Psychosocial Integrity 2

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?

Accepted Answer

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

Answer

'Many women with breast cancer go on to live full, healthy lives after treatment.'

Answer

'Try not to worry. The treatment options today are very effective.'

Answer

'Would you like me to bring in the social worker to discuss your concerns?'

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?

Accepted Answer

Assess for other signs of alcohol withdrawal, including vital signs

Answer

Reassure the client that the insects are not real

Answer

Administer the prescribed antihistamine for itching

Answer

Call security to perform a room search for substances

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?

Accepted Answer

Perform a direct suicide risk assessment

Answer

Notify the provider of the client's statement

Answer

Document the statement in the medical record

Answer

Remove all sharps and potentially harmful items from the environment

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?

Accepted Answer

Sit quietly beside the client without speaking

Answer

Leave the room to give the client privacy to grieve

Answer

Tell the client that crying is a healthy response to grief

Answer

Ask the client to describe their relationship with their spouse

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?

Accepted Answer

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

Answer

'You are definitely not fat — you weigh far too little to be fat.'

Answer

'If you don't eat, we will have to start tube feedings.'

Answer

'Let's talk about the nutritional content of your meal so you can see why it's important.'

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?

Accepted Answer

Post-traumatic stress disorder (PTSD)

Answer

Generalized anxiety disorder (GAD)

Answer

Acute stress disorder

Answer

Panic disorder