nursin
Psychosocial Integrity
The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of
sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which
action when making assignments?
1 Organize the nurse’s assignments to include clients who have been sexually abused to promote a therapeutic
. environment.
2
Create the nurse’s assignments as is normally done and request that the nurse begin outpatient counseling.
.
3 Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact
. therapeutically.
4 Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of
. sexual abuse.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the
initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is
important for the nurse to evaluate?
1. The client’s use of language.
2. The client’s insight into the depression.
3. The client’s socialization history and skills.
4. The client’s attitude toward medications.
An older adult client diagnosed with alcoholism receives chlordiazepoxide for 2 days for symptom management.
The client says to the nurse, “Get those bugs off of me! ” Which action does the nurse take?
1. Stop the chlordiazepoxide.
2. Assess the client for tachycardia and tremors.
3. Document an allergy to chlordiazepoxide in the client's health record.
Notify the health care provider that the client is experiencing
4.
delirium.
The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client
is experiencing a panic attack?
1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.
The nurse interacts with a client verbalizing a cocaine craving. The nurse acknowledges the client’s discomfort.
Which is the best activity for the nurse to suggest to the client?
, 1. Rest quietly alone in the client's room.
2. Do a crossword puzzle.
3. Say prayers for strength.
4. Walk laps around the activity area with another client.
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and
frustration. Which statement is best for the nurse to make to the parents at this time?
1. "You should focus on your baby’s personality, not appearance."
2. "Let me show you pictures of some babies before and after surgery."
3. "There are other problems with this condition that go beyond surgical correction."
4. "Has anyone else in either of your families had cleft lip or palate?"
The nurse receives hand-off communication from the unlicensed assistive personnel (UAP), who has been providing
care to clients in the home. Which situation requires intervention by the nurse?
1. A Mexican American female client who prefers not to bathe during menstruation.
2. A Hindu family places a terminally ill client on the floor after the bed bath.
3. An African American female client whose hair is shampooed every day.
4. A Pakistani male client on bedrest kneels on the floor several times during the day.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, "Became
angry and physically abusive." Which action does the nurse take first?
1. Encourage the client to verbalize feelings.
2. Assess the client for physical trauma.
3. Provide a list of shelters appropriate for the situation.
4. Assist the client to identify a support system.
The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which
observation does the nurse record before beginning a behavior modification plan for the aggressive impulses?
1. The client tells each nurse that she is his favorite nurse.
2. The client is flirtatious with female members of the staff.
3. The client threatened to hit two other clients within 2 hours.
4. The client appears insincere and superficial in his interactions.
,The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks
the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take
first?
1. Ride the elevator with the client.
2. Encourage the client to get into the elevator.
3. Allow the client to avoid the elevator.
4. Encourage the client to discuss the fear.
The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for
the nurse to take which action?
1. Give the client a brief orientation to the unit.
2. Explain the activities available to the client.
3. Introduce the client to the nursing staff.
4. Ask the client to choose activities in which to participate.
The nurse provides information about acute grief reaction to volunteers of a mobile disaster unit. Which statement
made by a volunteer indicates to the nurse the need to provide further teaching?
1. "We can expect people to react in different ways based on their cultural background."
2. "If we come upon a lone survivor, we should stay with the person until help arrives."
3. "We can expect that someone might accuse us of causing the death."
4. "We should not allow a survivor to assist us in our duties."
The community health nurse, working with social services, reviews data on four families. Which client does the
nurse evaluate first?
1. A preschool age client, underweight for height, whose parent screams profanities at the child.
2. A young school age client who is alone watching TV all day while parents run a busy company.
3. A school age client with poor hygiene and small-fitting clothes who has been caught stealing bicycles.
4. A school age client, small for age, whose parents are unemployed and are strict vegans.
The nurse provides care for a client with a fear of flying. The client is taking a job that will require frequent long-
distance travel. Which intervention is best for the nurse to recommend to the client?
Asking the health care provider for a prescription for
1.
lorazepam.
2. Suggesting insight-oriented therapy.
3. Calling the crisis hotline prior to a flight.
4. Using systematic desensitization.
The hospice home care nurse assists a terminally ill client with personal care. The client says to the nurse, “Why do
you bother with me?” Which response by the nurse is most appropriate?
, 1. “Would you like to be alone?”
2. “I care about you and how you are doing.”
3. “I understand how you feel.”
4. “This is a difficult time, isn’t it?”
The nurse cares for a Japanese American client. The nurse discusses preoperative procedures with the client. The
client continually smiles and nods while the nurse is talking. How does the nurse interpret this behavior?
1. It reflects the cultural value of interpersonal harmony.
2. It indicates acceptance of the treatment plan.
3. It indicates agreement with what the nurse is saying.
It reflects the client’s understanThe home care nurse visits an older adult client living with an adult child.
Which observations, if made by the nurse, may indicate elder abuse?
1. Poor nutritional status and hygiene.
4.
2. Difficulty with short-term memory.
3. Dirty laundry found in the client’s room.
4. Client is recovering from a fractured hip.
ding of the procedure.
The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining
what precipitates the client's eating disorder?
1. Observe the family communication patterns at a monitored mealtime.
2. Distract the client at mealtimes.
3. Assign the client a food/feelings/thoughts action journal.
4. Ask the client to write a history of eating behaviors.
The nurse on the psychiatric inpatient unit is notified in report of four admissions expected on that shift. There is
only one private room available. Which client will the nurse admit to the private room?
1
A client diagnosed with chronic undifferentiated schizophrenia.
.
2
A client diagnosed with bipolar disorder in the manic phase.
.
3
A client diagnosed with obsessive-compulsive disorder.
.
4
A client diagnosed with major depression and suicidal ideation.
.
The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene,
and command hallucinations." Which action is most important for the nurse to take when caring for this client?
Psychosocial Integrity
The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of
sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which
action when making assignments?
1 Organize the nurse’s assignments to include clients who have been sexually abused to promote a therapeutic
. environment.
2
Create the nurse’s assignments as is normally done and request that the nurse begin outpatient counseling.
.
3 Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact
. therapeutically.
4 Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of
. sexual abuse.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the
initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is
important for the nurse to evaluate?
1. The client’s use of language.
2. The client’s insight into the depression.
3. The client’s socialization history and skills.
4. The client’s attitude toward medications.
An older adult client diagnosed with alcoholism receives chlordiazepoxide for 2 days for symptom management.
The client says to the nurse, “Get those bugs off of me! ” Which action does the nurse take?
1. Stop the chlordiazepoxide.
2. Assess the client for tachycardia and tremors.
3. Document an allergy to chlordiazepoxide in the client's health record.
Notify the health care provider that the client is experiencing
4.
delirium.
The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client
is experiencing a panic attack?
1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.
The nurse interacts with a client verbalizing a cocaine craving. The nurse acknowledges the client’s discomfort.
Which is the best activity for the nurse to suggest to the client?
, 1. Rest quietly alone in the client's room.
2. Do a crossword puzzle.
3. Say prayers for strength.
4. Walk laps around the activity area with another client.
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and
frustration. Which statement is best for the nurse to make to the parents at this time?
1. "You should focus on your baby’s personality, not appearance."
2. "Let me show you pictures of some babies before and after surgery."
3. "There are other problems with this condition that go beyond surgical correction."
4. "Has anyone else in either of your families had cleft lip or palate?"
The nurse receives hand-off communication from the unlicensed assistive personnel (UAP), who has been providing
care to clients in the home. Which situation requires intervention by the nurse?
1. A Mexican American female client who prefers not to bathe during menstruation.
2. A Hindu family places a terminally ill client on the floor after the bed bath.
3. An African American female client whose hair is shampooed every day.
4. A Pakistani male client on bedrest kneels on the floor several times during the day.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, "Became
angry and physically abusive." Which action does the nurse take first?
1. Encourage the client to verbalize feelings.
2. Assess the client for physical trauma.
3. Provide a list of shelters appropriate for the situation.
4. Assist the client to identify a support system.
The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which
observation does the nurse record before beginning a behavior modification plan for the aggressive impulses?
1. The client tells each nurse that she is his favorite nurse.
2. The client is flirtatious with female members of the staff.
3. The client threatened to hit two other clients within 2 hours.
4. The client appears insincere and superficial in his interactions.
,The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks
the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take
first?
1. Ride the elevator with the client.
2. Encourage the client to get into the elevator.
3. Allow the client to avoid the elevator.
4. Encourage the client to discuss the fear.
The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for
the nurse to take which action?
1. Give the client a brief orientation to the unit.
2. Explain the activities available to the client.
3. Introduce the client to the nursing staff.
4. Ask the client to choose activities in which to participate.
The nurse provides information about acute grief reaction to volunteers of a mobile disaster unit. Which statement
made by a volunteer indicates to the nurse the need to provide further teaching?
1. "We can expect people to react in different ways based on their cultural background."
2. "If we come upon a lone survivor, we should stay with the person until help arrives."
3. "We can expect that someone might accuse us of causing the death."
4. "We should not allow a survivor to assist us in our duties."
The community health nurse, working with social services, reviews data on four families. Which client does the
nurse evaluate first?
1. A preschool age client, underweight for height, whose parent screams profanities at the child.
2. A young school age client who is alone watching TV all day while parents run a busy company.
3. A school age client with poor hygiene and small-fitting clothes who has been caught stealing bicycles.
4. A school age client, small for age, whose parents are unemployed and are strict vegans.
The nurse provides care for a client with a fear of flying. The client is taking a job that will require frequent long-
distance travel. Which intervention is best for the nurse to recommend to the client?
Asking the health care provider for a prescription for
1.
lorazepam.
2. Suggesting insight-oriented therapy.
3. Calling the crisis hotline prior to a flight.
4. Using systematic desensitization.
The hospice home care nurse assists a terminally ill client with personal care. The client says to the nurse, “Why do
you bother with me?” Which response by the nurse is most appropriate?
, 1. “Would you like to be alone?”
2. “I care about you and how you are doing.”
3. “I understand how you feel.”
4. “This is a difficult time, isn’t it?”
The nurse cares for a Japanese American client. The nurse discusses preoperative procedures with the client. The
client continually smiles and nods while the nurse is talking. How does the nurse interpret this behavior?
1. It reflects the cultural value of interpersonal harmony.
2. It indicates acceptance of the treatment plan.
3. It indicates agreement with what the nurse is saying.
It reflects the client’s understanThe home care nurse visits an older adult client living with an adult child.
Which observations, if made by the nurse, may indicate elder abuse?
1. Poor nutritional status and hygiene.
4.
2. Difficulty with short-term memory.
3. Dirty laundry found in the client’s room.
4. Client is recovering from a fractured hip.
ding of the procedure.
The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining
what precipitates the client's eating disorder?
1. Observe the family communication patterns at a monitored mealtime.
2. Distract the client at mealtimes.
3. Assign the client a food/feelings/thoughts action journal.
4. Ask the client to write a history of eating behaviors.
The nurse on the psychiatric inpatient unit is notified in report of four admissions expected on that shift. There is
only one private room available. Which client will the nurse admit to the private room?
1
A client diagnosed with chronic undifferentiated schizophrenia.
.
2
A client diagnosed with bipolar disorder in the manic phase.
.
3
A client diagnosed with obsessive-compulsive disorder.
.
4
A client diagnosed with major depression and suicidal ideation.
.
The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene,
and command hallucinations." Which action is most important for the nurse to take when caring for this client?
