Psychosocial Integrity ATI

Psychosocial Integrity ATI 1. A nurse in dialysis is caring for a client who has a new diagnosis of end-stage kidney disease. when he arrives for his first dialysis treatment, he tells the nurse, "I Decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.” The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving? A. Bargaining B. Denial C. Depression D. Anger 2. A nurse at a college campus mental health counseling center is caring for a student who just failed an exam. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as an example of the defense mechanism of: A. Conversion B. Projection (pt refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person) C. Undoing D. Regression 3. A nurse is planning care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care? A. Rotate assignment of daily caregivers B. Provide an activity schedule that changes from day to day C. Limit the client's choices for daily activities. D. Talk the clinet through tasks one step at a time 4. a nurse in a psychiatric unit is caring for several clients. Which of the following clinets should the nurse recommend for group therapy? A. A client who has been taking amitriptyline for 3 months for depression B. A client exhibiting psychotic behavior C. A client admitted 12 hrs ago for acute mania D. A client who is experiencing alcohol intoxication 5. A nurse in an emergency department is assessing a client for suspected cocaine intoxication. The nurse should know that which of the following manifestations is consistent with cocaine intoxication? A. Nystagmus B. Dilated pupils C. Hypersomnia D. Depression 6. A nurse in a drug and alcohol detoxification center is caring for a client who has a long history of alcohol abuse. Which of the following should be the nurse's primary focus of care during the early phase of alcohol withdrawal? A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Confronting the use of denial and other defense mechanisms D. Education the client about the consequences of alcohol misuse 7. A nurse is caring for a client who has delusional behavior and states, "I can't go to group today. I am expecting a high level official to visit today!" The nurse responds, "I understand, but it is time for group and we expect everyone to attend. Let's walk over together." Why is this nurse's response considered therapeutic? A. It clearly articulates what is expected of the client B. It demonstrates empathy towards the client C. It sets limits on the client’s manipulative behavior D. It uses reflection when talking with the client 8. A nurse is talking with a 13-year old female at her annual health screening visit. Which of the following comments made by the client should the nurse be most concerned about? 1. My parents treat me like a baby sometimes 2. I haven't gotten my period yet, and all my friends have theirs 3. None of the kids at school like me, and I don't like them either 4. There's a big pimple on my face and I worry that everyone will notice 9. A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context? A. The sense of self among individual family members B. The future goals of the family C. The roles of the family members D. The family’s religious practices 10. A nurse is teaching about ECT with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders? A. Narcotic addiction B. Vegetative depression C. Personality disorder D. Eating disorder 11. A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? A) "of course people care, your family comes to visit every day" B) "why do you feel that way?" C) "tell me who you think doesn't care about you" D) "I care about you, and I am concerned that you feel so sad" 12. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? A) instruct the client to sit down and stop pacing B) allow the client to pace alone until physically tired C) have a staff member escort the client to their room D) walk with the client at a gradually slower pace 13. A nurse caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? a. "Everyone worries about her baby when she's in labor." b. "We have a neonatal unit here that's equipped to handle emergencies." c. "Your pregnancy is advanced so your baby should be fine." d. "You must be feeling scared and powerless." 14. A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need IV antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of infection." What response should the nurse make? a. give your parents a chance, they'll understand b. if you want me to, i can tell your parents for you c. you seem scared to talk to your parents d. your parents will have to be told why you are being admitted 15. A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room containing personal belongings D. A room with dim lighting 16. A nurse is caring for a client who is depressed and refuses to participate in group therapy, or perform activities of daily living. Which of the following nursing statements by the nurse is appropriate? A. “I will assist you in getting out of bed and getting dressed” B. “You can remain in bed until you feel well enough to join the group” C. “The unit rules states that you may not remain in bed” D. “if you don’t participate in you care, you will not get better” 17. A nurse is caring for an older adult client who was alert and oriented on admission, but after 4 days of hospitalization, is becoming increasingly restless and intermittently confused. When making rounds at night, the nurse finds the client sleeping on the floor. After checking the client, which of the following actions is appropriate for the nurse to take? A. Move the client to a room closer to the nurse's station. B. Call the family and ask them to stay with the client C. Apply wrist and leg restraints to the client D. Administer medication to sedate the client 18. The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from post-traumatic stress disorder when the client states: A. “I check my room I enter because the enemy is still after me and could be hiding anywhere” B. “my child was born with a birth defect due to an exposure I had overseas” C. “I killed four enemy soldiers with my bare hands and saved my entire battalion” D. "In my dreams, all I can see are the wounded reaching out and trying to grab me." 19. A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (select all that apply) A. Avoid eye contact to prevent escalation of anxiety B. Establish rapport with the client C. Identify the cause of the anxiety D. Validate the client’s feelings E. Develop a flexible crisis intervention plan 20. A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrated the ethical concept of autonomy? A. Encouraging client feedback about satisfaction with the facility experience B. Explaining unit rules and policies regarding unacceptable behaviors C. Supporting the client's wish to refuse prescribed medications D. Making sure the client understands expectations for client participation 21. A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate? A. “you are being unreasonable, and I will not call your doctor at this hour” B. “go back to your room, and I’ll try to get in touch with your doctor” C. “I can’t call a doctor in the middle of the night unless it’s an emergency” D. "You must be very upset about something." 22. a nurse is caring for an adolescent who is experiencing indications of depression. which of the following findings should the nurse expect? A. Irritability B. Euphoria C. Insomnia D. Low self-esteem E. Chronic pain 23. A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home and see how my children are doing. I really hate to leave." Which of the following responses is the most appropriate for the nurse to give the daughter? A. Perhaps you could call your children to see how they are doing” B. “don’t worry. We’ll take good care of your parents while you are gone” C. “you are feeling drawn in two separate directions” D. “there’s nothing you can do here. You should go home to your children” E. 24. A nurse is admitting a client who has experienced a weight loss of 25 lb (11 kg) in the past 3 months. The client weighs 88 lb (40 kg) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A. Identify the client's nutritional status. B. Request a mental health consult. C. Plan a therapeutic diet for the client. D. Talk to family members to find out more about the client's dietary habits. 25. A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicate the client is exhibiting manifestations of prolonged grieving? A. Leaves the child’s room exactly as it was before the loss B. Volunteers at a local children’s hospital C. Talks about the child in the past tense D. Visits the child’s grave every week after worship service