Psychosocial Integrity

Question 1

A nurse is assessing a client who was admitted following a suicide attempt.
The client says, 'I just want to be left alone — what's the point of anything?' Which nursing response is most therapeutic?

Accepted Answer

'It sounds like you are feeling hopeless right now. Can you tell me more about what you are experiencing?'

Answer

'I understand — sometimes things seem hopeless, but you have so much to live for.'

Answer

'You have family members who love you and need you to get better.'

Answer

'You should not feel that way — we are here to help you feel better.'

Question 2

A nurse is caring for a client newly diagnosed with multiple sclerosis who says, 'This cannot be right. I am perfectly fine — there must be a mistake.' The nurse recognizes this as which stage of Kubler-Ross's grief model?

Accepted Answer

Denial

Answer

Anger

Answer

Bargaining

Answer

Acceptance

Question 3

A nurse is caring for a client with schizophrenia who states, 'The government has implanted a device in my brain to monitor my thoughts.' How should the nurse respond?

Accepted Answer

'I understand that seems very real to you. Let's talk about how these thoughts are affecting you.'

Answer

'That is not possible — there is no device in your brain.'

Answer

'If you take your medication, those thoughts will go away.'

Answer

'That sounds frightening. Have you told the doctor about the government?'

Question 4

A nurse is assessing a client who was recently diagnosed with breast cancer. The client is tearful and says, 'I feel completely out of control.' The nurse's priority intervention is to:

Accepted Answer

Acknowledge the client's feelings and involve her in decision-making about her care

Answer

Explain the full treatment plan in detail to give the client a sense of direction

Answer

Reassure the client that breast cancer has excellent survival rates

Answer

Refer the client to a psychiatrist for evaluation of depression

Question 5

A nurse is working with a client who has been experiencing domestic violence. The client is not ready to leave the relationship. Which response by the nurse is most appropriate?

Accepted Answer

'I understand this is your choice. I am here to support you and provide resources when you are ready.'

Answer

'You need to leave immediately — staying puts your life at risk.'

Answer

'Have you considered that you may be contributing to the situation?'

Answer

'I will need to report this to the police on your behalf for your safety.'

Question 6

A nurse is performing a mental status examination and asks the client to interpret the proverb, 'People who live in glass houses should not throw stones.' Which cognitive domain is the nurse assessing?

Accepted Answer

Abstract reasoning and thought processes

Answer

Orientation to person, place, and time

Answer

Short-term memory and recall

Answer

Attention span and concentration