Psychosocial Integrity Flashcards
6 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Psychosocial Integrity flashcards as text
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.