NCSBN - National Council of State Boards of Nursing Psychosocial Integrity Questions and Answers — Questions and Answers
Question 1: A nurse is caring for a client with schizophrenia who states, 'The aliens are sending me messages through the television and they want to take me away.' Which of the following responses by the nurse is most therapeutic?
- "That sounds very frightening. Let's turn off the TV and we can talk about how you're feeling." (Correct answer)
- "There are no aliens. You are safe here in the hospital and we are not going to let anyone take you away."
- "Why do you think the aliens are trying to send you messages through the television?"
- "I don't hear any messages from the television. Let's go play a game of cards."
Correct answer: "That sounds very frightening. Let's turn off the TV and we can talk about how you're feeling."
The most therapeutic response is to acknowledge the client's feelings and fear associated with the delusion without reinforcing or arguing about the delusion itself. This approach validates the client's experience while gently redirecting them to reality and offering support. Challenging the delusion (B) is ineffective and can damage the therapeutic relationship. Asking 'why' (C) can reinforce the delusional thought process. Dismissing the client's experience and changing the subject (D) invalidates their feelings.
Question 2: A client is admitted to the medical-surgical unit for a cholecystectomy. The client has a history of heavy alcohol use and the last drink was 24 hours ago. The nurse should prioritize monitoring for which of the following signs of alcohol withdrawal?
- Bradycardia and somnolence
- Hypotension and bradypnea
- Tachycardia, tremors, and diaphoresis (Correct answer)
- Constricted pupils and euphoria
Correct answer: Tachycardia, tremors, and diaphoresis
Signs of early to moderate alcohol withdrawal include autonomic hyperactivity such as tachycardia, tremors, anxiety, and diaphoresis (sweating). These symptoms can begin within hours of the last drink. Bradycardia, somnolence, hypotension, and bradypnea are more indicative of central nervous system depression, not withdrawal. Constricted pupils and euphoria are associated with opioid use, not alcohol withdrawal.
Question 3: A client who was recently diagnosed with type 2 diabetes mellitus states, 'There's no way I have diabetes. The lab must have made a mistake with my blood work. I feel perfectly fine.' The nurse recognizes the client is using which defense mechanism?
- Projection
- Denial (Correct answer)
- Rationalization
- Sublimation
Correct answer: Denial
Denial is the refusal to accept reality or facts to avoid dealing with the emotional impact. The client is refusing to accept the diagnosis despite evidence. Projection is attributing one's own unacceptable thoughts to another person. Rationalization is justifying behavior with logical-sounding reasons. Sublimation is channeling unacceptable impulses into socially acceptable actions.
Question 4: A nurse is caring for the family of a client who has just died. The client's spouse states, 'If only I had made him go to the doctor sooner, this wouldn't have happened. Maybe if we pray hard enough, God will give us a second chance.' This statement is characteristic of which stage of grief?
- Denial
- Anger
- Depression
- Bargaining (Correct answer)
Correct answer: Bargaining
The spouse's statements, 'If only...' and hoping for a second chance in exchange for prayer, are classic examples of bargaining. In this stage, the individual may try to make deals with a higher power to postpone the inevitable and change the reality of the loss. Denial would be an outright refusal to accept the death. Anger would involve directing frustration at others. Depression is characterized by sadness and hopelessness.
Question 5: An adult client who is a Jehovah's Witness has been in a motor vehicle accident and requires emergency surgery for internal bleeding. The client is alert and oriented and has a signed advance directive refusing all blood products. Which action should the nurse take?
- Inform the surgeon to proceed with the transfusion because it is a life-threatening emergency.
- Contact the hospital's ethics committee to get an order to override the client's refusal.
- Advocate for the client's wishes and explore bloodless alternative treatments with the healthcare team. (Correct answer)
- Explain to the client that a court order will be obtained to administer the necessary blood.
Correct answer: Advocate for the client's wishes and explore bloodless alternative treatments with the healthcare team.
A mentally competent adult has the legal and ethical right to refuse medical treatment, including life-saving blood transfusions, based on their religious beliefs. The nurse's primary role is to act as a patient advocate, respecting their autonomy and communicating their wishes to the team. The team should then explore all available bloodless alternatives, such as volume expanders or cell-saver technology. Overriding a competent adult's wishes is a violation of their rights.
Question 6: A client is admitted to the inpatient psychiatric unit with severe anxiety. The client is pacing the hallway and wringing their hands. Which initial action by the nurse is most appropriate?
- Tell the client to sit down and try to relax.
- Administer a prescribed PRN anxiolytic medication immediately.
- Acknowledge the behavior and ask about the client's feelings. (Correct answer)
- Encourage the client to participate in a quiet group activity.
Correct answer: Acknowledge the behavior and ask about the client's feelings.
The most therapeutic initial action is to acknowledge the client's nonverbal cues (pacing, wringing hands) and use an open-ended question to encourage the client to verbalize their feelings. This validates the client's experience and opens the door for communication. Telling the client to relax is dismissive. Administering medication may be necessary, but assessment should come first. Encouraging group activity may be too overwhelming for a client with severe anxiety.
NCSBN - National Council of State Boards of Nursing Psychosocial Integrity Questions and Answers
A nurse is caring for a client with schizophrenia who states, 'The aliens are sending me messages through the television and they want to take me away.' Which of the following responses by the nurse is most therapeutic?