PSYCHOSOCIAL ALTERATIONS EXAM
QUESTIONS AND CORRECT ANSWERS!!
The nurse is caring for a client who has been identified as a survivor of physical abuse by a
family member. Which action is the priority as the nurse plans care for the client?
C Removing the client from any immediate danger
Rationale: Whenever the abused client remains in the abusive environment, priority must be
placed on determining whether the person is in any immediate danger and, if so, taking
emergency action to remove the client from the situation. Notifying the caseworker of the
situation, adhering to mandatory abuse reporting laws, and obtaining treatment for the abusing
family member may be appropriate interventions but are not the priority.
A heroin addict who overdoses on the drug is brought into the emergency department. The
client is having seizures, and the nurse notes that his pupils are dilated. Which of the
following interventions does the nurse anticipate that the emergency department physician
will prescribe?
C Naloxone (Narcan)
Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose
to reverse central nervous system depression.
A mental health nurse is conducting the initial assessment of an obese client. The client
confides that she was sexually molested at age 7 and began putting on weight thereafter.
,The nurse determines that the client's symptoms are compatible with a somatization
disorder and recalls that obesity for this client most likely represents:
C Protection from the risk of intimacy
Rationale: Clients who become obese after a trauma such as the one described in the question
may be trying unconsciously to present themselves as unattractive as a means of protecting
themselves from the danger of intimacy.
A client says to the nurse, "I'm worried about my husband. He's talking about ending it all
since his law practice dropped off and his son by his late first wife died of a drug overdose
— but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is
appropriate?
D "Your husband is displaying behaviors that indicate a risk for self-harm."
Rationale: Risk factors for suicide include male gender, professional status (physician, attorney,
dentist, military personnel), loss to death, financial problems, and physical illness. Other risk
indicators include a suicide plan, depressed mood, and prior attempts at suicide.
The nurse is teaching a group of new employees ways to deescalate aggressive behavior
exhibited by a client with schizophrenia. After the course employees state several actions
they would take if a client with schizophrenia became increasingly aggressive. Which
comment causes the nurse to realizes further instruction is required?
D Standing close to the client and telling the client that the behavior is unacceptable
,Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a
nonaggressive posture. The nurse should also give the client clear instructions that are brief and
assertive and negotiate options with the client. Negotiation of options allows the client to feel
that he or she has some room in making decisions. The nurse needs to maintain personal space
and should not stand closer than about 8 feet from the client, which would convey a threatening
message.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a
cure! I get so angry when they carry on like this! I'm the one who's dying." Which response
by the nurse would be most therapeutic?
D "You're feeling angry that your family continues to hope for you to be cured."
Rationale: Reflection is the therapeutic communication technique in which the client's feelings
are restated to validate what the client is saying. The correct option involves the use of reflection.
A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I
keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for
the rest of my life." Which response by the nurse is therapeutic?
You seem to be saying that your choices are final and that you've lost any other opportunities."
Rationale: The client in this question is engaging in catastrophizing rather than reframing and
viewing other alternatives. The task for the nurse is to assess the lethality of the client's situation
and to help the client feel empowered to take another course of action and find the perseverance
and confidence to do so. The therapeutic response here is the one that is nonjudgmental.
, A client with major depression says to the nurse, "I should have died. I've always been a
failure." Which response by the nurse is therapeutic?
You've been feeling like a failure for some time now?"
A client in a retirement center rings the night alarm and says to the nurse, "Look at this
old man! He keeps breaking into my apartment! You've got to get him to stay out of here so
I can sleep." Which statement by the nurse would be most therapeutic?
C "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you
for an hour or so while you try to rest."
A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial
nursing intervention for this client?
A Providing authority and action
Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational,
developmental, or societal sources of stress. A person in this state is temporarily unable to cope
with or adapt to the stressor with the use of previously successful problem-solving methods.
Someone who intervenes in this situation (the nurse) takes over for the client who is not in
control (authority) and devises a plan (action) to secure and maintain the client's safety. The
nurse then works collaboratively with the client, demonstrating confidence in the client's ability
to cope and providing reassurance that the crisis is temporary. Displaying an attitude of
detachment is inappropriate.
A client says to the nurse, "I'm really phobic about flying, so my husband and I always
drove or took the train everywhere. Now he's been offered a big job in Europe, and if I
QUESTIONS AND CORRECT ANSWERS!!
The nurse is caring for a client who has been identified as a survivor of physical abuse by a
family member. Which action is the priority as the nurse plans care for the client?
C Removing the client from any immediate danger
Rationale: Whenever the abused client remains in the abusive environment, priority must be
placed on determining whether the person is in any immediate danger and, if so, taking
emergency action to remove the client from the situation. Notifying the caseworker of the
situation, adhering to mandatory abuse reporting laws, and obtaining treatment for the abusing
family member may be appropriate interventions but are not the priority.
A heroin addict who overdoses on the drug is brought into the emergency department. The
client is having seizures, and the nurse notes that his pupils are dilated. Which of the
following interventions does the nurse anticipate that the emergency department physician
will prescribe?
C Naloxone (Narcan)
Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose
to reverse central nervous system depression.
A mental health nurse is conducting the initial assessment of an obese client. The client
confides that she was sexually molested at age 7 and began putting on weight thereafter.
,The nurse determines that the client's symptoms are compatible with a somatization
disorder and recalls that obesity for this client most likely represents:
C Protection from the risk of intimacy
Rationale: Clients who become obese after a trauma such as the one described in the question
may be trying unconsciously to present themselves as unattractive as a means of protecting
themselves from the danger of intimacy.
A client says to the nurse, "I'm worried about my husband. He's talking about ending it all
since his law practice dropped off and his son by his late first wife died of a drug overdose
— but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is
appropriate?
D "Your husband is displaying behaviors that indicate a risk for self-harm."
Rationale: Risk factors for suicide include male gender, professional status (physician, attorney,
dentist, military personnel), loss to death, financial problems, and physical illness. Other risk
indicators include a suicide plan, depressed mood, and prior attempts at suicide.
The nurse is teaching a group of new employees ways to deescalate aggressive behavior
exhibited by a client with schizophrenia. After the course employees state several actions
they would take if a client with schizophrenia became increasingly aggressive. Which
comment causes the nurse to realizes further instruction is required?
D Standing close to the client and telling the client that the behavior is unacceptable
,Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a
nonaggressive posture. The nurse should also give the client clear instructions that are brief and
assertive and negotiate options with the client. Negotiation of options allows the client to feel
that he or she has some room in making decisions. The nurse needs to maintain personal space
and should not stand closer than about 8 feet from the client, which would convey a threatening
message.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a
cure! I get so angry when they carry on like this! I'm the one who's dying." Which response
by the nurse would be most therapeutic?
D "You're feeling angry that your family continues to hope for you to be cured."
Rationale: Reflection is the therapeutic communication technique in which the client's feelings
are restated to validate what the client is saying. The correct option involves the use of reflection.
A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I
keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for
the rest of my life." Which response by the nurse is therapeutic?
You seem to be saying that your choices are final and that you've lost any other opportunities."
Rationale: The client in this question is engaging in catastrophizing rather than reframing and
viewing other alternatives. The task for the nurse is to assess the lethality of the client's situation
and to help the client feel empowered to take another course of action and find the perseverance
and confidence to do so. The therapeutic response here is the one that is nonjudgmental.
, A client with major depression says to the nurse, "I should have died. I've always been a
failure." Which response by the nurse is therapeutic?
You've been feeling like a failure for some time now?"
A client in a retirement center rings the night alarm and says to the nurse, "Look at this
old man! He keeps breaking into my apartment! You've got to get him to stay out of here so
I can sleep." Which statement by the nurse would be most therapeutic?
C "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you
for an hour or so while you try to rest."
A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial
nursing intervention for this client?
A Providing authority and action
Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational,
developmental, or societal sources of stress. A person in this state is temporarily unable to cope
with or adapt to the stressor with the use of previously successful problem-solving methods.
Someone who intervenes in this situation (the nurse) takes over for the client who is not in
control (authority) and devises a plan (action) to secure and maintain the client's safety. The
nurse then works collaboratively with the client, demonstrating confidence in the client's ability
to cope and providing reassurance that the crisis is temporary. Displaying an attitude of
detachment is inappropriate.
A client says to the nurse, "I'm really phobic about flying, so my husband and I always
drove or took the train everywhere. Now he's been offered a big job in Europe, and if I
