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

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.

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

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.

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

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.

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

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.

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

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.

NCLEX Practice Test

NCLEX Practice Test

Psychosocial Integrity 2