeutic response by the nurse?

A nurse is providing care for a client who experienced a pregnancy loss at 10 weeks of gestation. The client is crying and states, 'I must have done something wrong to cause this to happen.' Which of the following is the most therapeutic response by the nurse?

A nurse in a rheumatology clinic is caring for a client newly diagnosed with systemic lupus erythematosus. The client speaks harshly to the nurse, stating, "You are all incompetent and clearly have no idea how to manage my care!" The client's spouse privately shares that the client is actually terrified of the disease progression and the potential loss of independence.

Which of the following nursing interventions are most therapeutic when responding to this client's coping behavior? (Select all that apply.)

A 68-year-old client is admitted to an inpatient hospice unit with end-stage chronic obstructive pulmonary disease. The client's adult child, who lives in another country and has not visited in five years, arrives at the facility. Within minutes, the adult child begins shouting in the hallway, stating, 'You are all completely neglecting my parent! The bed linens are wrinkled, the oxygen tubing is twisted, and none of you have any idea how to provide proper care!' The nurse recognizes this behavior as a defense mechanism utilized to cope with overwhelming anticipatory grief. Which of the following is the most therapeutic nursing response?

A nurse in an outpatient clinic is preparing to provide dietary teaching to a client from a diverse cultural background. Which action should the nurse take first to ensure culturally competent care?

A nurse is managing care for a client admitted with borderline personality disorder, severe anxiety, and a recent history of superficial self-inflicted lacerations. Over the past 48 hours, the client has been highly agitated, frequently requesting PRN lorazepam, and repeatedly attempting to manipulate unit rules. Today, the client suddenly stops pacing, appears completely relaxed, and hands a favorite jacket to another client, stating, "I finally made a decision about how to solve my problems. I won't be bothering the staff anymore." Which of the following is the priority behavioral intervention for the nurse to implement?

A 65-year-old individual with a documented history of severe alcohol dependence and combat-related post-traumatic stress disorder is receiving treatment for acute pancreatitis. Exactly 48 hours after admission, the individual's behavior drastically changes. They begin pacing the corridor, sweating profusely, and displaying coarse bilateral hand tremors. The individual suddenly shouts, "The food here is laced with poison! I am leaving right now!" and aggressively steps toward the unit's exit doors.

What is the priority nursing intervention to safely manage this situation?

A young adult client undergoing a hematopoietic stem cell transplant is maintained in a windowless protective isolation room with a constantly humming high-efficiency particulate air (HEPA) filter. On the eighth day of isolation, the client retreats to the corner of the room, points at the ceiling vent, and screams, "They are pumping toxic gas in here to suffocate me! The hissing is getting louder!" Vital signs reveal a heart rate of 124 bpm and respirations of 26 breaths/minute. Which action is most appropriate for the nurse to take?

A mental health clinic nurse evaluates a client who recently experienced a traumatic home eviction. The client paces the examination room, wrings their hands, and states, "I have nowhere to go. I am a complete failure as a provider." Which of the following responses by the nurse demonstrate therapeutic communication? Select all that apply.

Upon returning to the inpatient mental health facility from a supervised community outing, a client with a history of substance use disorder walks briskly toward the dormitory area. The registered nurse notices the client keeping their right hand tightly concealed inside their jacket pocket. When approached, the client avoids eye contact, turns away, and says, "Leave me alone, I'm just exhausted." Which action should the nurse take to best maintain the safety of the therapeutic environment?

A nurse is caring for a postpartum client who is tearful in her room. The client states, "I am a terrible mother. I cannot even produce enough milk to feed my own baby." Which of the following responses by the nurse are therapeutic? Select all that apply.

A nurse in a palliative care unit is caring for a terminally ill client who has entered the active phase of dying. The client suddenly becomes highly restless, pulls at the bed linens, and converses with deceased relatives. The client's adult child is visibly distressed and pleads with the nurse, 'Please tell my mother she is in the hospital and her parents are not here.' Which is the priority nursing action?

A nurse is caring for a client with post-traumatic stress disorder (PTSD) on an inpatient mental health unit. Following a loud argument between two other clients in the dayroom, the client retreats to a corner, begins hyperventilating, covers their ears, and screams, "Don't touch me! Keep away!" The client is trembling, visually scanning the room, and clenching their fists. Which initial nursing action is the priority?

A middle-aged adult with a history of schizophrenia is brought to a busy, brightly lit emergency department triage area by law enforcement. The client is pacing rapidly near the exit, covering their ears, and visibly trembling. Diaphoresis is noted, and the client is whispering, 'They are telling me the lights will burn my skin if I do not run.' Vital signs reveal a heart rate of 114 bpm and respirations of 26/min. Which action should the triage nurse take first?

A home health nurse arrives at the residence of a client with paraplegia for a scheduled wound care visit. The client's spouse is pacing erratically and shouts, 'I cannot take care of this anymore!' The nurse notices three circular, crusted lesions resembling cigarette burns on the client's forearms. The client avoids eye contact and appears fearful. The spouse insists on remaining at the bedside. In what order should the nurse perform the following actions? Arrange the actions from first priority to last.

A school nurse evaluates a 10-year-old student who frequently visits the health office with vague somatic complaints. The nurse observes that the student is wearing unseasonably warm, oversized clothing, flinches when approached, and exhibits poor personal hygiene. During the interaction, the student quietly states, "I am not allowed to eat breakfast anymore because I am bad." Which of the following actions is the most appropriate for the nurse to take?

A palliative care nurse is caring for an unresponsive client who is in the active phase of dying from metastatic lung cancer. The client exhibits Cheyne-Stokes respirations accompanied by loud, gurgling sounds during expiration. The client's spouse is visibly frantic and demands, "You need to suction his lungs immediately! He is drowning in his own fluids!" The nurse has a PRN prescription for sublingual atropine drops. Which of the following is the most appropriate initial nursing action?

A client with severe chronic obstructive pulmonary disease is informed by the pulmonologist that their condition has deteriorated and they will require continuous home oxygen therapy. After the physician leaves the room, the client tightly grips the bedrails and states in an elevated voice, 'This is completely unacceptable. There has to be a new medication I haven't tried. I refuse to drag a tank around with me everywhere I go.' Which of the following is the most therapeutic response by the nurse?

A client on a medical-surgical unit has just been informed by the healthcare provider that a lower extremity amputation is required due to severe vascular complications. The client is tachycardic, pacing the room rapidly, crying loudly, and states, "My life is over. I cannot do this." Which of the following nursing interventions are appropriate for managing the client's acute stress? Select all that apply.