Psychosocial Integrity

The nurse is evaluating the coping mechanisms of several clients. Match each clinical scenario or behavioral observation with the correct defense mechanism it best illustrates.

A client admitted to the medical-surgical unit is pacing the hallway and speaking loudly. The client states to the nurse, "Nobody here knows what they are doing! I waited twenty minutes for someone to answer my call light!" Which of the following is the most therapeutic response by the nurse?

An occupational health nurse is called to the office of an employee who was just unexpectedly terminated after 20 years with the company. The employee initially threw a chair and screamed at the manager. When the nurse arrives 15 minutes later, the employee is sitting quietly, neatly organizing their desk, and states with a flat, calm affect, "It's fine. I have a very permanent solution to this problem waiting in my car. Tell my manager he won't have to worry about me ever again." Which of the following is the priority nursing intervention?

An occupational health nurse is responding to an incident where a factory worker witnessed a severe machinery accident involving a colleague. The witness is trembling, hyperventilating, and repeats, "I should have stopped it. This is entirely my fault. I don't deserve to be here." Which of the following interventions by the nurse are appropriate? Select all that apply.

A nurse in a community mental health clinic is assessing clients experiencing varying psychosocial stressors. Match each client's documented statement and objective behavioral cue to the specific defense mechanism being demonstrated.

An oncology nurse has just finished participating in a care conference where a client's transition to palliative care was finalized. The rest of the interdisciplinary team has left, and the client is sitting alone, crying silently. Arrange the following nursing interventions in the most appropriate sequence to support this client.

An 8-year-old child is brought to an urgent care clinic by a stepparent for a painful right arm. The nurse observes faded bruising in various stages of healing on the child's torso, and a radiograph reveals a spiral fracture of the right humerus. The stepparent states, "He is so clumsy, he fell off his skateboard yesterday." The child remains completely silent, avoids eye contact, and shrinks away when the stepparent approaches. The attending physician examines the child, splints the arm, and states to the nurse, "The mechanism of injury does not match the fracture, but we lack concrete proof of abuse. Let's discharge them to outpatient orthopedics and have the clinic social worker follow up next week to avoid making a false accusation." Which of the following is the priority nursing action?

A client on the behavioral health unit is pacing rapidly in the hallway, wringing their hands, and states, "I cannot take this anymore! Everything is falling apart." Which of the following are therapeutic nursing responses? Select all that apply.

A client with a documented intellectual developmental disorder is admitted to the medical-surgical unit with a fractured right tibia. Upon exposing the client's back to place a telemetry monitor, the nurse notes several well-demarcated, healed circular burns. The client's sibling, who is the primary caregiver, immediately steps between the nurse and the client, stating, 'Those are just old rashes from an allergy.' The client remains completely silent, avoids eye contact, and stares at the floor. Which of the following is the most appropriate initial action by the nurse?

A home health nurse is assessing an older adult client who is dependent on a family caregiver for activities of daily living. Which of the following findings should prompt the nurse to suspect elder abuse or neglect? (Select all that apply.)

An older adult client is admitted to the medical-surgical unit with end-stage heart failure and is transitioning to palliative care. While the nurse is administering morning medications, the client stares out the window and states, 'I have worked tirelessly my entire life, and now my body is just quitting on me. It feels like absolutely none of it mattered.' Which of the following responses by the nurse demonstrate appropriate therapeutic communication? (Select all that apply)

A 19-year-old client with a history of severe major depressive disorder is brought to the emergency department by a roommate. The roommate reports the client had been profoundly withdrawn for several weeks, but today appeared unusually calm, energetic, and insisted on giving the roommate a prized vintage guitar. During the private nursing assessment, the client states, "I finally figured out how to stop the pain entirely, and my little sister won't have to suffer our stepfather's touching anymore once I'm gone." Which of the following is the priority nursing action?

A 19-year-old client with a history of major depressive disorder is admitted to the medical-surgical unit after a severe acetaminophen overdose. The client is medically stable but refuses eye contact and states flatly to the nurse, "I don't know why you all worked so hard to save me. I'm just going to try again the minute I get out of here. Nothing is ever going to get better." Which of the following responses by the nurse demonstrate the effective use of therapeutic communication? Select all that apply.

A nurse is conducting an admission assessment for an 82-year-old client with moderate dementia who resides with a family member. The nurse discovers multiple unexplained bruises in various stages of healing on the client's torso and upper arms. Which of the following is the nurse's legally mandated priority action?

While preparing a middle-aged client with chronic schizophrenia for discharge from an inpatient psychiatric unit, the client's elderly parent expresses profound exhaustion. The parent tearfully reports being the sole caregiver and expresses an inability to safely manage the client's complex daily medication regimen anymore. Which action should the nurse take to address this family's support needs?

Match each example of a nurse's verbal statement to the specific therapeutic communication technique it best demonstrates.

While attending a morning community meeting, an adult client abruptly pushes their chair back, begins pacing the room, and yells profanities at the facilitator. Which initial actions should the nurse implement to de-escalate the situation and maintain safety? (Select all that apply)

A nurse is preparing to obtain a health history from a newly admitted client who speaks a language that the nurse does not understand. The client's bilingual teenage child is present in the room and offers to translate. Which of the following is the most appropriate action by the nurse?

A community health nurse is speaking with an older adult who recently transitioned to an assisted living facility. The resident sits quietly, avoids eye contact, and states, "My children put me here because they do not care about me anymore. I am just a burden." Which response by the nurse is the most therapeutic?

During morning rounds on a cardiac telemetry unit, the nurse observes a client who sustained a myocardial infarction 48 hours ago performing vigorous push-ups on the floor. When instructed to stop, the client aggressively states, "Leave me alone! My heart is perfectly fine and I am discharging myself today!" Which action by the nurse is the most therapeutic priority?