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

Therapeutic communication involves reflecting the client's expressed feeling and using an open-ended question to encourage further exploration. Offering false reassurance, minimizing feelings, or telling a client how they should feel are non-therapeutic responses that shut down communication.

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

Denial is the first stage of Kubler-Ross's grief model and is characterized by refusal to accept a difficult reality. It is a protective psychological response to overwhelming news. The nurse should allow the client to express feelings without reinforcing or challenging the denial.

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

The nurse should neither reinforce nor argue with a delusion. The therapeutic approach acknowledges that the experience feels real to the client and redirects to the emotional impact rather than the content of the belief. This maintains trust while avoiding reinforcement of the delusional thinking.

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

Acknowledging the client's feelings validates her experience and addresses the immediate psychosocial need. Involving the client in care decisions restores a sense of control and autonomy, which is central to coping with a new cancer diagnosis. Immediate psychiatric referral is premature.

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

Respecting client autonomy is essential in domestic violence situations. Research shows that pressuring a victim to leave before they are ready can be dangerous. The nurse's role is to provide safety information, resources, and non-judgmental support without coercing the client.

NCLEX Practice Test

NCLEX Practice Test

Psychosocial Integrity