Examkin

Psychosocial Integrity

368 soru

Tüm türler368Çoktan seçmeli190Çoklu seçim86Eşleştirme19Sıralama73
Soru 81Soru →

A 35-year-old client is admitted to the trauma unit following a motor vehicle collision. The electronic health record notes a history of daily, heavy consumption of both opioids and alcohol, though the client's family reports the client has not used any substances for the past 36 hours. The client suddenly becomes intensely restless, exhibits coarse bilateral hand tremors, profuse diaphoresis, and attempts to pull out their peripheral intravenous (IV) line, shouting, "You are pumping poison into my veins!" Current vital signs are a heart rate of 128 bpm, blood pressure of 172/98 mmHg, and respiratory rate of 22 breaths/min. The registered nurse (RN) is coordinating care with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which action should the RN take FIRST?

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Cevap: Initiate seizure precautions, remain at the bedside in a low-stimulation environment, and direct the LPN to urgently notify the healthcare provider of the client's status.

Cevap

The RN should initiate seizure precautions, remain at the bedside in a low-stimulation environment, and direct the LPN to urgently notify the healthcare provider of the client's status.
The correct action directly addresses the highest priority need: patient safety during a life-threatening alcohol withdrawal crisis. By initiating seizure precautions and staying with the client, the RN prevents injury. Delegating the provider notification to the LPN is an excellent use of team resources, ensuring the client is not left alone while rapidly securing the necessary medical orders (such as benzodiazepines).

Adım Adım Çözüm

1
Analyze the client's history, timeline of substance cessation, and current clinical manifestations.
Identifies that 36 hours post-cessation with coarse tremors, extreme autonomic hyperactivity (HR 128, BP 172/98), and hallucinations strongly indicate severe alcohol withdrawal, not opioid withdrawal.
Accurate differentiation between withdrawal syndromes is required to anticipate the correct medical and nursing interventions.
2
Determine the physiological risk and prioritize the nursing framework.
Recognizes the onset of impending Delirium Tremens (DTs), which carries a high risk of fatal seizures and cardiovascular collapse, placing physiological safety as the absolute priority.
Safety protocols must be established immediately to prevent injury before or while waiting for pharmacological treatment.
3
Select the safest, most effective initial nursing action incorporating proper delegation.
Chooses to initiate seizure precautions and maintain a safe RN presence, while delegating the critical task of provider notification to the LPN.
The RN must not leave an unstable, hallucinating client unattended. The LPN is operating within their scope of practice by communicating urgent assessment findings to the provider on the RN's behalf.

Anahtar Kavram

Nursing management of severe alcohol withdrawal requires immediate recognition of autonomic hyperactivity and delirium, prioritization of seizure precautions and continuous observation, and rapid communication with the provider for pharmacological intervention.
Soru 82Soru →

The nurse is developing a discharge plan for a 7-year-old client with newly diagnosed end-stage renal disease who will require home peritoneal dialysis. The client's parents are divorced, share joint legal and medical custody, and have a known history of severe interpersonal conflict. Which of the following nursing actions are appropriate to establish an effective support system for this client and family? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Coordinate separate but identical dialysis training sessions for each parent.; Request a social work consult to help establish a structured communication plan between the parents.; Provide both parents with information about local and virtual support groups for families of children with chronic kidney disease.

Cevap

The correct actions are to coordinate separate identical dialysis training sessions for each parent, request a social work consult to establish a structured communication plan, and provide information about chronic kidney disease support groups to both parents.
Establishing an effective support system in a high-conflict, joint-custody family requires the nurse to facilitate the involvement of both parents without forcing them into hostile interactions. Coordinating separate training sessions ensures both parents learn vital medical skills in a stress-free environment. Consulting a social worker provides the family with professional mediation to handle medical communication objectively. Providing external support group information to both parents helps build a broader community support network, reducing individual caregiver strain.

Adım Adım Çözüm

1
Analyze the client's psychosocial context and healthcare needs.
The client is a 7-year-old requiring complex home care (peritoneal dialysis). The primary caregivers (parents) share joint medical custody but have high interpersonal conflict.
Understanding the family dynamics and legal boundaries is required to identify appropriate support system interventions.
2
Evaluate interventions that foster a strong support system while safely navigating the family conflict.
Providing separate training, involving a social worker for communication strategies, and offering community support group information directly address the need for competent, supported caregivers across both households.
These actions empower both caregivers, respect legal custody arrangements, and mitigate the negative impact of parental conflict on the child's care.
3
Identify and eliminate inappropriate or non-therapeutic interventions.
Exclude options that violate developmental expectations (asking the 7-year-old to choose a residence), breach legal/ethical boundaries (isolating one parent from the healthcare team), or violate delegation rules (assigning initial psychosocial assessments to a UAP).
Nursing actions must adhere to developmental science, legal standards of custody, and scope of practice.

Anahtar Kavram

Navigating complex family dynamics to optimize the client's support system while maintaining legal, developmental, and professional boundaries.
Soru 83Soru →

A home health nurse is visiting a 68-year-old client whose spouse died unexpectedly 6 weeks ago. The client was recently diagnosed with complicated grief and major depressive disorder, and was started on fluoxetine 3 weeks ago. Previously, the client exhibited profound psychomotor retardation, severe insomnia, and an inability to complete activities of daily living. Today, the client is fully dressed, appears noticeably energetic and calm, and states, 'I finally see things clearly now. I gave my prized vintage car to my nephew this morning because I won't be needing it anymore.' Which action is the nurse's priority?

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Cevap: Directly inquire if the client is experiencing thoughts of self-harm or has a specific suicide plan.

Cevap

The nurse must directly inquire if the client is experiencing thoughts of self-harm or has a specific suicide plan.
The client's presentation of sudden calmness and increased energy, combined with giving away prized possessions and making finalizing statements ('won't be needing it anymore'), are critical warning signs of an impending suicide attempt. This is especially concerning approximately three weeks after initiating an SSRI, as the medication provides the physical energy to carry out a suicide plan before the severe psychological despair fully resolves. The immediate priority is a direct assessment of suicidal ideation and intent to ensure client safety.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and timeline of symptoms.
The client is 6 weeks post-loss, 3 weeks into SSRI therapy for complicated grief, and exhibiting sudden mood improvement with increased energy.
Differentiating between normal progression through the stages of grief and pathological changes requires assessing the timeline of interventions and behaviors.
2
Evaluate the clinical significance of the client's specific actions and statements.
Giving away a prized possession and stating 'I won't be needing it anymore' alongside sudden calmness are classic behavioral cues for an organized suicide plan.
In clients with severe depression, the energy gained from 2 to 3 weeks of SSRI therapy is often used to carry out a suicide plan before the cognitive symptoms of depression fully lift.
3
Apply prioritization principles to determine the immediate nursing focus.
The immediate threat to life (suicide risk) supersedes all other psychosocial interventions, documentation, or routine referrals.
According to basic safety principles, preserving the client's life is the absolute highest priority in any psychiatric or community health setting.
4
Select the most appropriate, direct intervention to address the primary concern.
The nurse must directly and unambiguously ask the client about suicidal ideation and intent.
Direct questioning is the only definitive way to assess immediate risk; indirect approaches or assumptions delay life-saving interventions.

Anahtar Kavram

Identifying Suicide Risk in Complicated Grief
Soru 84Soru →

A pediatric oncology nurse is caring for a 7-year-old client who is transitioning to the actively dying phase. The client's parents and 4-year-old sibling are present at the bedside. Which of the following nursing actions are most appropriate to support the family through the anticipatory grief process? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Use clear, concrete terms to explain to the 4-year-old sibling that the client's body will stop working.; Encourage the parents to participate in physical care activities, such as providing oral care, if they express interest.; Offer periods of therapeutic silence while remaining physically present in the client's room.

Cevap

The appropriate nursing actions include using clear and concrete terms to explain death to the preschool-aged sibling, encouraging the parents to participate in physical care activities, and offering periods of therapeutic silence while remaining present in the room.
Using clear, concrete terms to explain death is essential for a 4-year-old due to their literal cognitive development stage. Encouraging parental participation in physical care empowers the parents, helps maintain their parental identity, and facilitates the anticipatory grieving process. Furthermore, providing therapeutic silence and physical presence demonstrates profound empathy and support without risking the use of minimizing verbal statements.

Adım Adım Çözüm

1
Analyze the developmental stage of the 4-year-old sibling.
The sibling is in the preschool stage, characterized by literal and magical thinking.
To determine the most appropriate and safe way to communicate about death without causing unintended phobias.
2
Evaluate the proposed communication statements for therapeutic value.
Clichés and equating death to sleep are non-therapeutic and potentially harmful to the grieving process.
Therapeutic communication should validate the client's unique feelings and provide accurate, developmentally appropriate information.
3
Determine appropriate supportive interventions for parents experiencing anticipatory grief.
Encouraging participation in basic care and providing a silent, supportive presence are highly effective.
These actions empower the parents, validate their emotional experience, and prevent feelings of helplessness.
4
Assess the scope of practice for delegation regarding family psychosocial needs.
Initial psychosocial, cultural, and spiritual assessments must be conducted by the RN.
Assessments require nursing judgment and are strictly outside the scope of practice for a UAP.

Anahtar Kavram

Therapeutic Management of Anticipatory Grief and Pediatric Developmental Considerations
Soru 85Soru →

A nurse is caring for a client whose spouse died unexpectedly 3 days ago. The client is pacing the room, crying, and states, 'I do not know how I am going to survive without him. Everything is ruined, and it is my fault for not making him go to the hospital sooner.' Which of the following is the most therapeutic response by the nurse?

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Cevap: You are feeling completely overwhelmed and carrying a heavy burden of blame right now.

Cevap

The response that reflects and validates the client's feelings of being overwhelmed and carrying a burden of blame.
The correct response utilizes the therapeutic techniques of reflection and empathy. By restating the client's feelings of being overwhelmed and taking on blame, the nurse validates the client's emotional experience. This supportive approach does not judge the client or attempt to prematurely 'fix' an unfixable situation, thereby encouraging the client to continue expressing their feelings safely.

Adım Adım Çözüm

1
Analyze the client's behavior and statement.
The client is in the acute stage of grief, expressing profound helplessness, anxiety (manifested by pacing), and unwarranted guilt over the unexpected loss.
Identifying the client's current emotional state is necessary to select an appropriate therapeutic communication technique.
2
Evaluate the nursing responses based on therapeutic communication principles.
The correct response uses reflection and empathy to validate the client's feelings. The other responses use non-therapeutic blocks such as false reassurance, asking 'why' questions, and relying on clichés.
Therapeutic communication should focus on the client's feelings and encourage emotional expression without judging, minimizing, or prematurely attempting to 'fix' the grief.

Anahtar Kavram

Therapeutic Communication in Acute Grief
Soru 86Soru →

A nurse is preparing to discharge an older adult client who recently had a stroke. The client's spouse, who will be the primary caregiver, states, 'I am terrified. I do not know how I will be able to provide care 24 hours a day by myself.' Which response by the nurse best identifies and utilizes an appropriate support system?

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Cevap: Let's consult with the social worker to explore home health services and respite care options.

Cevap

Consulting with the social worker to explore home health services and respite care options.
The spouse is expressing high risk for caregiver role strain and a lack of support. Providing interdisciplinary referrals to a social worker for home health and respite care directly addresses the need for a practical support system, helping to prevent caregiver burnout and ensuring safe continuous care for the client.

Adım Adım Çözüm

1
Identify the primary concern expressed by the client's spouse.
The spouse is expressing fear and overwhelming burden regarding providing 24-hour care alone.
Understanding the core issue is necessary to determine the appropriate nursing intervention.
2
Recognize the need for an external support system.
The situation requires professional resources and community assistance, not just emotional encouragement or task training.
Providing 24-hour care alone leads to high risk for caregiver role strain and unsafe client conditions.
3
Select the intervention that connects the caregiver to appropriate resources.
Collaborating with a social worker for home health and respite care is the correct action.
Social workers specialize in coordinating community support systems, discharge planning, and respite care services.

Anahtar Kavram

Caregiver Support Systems and Interdisciplinary Referrals
Tahmini Süre:45s
Soru 87Soru →

During the evening shift, a client admitted for osteomyelitis returns from an unescorted pass off the unit. The nurse immediately notes that the client is exhibiting severe psychomotor agitation, profound diaphoresis, and pupillary dilation. The client is rapidly pacing the hallway and shouting about hidden cameras. Current vital signs include a heart rate of 128 beats per minute and a blood pressure of 188/110 mm Hg. Based on these manifestations of suspected acute stimulant intoxication, which nursing actions should be prioritized? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Establish continuous electrocardiographic (ECG) monitoring.; Administer a prescribed short-acting benzodiazepine for severe agitation.; Maintain a calm, low-stimulus environment by dimming the lights and speaking softly.

Cevap

The nurse should establish continuous electrocardiographic (ECG) monitoring, administer a prescribed short-acting benzodiazepine, and maintain a calm, low-stimulus environment.
The correct responses directly address the severe physiological and psychological threats of acute stimulant intoxication. Because stimulants cause massive sympathetic activation, continuous ECG monitoring is crucial to detect arrhythmias or ischemia. Benzodiazepines are the drug of choice to reduce central nervous system irritability, thereby preventing seizures, lowering heart rate, and reducing blood pressure. Concurrently, modifying the environment by reducing stimuli is a fundamental non-pharmacological strategy to de-escalate paranoia and severe agitation.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client displays severe psychomotor agitation, paranoia, extreme hypertension (188/110 mm Hg), tachycardia (128 bpm), diaphoresis, and mydriasis.
Recognizing this cluster of symptoms is necessary to identify acute severe stimulant (e.g., cocaine, methamphetamine) intoxication.
2
Determine the highest priority physiological and psychological risks associated with the suspected condition.
The primary risks are cardiac ischemia, fatal arrhythmias, seizures, and violent behavior secondary to paranoia.
Nursing care must prioritize immediate life-saving interventions (ABCs) and environmental safety over routine unit protocols.
3
Select the appropriate nursing interventions that mitigate these identified risks.
ECG monitoring addresses the cardiac risk; benzodiazepines suppress the hyperactive central nervous system to prevent seizures and lower blood pressure; and a low-stimulus environment manages the paranoia and agitation.
These actions represent the evidence-based standard of care for sympathomimetic toxidromes.
4
Eliminate contraindicated actions.
Do not delegate assessments of an unstable client, do not apply physical restraints before attempting less restrictive measures, and avoid non-therapeutic communication blocks.
These incorrect actions compromise client safety, violate legal/ethical guidelines, and worsen the clinical presentation.

Anahtar Kavram

Prioritization in Acute Stimulant Intoxication
Soru 88Soru →

A nurse is providing support to the parents of a 4-year-old child whose grandfather recently passed away. The parents ask for guidance on how to discuss the loss with their child. Which of the following statements by the nurse is the most appropriate?

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Cevap: Explain the loss using simple, direct words, keeping in mind that children this age often view death as temporary.

Cevap

The nurse should advise the parents to explain the loss using simple, direct words, keeping in mind that the child may view death as a temporary state.
For a 4-year-old child (preschool age), death is often perceived as a temporary and reversible event due to their cognitive stage, which is characterized by magical thinking. The nurse should encourage parents to use simple, direct, and honest language. Acknowledging that the child may expect the deceased person to return is crucial for providing appropriate ongoing emotional support without overcomplicating the explanation.

Adım Adım Çözüm

1
Analyze the developmental stage of the 4-year-old child.
A 4-year-old is in the preschool stage of development.
A child's developmental stage determines their cognitive understanding of complex concepts like finality and death.
2
Evaluate how preschool-aged children typically perceive death.
Preschoolers engage in magical thinking and generally view death as a temporary, reversible condition, similar to going on a trip or sleeping.
Understanding this cognitive limitation guides the appropriate level and type of communication required.
3
Select the nursing response that best aligns with this developmental understanding.
The nurse should advise parents to use simple, direct, and honest terms, while anticipating that the child will not fully grasp the permanence of the loss.
This provides supportive communication tailored to the child's cognitive abilities without causing unnecessary confusion or fear.

Anahtar Kavram

Developmental understanding of grief and loss in preschool-aged children
Soru 89Soru →

A hospice nurse is evaluating the home support system for a client with terminal cancer. The client is alert, oriented, and has explicitly stated a wish to remain at home. The client's spouse is the primary caregiver but suffers from severe rheumatoid arthritis, which causes difficulty opening medication bottles and drawing up oral syringes. The couple's estranged adult child recently moved in to assist, but the spouse refuses to let the child administer liquid morphine, stating, 'I do not trust them with narcotics, so I struggle to do it myself.' The adult child privately reports to the nurse that the spouse often delays the client's scheduled doses by over an hour because of severe hand pain. Which action by the nurse is the priority?

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Cevap: Observe the spouse's physical ability to prepare the medications and facilitate a family meeting to establish safe, agreeable caregiving roles.

Cevap

The correct action is to observe the spouse's physical ability to prepare the medications and facilitate a family meeting to establish safe, agreeable caregiving roles.
The priority intervention when a support system is fractured by mistrust and physical limitations is to objectively assess the barrier and facilitate open communication. By observing the spouse's actual ability to manage the medication, the nurse gathers objective data. Facilitating a family meeting brings the conflict into a therapeutic space where the nurse can mediate, help the family establish boundaries, and integrate the adult child into the support system in a way that the spouse finds acceptable, all while honoring the client's wish to remain at home.

Adım Adım Çözüm

1
Analyze the clinical situation and the client's wishes.
The client is alert and wishes to stay home. Pain management is being delayed due to the primary caregiver's physical limitations.
Establishing the baseline of client autonomy and identifying the physical barrier to care.
2
Identify the root cause of the barrier within the support system.
The delay is caused by a family conflict (mistrust) that prevents the primary caregiver from utilizing the available secondary support (the adult child).
Understanding whether the issue is a lack of resources or an inability to use existing resources due to psychosocial dynamics.
3
Evaluate the proposed interventions against therapeutic communication and the nursing process.
Going behind the spouse's back, calling state authorities, or transferring the client all bypass the necessary steps of assessment and mediation.
Nursing interventions must be the least restrictive, promote trust, and follow the assessment-first rule.
4
Select the intervention that addresses both the physical and psychosocial needs.
Directly assessing the spouse's physical ability while providing a structured, mediated environment (family meeting) to safely integrate the adult child into the care plan.
This optimizes the existing support system, respects client autonomy, and resolves the conflict therapeutically.

Anahtar Kavram

Family Dynamics and Support System Optimization in Hospice Care
Soru 90Soru →

Match each client scenario or statement to the correct defense mechanism it demonstrates.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

A client with intense feelings of aggression channels their energy into becoming a successful professional boxer.
A client who deeply resents their aging parent expresses exaggerated feelings of devotion and becomes overly protective of them.
A 7-year-old child hospitalized for surgery begins sucking their thumb and experiencing enuresis (bedwetting).
A client fired for chronic tardiness tells a friend, 'I didn't want that job anyway because the commute was terrible.'

Eşleşmeler

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Cevap

The aggressive client boxing demonstrates Sublimation. The resentful client acting overly protective demonstrates Reaction formation. The 7-year-old sucking their thumb demonstrates Regression. The fired client blaming the commute demonstrates Rationalization.
Each defense mechanism has a distinct clinical presentation. Sublimation turns negative energy into positive actions. Reaction formation turns unacceptable feelings into their exact opposite expressions. Regression involves falling back to childhood coping behaviors under severe stress. Rationalization creates self-serving, logical-sounding excuses to protect the ego from harsh realities.

Adım Adım Çözüm

1
Analyze the scenario of the client who channels aggression into boxing.
Identify that an unacceptable instinctual drive is being converted into a socially acceptable action.
This is the classic clinical definition of sublimation, which is an adaptive coping mechanism.
2
Analyze the scenario of the client with the aging parent.
Identify that the client's outward behavior (extreme devotion) is the exact opposite of their internal feeling (deep resentment).
Displaying the opposite behavior to conceal true, unacceptable feelings is the definition of reaction formation.
3
Analyze the scenario of the hospitalized 7-year-old child.
Recognize that thumb-sucking and enuresis are behaviors typical of a younger developmental stage.
Returning to earlier developmental behaviors during times of severe physiological or psychological stress is known as regression.
4
Analyze the scenario of the fired client.
Notice the client is making a socially acceptable excuse (terrible commute) to cover up the real reason for their failure (chronic tardiness).
Using logical-sounding excuses to justify a bruised ego or unacceptable outcome is the mechanism of rationalization.

Anahtar Kavram

Defense Mechanisms
Tahmini Süre:1m 0s
Soru 91Soru →

A home health nurse is visiting a client with early-onset Alzheimer's disease who is being cared for at home by their spouse. The spouse appears fatigued, tearful, and states, "I feel completely isolated. My friends have stopped visiting, and I have to do everything myself. I do not know how much longer I can handle this alone." Which of the following is the priority nursing intervention?

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Cevap: Collaborate with the spouse to identify available community resources and facilitate a referral for respite care.

Cevap

The priority intervention is to collaborate with the spouse to identify community resources and facilitate a referral for respite care.
The caregiver is expressing severe role strain, fatigue, and isolation, which threatens the stability of the client's home care environment. The priority intervention is to support the caregiver by identifying and initiating referrals to community resources, such as respite care. This directly strengthens the family's support system and provides the caregiver with much-needed temporary relief.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary issue.
The primary issue is acute caregiver role strain and a collapsed support system, rather than an immediate physical change in the client.
Identifying the root cause of the immediate crisis dictates the priority nursing action.
2
Evaluate the proposed interventions against the immediate need.
The caregiver requires immediate psychosocial support and tangible assistance to prevent burnout and ensure the client's continued safety at home.
Nursing care must encompass the family unit, especially when the primary caregiver is exhibiting signs of exhaustion and inability to cope.
3
Select the most therapeutic and effective action.
Connecting the spouse with respite care and community resources directly addresses the lack of support.
Respite care provides temporary relief for caregivers, which is essential for maintaining the long-term support system of the client.

Anahtar Kavram

Caregiver Support Systems and Role Strain
Soru 92Soru →

A 28-year-old client is admitted to the oncology unit after receiving a new diagnosis of acute leukemia. The client sits quietly, staring out the window, and states, "Everything happens for a reason. I'm sure this is just a minor infection, and I'll be home by the weekend." The nurse observes that the client's lunch tray is untouched. Which nursing intervention is the most appropriate priority action based on the client's current coping mechanism?

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Cevap: Sit quietly at eye level with the client and state, "It can be very overwhelming to be admitted to the hospital."

Cevap

The most appropriate priority action is to sit quietly at eye level with the client and acknowledge that being admitted to the hospital can be very overwhelming.
The correct response utilizes the therapeutic techniques of 'offering self' (sitting with the client) and 'reflecting feelings' (acknowledging the situation is overwhelming). Denial is a common and often necessary initial coping mechanism following a traumatic diagnosis because it protects the ego from sudden, overwhelming anxiety. The nurse should support the client and open lines of communication without aggressively challenging the denial, which could increase anxiety and break trust.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and verbal statements.
The client attributes a leukemia diagnosis to a 'minor infection' and expects to go home immediately. This indicates the use of denial as an initial coping mechanism.
Identifying the active defense mechanism is necessary to determine the appropriate therapeutic nursing response.
2
Evaluate the nursing interventions against therapeutic communication and safety standards.
Asking 'why', giving false reassurance, or delegating the psychological assessment are contraindicated actions.
Non-therapeutic techniques block communication, and evaluating coping requires the RN's clinical judgment.
3
Select the priority action that safely supports adaptive coping.
Sitting with the client and acknowledging the overwhelming nature of the situation is the best action.
This approach offers self and validates feelings, keeping communication lines open without prematurely challenging the client's protective denial.

Anahtar Kavram

Therapeutic Communication and Defense Mechanisms
Soru 93Soru →

A home health nurse is evaluating the support system of a family. A 35-year-old client with advanced multiple sclerosis is completely dependent for activities of daily living. The client's 65-year-old parent is the sole caregiver. During the visit, the parent appears disheveled, exhibits a flat affect, and states, 'I almost gave them a double dose of muscle relaxers last night because I was so exhausted I could not read the label.' The nurse assesses the client and finds them to be physically stable. Which intervention regarding the family's support system is the priority?

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Cevap: Collaborate with the interdisciplinary team to arrange immediate in-home assistance or temporary respite care.

Cevap

The correct answer is to collaborate with the interdisciplinary team to arrange immediate in-home assistance or temporary respite care.
The priority intervention is to secure immediate respite care or in-home assistance. The scenario clearly depicts severe caregiver role strain leading to unsafe conditions (a near-miss medication error due to exhaustion). According to Maslow's Hierarchy of Needs, the caregiver's physiological need for sleep must be met to ensure the physical safety of the dependent client. Providing direct support resources resolves the immediate crisis safely and therapeutically.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary problem.
The primary problem is severe caregiver role strain and exhaustion, leading to an unsafe environment and a near-miss medication error.
Identifying the root cause of the safety concern determines the appropriate intervention pathway.
2
Evaluate the options based on prioritization frameworks (Maslow's Hierarchy of Needs and Safety/Risk Reduction).
Immediate respite care addresses the caregiver's foundational physiological need for sleep and ensures the client's physical safety.
Physiological needs and immediate safety take precedence over long-term education or non-therapeutic psychosocial probing.
3
Eliminate distractors that represent inappropriate or poorly timed nursing actions.
Reporting to adult protective services is eliminated as this is an overwhelmed support system, not malicious neglect. The 'why' question is eliminated as non-therapeutic. Education is eliminated as it is not the immediate priority.
Nursing interventions must be therapeutic, supportive, and accurately differentiate between role strain and reportable abuse.

Anahtar Kavram

Caregiver Role Strain and Support Systems
Tahmini Süre:1m 30s
Soru 94Soru →

A critical care nurse is caring for a client who has just been pronounced brain dead following a severe traumatic brain injury. The client is a registered organ donor, and mechanical ventilation is being maintained. The client's 16-year-old child enters the room, becomes highly agitated, and shouts, "You are killing him! His heart is still beating and his skin is warm! Stop trying to take his organs!" Which of the following is the most appropriate initial nursing action?

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Cevap: Acknowledge the adolescent's distress and explain clearly that the mechanical ventilator is keeping the heart beating even though the brain has died.

Cevap

The most appropriate action is to acknowledge the adolescent's distress and explain clearly that the mechanical ventilator is keeping the heart beating even though the brain has died.
The adolescent is experiencing acute grief and confusion regarding the concept of brain death, which is visually contradicted by the body's warmth and a beating heart. The most appropriate initial action is to validate the emotional distress while providing clear, factual information about the finality of the brain death despite the artificial support. This addresses the immediate source of the agitation using developmentally appropriate, direct communication suitable for an adolescent.

Adım Adım Çözüm

1
Analyze the client presentation.
The 16-year-old is exhibiting anger and denial, which are expected acute grief reactions, complicated by the confusing physical presentation of a brain-dead client on life support (warm skin, beating heart).
Understanding the root cause of the agitation (misunderstanding of brain death) guides the appropriate intervention.
2
Determine the developmental needs of the adolescent.
Adolescents (Piaget's formal operations stage) have an adult understanding of the finality of death but require respectful, factual, and direct communication during a crisis.
Interventions must be tailored to the cognitive and psychosocial stage of the individual to be effective.
3
Evaluate the nursing priorities and select the best response.
The highest priority is addressing the acute psychological distress through therapeutic communication. Validating the fear while correcting the misconception about the beating heart fulfills this priority.
Therapeutic communication prioritizes reality orientation paired with empathy, avoiding platitudes or unnecessary escalation.

Anahtar Kavram

Therapeutic Communication in Acute Grief and Brain Death
Soru 95Soru →

A nurse is preparing to perform post-mortem care for a client who has just passed away. Place the following nursing actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct chronological sequence is: Verify the pronouncement of death, ascertain if an autopsy is required, remove medical tubes and lines, cleanse and position the body, and finally attach identification tags.
Post-mortem care must follow a specific sequence to ensure legal requirements are met, evidence is preserved if needed, and the body is treated with dignity. Pronouncement must happen first. Checking for autopsy requirements is critical before altering the body (such as removing tubes). Once cleared, tubes are removed, the body is cleaned, and tags are placed for proper identification.

Adım Adım Çözüm

1
Ensure death has been legally pronounced.
Legal requirements are met to begin post-mortem care.
Nurses cannot begin preparing a body or altering its state until a provider has formally documented the death.
2
Check if an autopsy or medical examiner review is required.
Determines whether the body must be preserved as-is.
If an autopsy is required, all tubes and lines must be left in place to avoid interfering with the medical examiner's findings.
3
Remove tubes, lines, and catheters.
The body is freed from medical equipment.
Prepares the body for cleaning and viewing, assuming an autopsy is not indicated.
4
Cleanse the body and position it appropriately.
The body is made presentable and positioned to prevent pooling of blood in the face.
Maintains the client's dignity and prepares the body for the family to view in a respectful manner.
5
Apply identification tags.
The body is correctly identified for transport.
Ensures accurate identification when the body is transferred to the morgue or funeral home, which is a critical safety protocol.

Anahtar Kavram

Post-Mortem Care Sequence
Tahmini Süre:1m 0s
Soru 96Soru →

A nurse is preparing to perform post-mortem care for a client who has just passed away. The client's family has temporarily stepped out of the room but wishes to return to view the body before it is transported. Arrange the following nursing actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first verify the pronouncement of death, then elevate the head of the bed, determine autopsy requirements, cleanse and prepare the body, and finally invite the family back into the room.
The priority in post-mortem care is legal verification (pronouncement), followed immediately by physiological interventions that prevent tissue damage or discoloration (elevating the head). Next, legal constraints regarding autopsies must be checked before altering the body (removing tubes). Once cleared, the nurse performs hygiene and presentation care, which ultimately prepares a therapeutic and respectful environment for the family to begin their grieving process.

Adım Adım Çözüm

1
Ensure legal confirmation of death.
Pronouncement of death is verified.
Post-mortem care cannot be initiated until the death is officially confirmed and documented.
2
Position the client's head.
The head of the bed is elevated with a pillow.
This prevents blood from pooling in the face, preserving a natural appearance for the family.
3
Check legal and medical requirements.
Autopsy status is determined.
Tubes, lines, and dressings cannot be removed if the case requires an autopsy or medical examiner review.
4
Prepare the body and the environment.
The client is cleansed, dressed in a clean gown, and placed on fresh linens.
A clean and peaceful presentation demonstrates respect for the deceased and supports the family's psychosocial needs.
5
Facilitate the grieving process.
The family is invited back for viewing.
Providing a prepared environment and privacy allows the family to begin their grieving process without unnecessary distress from medical equipment or poor body presentation.

Anahtar Kavram

Post-Mortem Care Sequence and Family Support
Soru 97Soru →

A pediatric nurse is caring for a 5-year-old client who was recently diagnosed with acute lymphoblastic leukemia. The client's single parent is visibly overwhelmed and states, 'I do not know how I will manage my full-time job, caring for my 3-year-old at home, and being here at the hospital.' Which of the following nursing interventions are appropriate to assess and strengthen the parent's support systems? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Explore the parent's existing network by asking who typically helps with childcare for the toddler.; Initiate a referral to a medical social worker to discuss family medical leave and financial assistance programs.; Provide the parent with contact information for local and online childhood cancer support groups.

Cevap

The appropriate nursing actions include exploring the parent's existing childcare network, initiating a referral to a medical social worker, and providing information about childhood cancer support groups.
Appropriate interventions for a family in crisis involve assessing their current informal support networks (family/friends for childcare), collaborating with the interdisciplinary team (medical social workers for financial and structural resources), and connecting the family with formal community resources (support groups). These actions empower the parent to make autonomous decisions while providing practical solutions to mitigate caregiver strain and role conflict.

Adım Adım Çözüm

1
Analyze the parent's statement to identify the primary concerns.
The parent is experiencing significant caregiver strain, role conflict, and emotional overwhelm related to balancing work, healthy siblings, and a hospitalized child.
Identifying the root cause of the client's distress directs the appropriate support system interventions.
2
Select interventions that empower the parent and utilize interdisciplinary resources.
Assessing current childcare help, referring to a social worker, and offering support group information are chosen.
These actions practically address the parent's identified needs for childcare, financial guidance, and psychosocial support.
3
Eliminate interventions that utilize non-therapeutic communication or inappropriate escalations.
Options involving giving personal advice, offering false reassurance, and reporting to child protective services are discarded.
Nurses must maintain professional boundaries, validate client feelings, and understand the legal criteria for abuse reporting.

Anahtar Kavram

Assessment and enhancement of family support systems and caregiver resources during a health crisis.
Tahmini Süre:1m 30s
Soru 98Soru →

A nurse is evaluating the psychosocial responses of several clients on a medical-surgical unit. Pair each documented clinical observation or client statement with the specific defense mechanism it best demonstrates.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

A client angry at the healthcare provider for a surgical delay yells at the dietary aide about the temperature of the food.
A client who feels deep resentment toward a demanding older parent speaks with exaggerated, overly sweet devotion about how much they adore caregiving.
A client struggling with unacknowledged hostility toward the treatment team files a complaint claiming that the nurses are constantly angry and aggressive.
A client who recently received a diagnosis of chronic kidney disease states, 'I will worry about my dialysis schedule after my daughter's wedding this weekend.'

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The client yelling at the aide demonstrates displacement. The client with exaggerated devotion demonstrates reaction formation. The client claiming nurses are angry demonstrates projection. The client delaying thoughts about dialysis demonstrates suppression.
Each clinical observation accurately corresponds to a distinct psychiatric defense mechanism. Displacement shifts emotion to a substitute target. Reaction formation expresses the opposite of true feelings. Projection attributes one's own feelings onto others. Suppression consciously delays processing a stressor.

Adım Adım Çözüm

1
Analyze the client yelling at the dietary aide.
Matches with Displacement.
The client redirects anger from a high-stakes target (the healthcare provider causing the delay) to a less threatening target (the dietary aide).
2
Analyze the client expressing exaggerated devotion toward a demanding parent.
Matches with Reaction formation.
The client is masking their true, unacceptable feelings of resentment by overcompensating and adopting the exact opposite attitude.
3
Analyze the client complaining that the nursing staff is angry and aggressive.
Matches with Projection.
The client avoids acknowledging their own hostility by falsely attributing those exact feelings to the nursing staff.
4
Analyze the client delaying worry about their dialysis schedule.
Matches with Suppression.
Unlike repression (which is an unconscious process), this client makes a conscious, deliberate choice to temporarily set aside a stressor to participate in a significant life event.

Anahtar Kavram

Defense and Coping Mechanisms
Soru 99Soru →

A client who is scheduled for surgery the next morning tells the nurse, "I am really terrified of being put to sleep. What if I do not wake up?" Which of the following is the most therapeutic response by the nurse?

Cevabı ve açıklamayı göster

Cevap: It sounds like you are very concerned about the anesthesia. Tell me more about what you are feeling.

Cevap

The most therapeutic response is to reflect the client's feelings and invite them to share more, such as stating, 'It sounds like you are very concerned about the anesthesia. Tell me more about what you are feeling.'
The correct answer utilizes reflection ('It sounds like you are very concerned') and an open-ended prompt ('Tell me more'). This validates the client's fear and keeps the lines of communication open, which is the primary goal of therapeutic communication.

Adım Adım Çözüm

1
Analyze the client's statement to identify the core emotion and need.
The client is expressing severe anxiety ('terrified') regarding anesthesia and the fear of death ('not wake up').
Understanding the client's affective state is necessary to choose a response that directly addresses their emotional needs.
2
Evaluate each nursing response for therapeutic communication principles.
Identify responses that validate feelings and encourage dialogue versus those that block communication (false reassurance, asking 'why', giving advice).
Therapeutic communication facilitates a trusting nurse-client relationship and allows the client to process their emotions safely.
3
Select the response that best applies therapeutic techniques.
The response that reflects the client's concern and uses an open-ended statement ('Tell me more...') is the only therapeutic option.
It acknowledges the fear without minimizing it and gives the client control over the conversation.

Anahtar Kavram

Therapeutic Communication Principles
Soru 100Soru →

While making morning rounds on the pediatric unit, the nurse encounters a frustrated parent. The parent's 8-year-old child, who was admitted yesterday for acute respiratory distress, has wet the hospital bed overnight despite being completely toilet trained for several years. The parent asks, "Why is my child acting like a baby again?" What is the most therapeutic response by the nurse?

Cevabı ve açıklamayı göster

Cevap: Children often return to earlier behaviors when hospitalized due to the stress of the illness.

Cevap

The correct response educates the parent that the child is experiencing regression, a common and temporary defense mechanism used to cope with the severe stress and anxiety of hospitalization.
The correct statement accurately identifies the child's behavior as regression, an adaptive but temporary defense mechanism where an individual reverts to an earlier developmental stage to cope with severe stress or anxiety. By explaining this to the parent factually and empathetically, the nurse provides therapeutic education and reduces parental frustration.

Adım Adım Çözüm

1
Analyze the clinical scenario and the child's behavior.
An 8-year-old child is exhibiting bedwetting (loss of a previously mastered skill) during a stressful hospitalization.
Identifying the underlying psychosocial concept helps recognize that the child is using the defense mechanism of regression to cope with acute anxiety.
2
Evaluate the nursing responses based on therapeutic communication principles.
The nurse must provide accurate educational information while validating the parent's concern, without being judgmental or dismissive.
Therapeutic communication builds trust, reduces parental anxiety, and helps the family understand normal coping mechanisms.

Anahtar Kavram

Regression as a Coping Mechanism in Pediatrics
ÖncekiSayfa 5 / 19Sonraki
Psychosocial Integrity Alıştırma Soruları — NCLEX-RN — Sayfa 5 | Examkin