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

An idea of reference is a type of delusion in which the client believes that ordinary objects, events, or media (such as television broadcasts) are specifically directed at or have special meaning for them. The television sending 'secret messages' is the classic example.

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

Consistent boundaries and therapeutic limit-setting are essential in caring for clients with BPD. Inconsistency reinforces splitting behavior and manipulative patterns. Consistency across all staff reduces boundary violations and promotes a therapeutic environment.

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

A safety plan that includes concrete coping strategies and emergency resources (calling the crisis line or going to the ER when distressed) indicates the client has internalized a plan to protect themselves. This is the strongest indicator of safe discharge readiness.

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

Avoiding discussion of the surgery and redirecting to mundane topics (cafeteria hours) after receiving devastating news is classic avoidant denial — the client is psychologically retreating from the overwhelming reality of the diagnosis.

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

Sundowning in dementia clients is best managed with non-pharmacological interventions: providing familiar objects, maintaining consistent routines, and offering calm reassurance. These address the underlying disorientation without the risks of restraints or sedating medications.

NCLEX Practice Test

NCLEX Practice Test

Psychosocial Integrity 3