Psychosocial Integrity 2 — Questions and Answers

Question 1: A nurse is caring for a client who was recently diagnosed with breast cancer. The client says, 'I can't believe this is happening to me. I feel completely overwhelmed.' Which response by the nurse is most therapeutic?

'Many women with breast cancer go on to live full, healthy lives after treatment.'
'Try not to worry. The treatment options today are very effective.'
'It sounds like you're going through a lot right now. I'm here to listen.' (Correct answer)
'Would you like me to bring in the social worker to discuss your concerns?'

Correct answer: 'It sounds like you're going through a lot right now. I'm here to listen.'

Reflecting the client's feelings and offering presence is the most therapeutic initial response. It validates the client's emotional experience without minimizing it, prematurely reassuring, or redirecting away from the feeling.

Therapeutic communication is foundational to nursing practice, particularly when clients face serious diagnoses or emotional distress. The nurse's role is first to establish a therapeutic relationship through empathic, non-judgmental listening before moving to education, problem-solving, or resource referrals. The most therapeutic response acknowledges and reflects the client's expressed feeling ('overwhelmed') while communicating the nurse's presence and willingness to listen. This validates that the client's emotional response is normal and appropriate, and creates psychological safety for the client to express more of what they're experiencing. Reasurances such as 'Many women go on to live full lives' or 'Don't worry, treatments are effective' are examples of false reassurance — they dismiss the client's immediate emotional reality, however well-intentioned, and can make the client feel unheard. False reassurance is consistently identified as a barrier to therapeutic communication. Offering the social worker is a helpful action but prematurely redirects the client before the nurse has acknowledged their feelings. A referral may be appropriate later in the interaction, but the immediate response should address the emotional content first. Other therapeutic techniques include: open-ended questions, restating, clarifying, silence (therapeutic use of silence allows the client space to process), focusing, and summarizing.

Question 2: A nurse is caring for a client with alcohol use disorder who was admitted for detoxification. On day 2 of admission, the client reports seeing insects crawling on the walls. Which nursing action is the highest priority?

Reassure the client that the insects are not real
Assess for other signs of alcohol withdrawal, including vital signs (Correct answer)
Administer the prescribed antihistamine for itching
Call security to perform a room search for substances

Correct answer: Assess for other signs of alcohol withdrawal, including vital signs

Visual hallucinations on day 2 of alcohol withdrawal are a sign of alcohol withdrawal syndrome progressing toward delirium tremens (DT). The nurse's highest priority is to assess for other symptoms of severe withdrawal (including vital signs) to determine the urgency and guide treatment.

Alcohol withdrawal syndrome (AWS) is a potentially life-threatening condition that occurs when alcohol-dependent individuals abruptly reduce or stop drinking. The timeline of symptoms is predictable and critical for nursing assessment: 6-12 hours after last drink: Minor withdrawal — anxiety, tremors, diaphoresis, tachycardia, hypertension, insomnia. 12-24 hours: Alcoholic hallucinosis — visual, auditory, or tactile hallucinations (client may be alert and oriented; insects or formication are common). 24-48 hours: Seizure risk peaks — grand mal seizures may occur. 48-72 hours: Delirium tremens (DT) — the most severe form, characterized by agitation, confusion, profound autonomic instability (hyperthermia, hypertension, tachycardia), and diaphoresis. DT carries 5-15% mortality if untreated. Visual hallucinations (seeing insects on the walls) on day 2 signal that this client is progressing through the withdrawal spectrum and is at high risk for seizures and DT. The nurse's immediate action is to perform a comprehensive assessment including vital signs and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score. Benzodiazepines (lorazepam, diazepam, chlordiazepoxide) are the first-line pharmacological treatment for AWS — dosed per CIWA-Ar score. The nurse should be prepared to escalate care rapidly.

Question 3: A nurse is caring for a client with major depressive disorder who states, 'I've been thinking that everyone would be better off without me.' Which nursing action is the highest priority?

Notify the provider of the client's statement
Document the statement in the medical record
Perform a direct suicide risk assessment (Correct answer)
Remove all sharps and potentially harmful items from the environment

Correct answer: Perform a direct suicide risk assessment

Directly asking about suicidal ideation is the priority — the nurse must assess the severity of the risk (presence of plan, means, intent, timeline) before determining and implementing appropriate safety interventions.

Statements like 'everyone would be better off without me' are passive suicidal ideation — indicating the client has thoughts about death or self-harm. The priority nursing action is to directly assess suicide risk. Contrary to common misconception, directly asking about suicide does NOT plant the idea — research consistently shows that asking about suicide actually reduces short-term risk by creating an opportunity for honest discussion. Suicide risk assessment includes asking directly: 'Are you thinking about harming yourself or ending your life?' If yes: assess for a plan (What is the plan?), means (Do you have access to those means?), intent (Do you intend to act on this plan?), and timeline (When?). This information determines the urgency of intervention. After assessing risk: notify the provider immediately with assessment findings; implement safety precautions (1:1 observation, environment of care — remove ligatures, sharps, and potentially lethal items); ensure the client does not leave unattended; document assessment findings and interventions. Removing environmental hazards is an important safety intervention but cannot be done intelligently without first knowing the level of risk. Documentation and provider notification follow assessment. The sequence is: assess → intervene based on findings → notify → document.

Question 4: A nurse is caring for a client who has just learned their spouse died. The client is crying and does not speak. Which action by the nurse is most therapeutic?

Leave the room to give the client privacy to grieve
Sit quietly beside the client without speaking (Correct answer)
Tell the client that crying is a healthy response to grief
Ask the client to describe their relationship with their spouse

Correct answer: Sit quietly beside the client without speaking

Sitting quietly with a grieving client (therapeutic use of silence and presence) communicates compassion and support without the nurse intruding on the client's grief with words. Therapeutic presence — being there without needing to speak — is highly valued in acute grief.

Grief is an intensely personal and often nonverbal experience. When a client is actively crying and unable to speak after receiving news of a spouse's death, the most therapeutic nursing response is to use the therapeutic use of silence and presence — sitting with the client, communicating through proximity, eye contact, and possibly a gentle touch on the hand (if appropriate for the client's cultural background and personal comfort). Therapeutic presence communicates: 'I am here with you. You don't have to be alone in this moment. You don't need to say anything.' This is often more comforting than any words, however well-intentioned. Leaving the room removes support at the most critical moment. While the intention is to give privacy, abandonment during acute grief can be perceived as uncaring. The client may feel alone and unsupported. Labeling the behavior ('Crying is healthy') can feel condescending or clinical to someone in acute grief. Asking questions about the relationship shifts the client from experiencing their grief to describing it, which may not be appropriate at this immediate moment. The nurse's physical presence, empathic face, and calm demeanor convey more than words at this time. When the client is ready to talk, the nurse follows the client's lead with open-ended questions and active listening.

Question 5: A nurse is caring for a client with anorexia nervosa who has been hospitalized for malnutrition. The client refuses to eat lunch, saying, 'I'm already fat enough.' Which response is most therapeutic?

'You are definitely not fat — you weigh far too little to be fat.'
'If you don't eat, we will have to start tube feedings.'
'I noticed you didn't eat lunch. Can you tell me what that was like for you?' (Correct answer)
'Let's talk about the nutritional content of your meal so you can see why it's important.'

Correct answer: 'I noticed you didn't eat lunch. Can you tell me what that was like for you?'

Exploring the client's feelings and experience without challenging the distorted body image is the most therapeutic response. Directly correcting the body image distortion ('you're not fat') is ineffective and can increase defensiveness.

Anorexia nervosa is a serious, complex eating disorder characterized by severe restriction of food intake, intense fear of gaining weight, and distorted body image (perceiving oneself as overweight despite being critically underweight). Nursing care of clients with anorexia requires specialized therapeutic communication skills. Directly contradicting the client's body image perception ('You're not fat') is counterproductive — it is perceived as dismissive, challenges the client's core self-perception, and often triggers defensiveness. The client's belief is ego-syntonic (aligned with their sense of self), making direct confrontation ineffective and potentially damaging to the therapeutic relationship. Threats ('We'll tube feed you') may be necessary in extreme medical emergencies but are not therapeutic communication — they increase power struggles and damage trust. Nutritional education is appropriate but not the priority when the client is in emotional distress about eating. Exploring the experience ('Can you tell me what that was like for you?') is an open-ended therapeutic response that acknowledges the behavior (not eating), invites the client to share their perspective, and opens dialogue without confrontation. This approach builds the therapeutic relationship and provides the nurse with insight into the client's emotional state and triggers. Treatment for anorexia is multidisciplinary: nursing (vital signs, weight restoration, medical monitoring), nutrition (meal planning, nutritional rehabilitation), psychiatry/psychology (cognitive behavioral therapy, dialectical behavior therapy), and family therapy.

Question 6: A nurse is assessing a client who has just returned from combat deployment and is experiencing frequent nightmares, hypervigilance, and avoidance of crowded places. Which condition should the nurse suspect?

Generalized anxiety disorder (GAD)
Post-traumatic stress disorder (PTSD) (Correct answer)
Acute stress disorder
Panic disorder

Correct answer: Post-traumatic stress disorder (PTSD)

The triad of nightmares (re-experiencing), hypervigilance (arousal/reactivity), and avoidance following exposure to a traumatic event (combat deployment) is the classic presentation of PTSD. Symptoms lasting >1 month after the trauma meet the PTSD criteria.

Post-traumatic stress disorder (PTSD) is a trauma- and stressor-related disorder that develops in some individuals following exposure to a traumatic event — including combat, sexual assault, serious accidents, natural disasters, or witnessing death. DSM-5 diagnostic criteria for PTSD include symptoms in four clusters, lasting more than 1 month, causing significant functional impairment: 1. Intrusion symptoms (re-experiencing): nightmares, flashbacks, intrusive memories, psychological/physiological distress when exposed to reminders. 2. Avoidance: avoiding trauma-related thoughts, memories, people, places, activities (e.g., crowded places that feel unsafe). 3. Negative alterations in cognition and mood: distorted blame, persistent negative emotions, estrangement from others, inability to experience positive emotions. 4. Alterations in arousal and reactivity: hypervigilance, exaggerated startle response, irritability, reckless behavior, sleep disturbance, concentration difficulties. This client demonstrates nightmares (intrusion), hypervigilance (arousal), and avoidance — three of the four clusters, following a known traumatic exposure (combat deployment). Acute stress disorder has identical symptom criteria but lasts 3 days to 1 month after the trauma; PTSD diagnosis requires symptoms >1 month. GAD involves generalized worry without a specific trauma link. Panic disorder involves discrete panic attacks. Appropriate nursing interventions include trauma-informed care, ensuring safety, providing psychoeducation, and referring to mental health services.

Psychosocial Integrity 2

A nurse is caring for a client who was recently diagnosed with breast cancer.
The client says, 'I can't believe this is happening to me.
I feel completely overwhelmed.' Which response by the nurse is most therapeutic?