Psychosocial Integrity 3

Question 1

A nurse is caring for a client with schizophrenia who says, 'The television is sending me secret messages.' Which type of thought disturbance is the client experiencing?

Accepted Answer

Idea of reference

Answer

Hallucination

Answer

Delusion of grandeur

Answer

Thought broadcasting

Question 2

A nurse is working with a client who has borderline personality disorder (BPD). Which nursing approach is most effective for managing care?

Accepted Answer

Maintaining consistent boundaries and clear therapeutic limit-setting

Answer

Adapting rules and boundaries when the client becomes upset to prevent escalation

Answer

Providing the client with maximum autonomy to avoid power struggles

Answer

Assigning a different nurse each shift to prevent unhealthy attachment

Question 3

A nurse is preparing to discharge a client who has been hospitalized following a suicide attempt. Which statement by the client most indicates readiness for safe discharge?

Accepted Answer

'I've thought about this, and if things get bad again I'll call the crisis line or go to the ER.'

Answer

'I won't try to hurt myself again as long as I stay on my medication.'

Answer

'I understand that I need to follow up with the psychiatrist next week.'

Answer

'My family is going to keep an eye on me so nothing happens.'

Question 4

A nurse is caring for a client who has just been told they need an above-knee amputation due to vascular disease. The client refuses to discuss the surgery and asks about the cafeteria hours. Which stage of the Kübler-Ross model does this behavior represent?

Accepted Answer

Denial

Answer

Anger

Answer

Bargaining

Answer

Acceptance

Question 5

A nurse is providing care for a client with dementia who becomes agitated during evening hours and tries to get out of bed repeatedly. Which intervention is most appropriate?

Accepted Answer

Provide familiar objects, consistent routines, and calm reassurance during evening hours

Answer

Apply soft wrist restraints to prevent the client from getting out of bed

Answer

Administer the prescribed PRN haloperidol to reduce agitation

Answer

Turn off all lights and close the door to minimize stimulation

Question 6

A nurse is using motivational interviewing techniques to help a client who smokes reduce their cigarette use. The client states, 'I know I should quit, but I enjoy smoking and it helps me deal with stress.' Which response by the nurse best demonstrates a motivational interviewing approach?

Accepted Answer

'It sounds like smoking gives you some real benefits. What concerns do you have about it?'

Answer

'Smoking is a serious health risk and you really need to quit as soon as possible.'

Answer

'Have you tried nicotine patches? They're very effective for quitting.'

Answer

'I'll schedule you for a smoking cessation class — it starts next Monday.'