Psychosocial Integrity QUESTIONS AND
ANSWERS ALL CORRECT
A nurse is assessing the health status of an older adult client. Although the client
denies a problem, the caregiver explains that the client is alert and oriented but
consistently has an unkempt appearance, body odor, and soiled clothing. The nurse
understands that the client's behavior is likely related to which of the following?
Select one:
a. Manifesting typical early symptoms of delirium.
b. Experiencing side effects from a medication.
c. Restricting activities in response to disease symptoms.
d. Exhibiting evidence of asymptomatic pathology. Correct Answer: c. Restricting
activities in response to disease symptoms.
During an assessment, an adolescent client whispers to the nurse, "I have to tell
you something, but you have to promise you won't tell anyone else." Which of the
following is the most appropriate response for the nurse to make?
Select one:
a. "I cannot make that promise if it affects your or someone else's safety."
b. "What is said in this room stays in this room."
c. "I am bound by the nurse-client relationship to keep your comments private."
d. "I feel that you should share this with your parents first." Correct Answer: a. "I
cannot make that promise if it affects your or someone else's safety."
Nurses should not promise what they cannot do. If a client admits to behaviors that
are dangerous to self or others, the nurse is obligated to report these behaviors.
A nurse is caring for a terminally ill client of the Muslim faith and observes the
client to be unconscious and having Cheyne-Stokes respirations. The family has
repositioned the bed so that the client is on the right side facing toward the wall.
The nurse does not question this action because of which of the following?
Select one:
, a. The religious practice of concealing the face of the dying client should be
supported.
b. This positioning is preferred for a client with respiratory distress.
c. This positioning has religious significance for the client and family.
d. The nurse should support the family in their efforts to make the client
comfortable. Correct Answer: c. This positioning has religious significance for the
client and family.
According to Muslim teachings, it may be comforting to the dying client and
family to turn the client on the right side to face Mecca. When death occurs, the
body must be kept covered at all times, and it is preferred that only healthcare
professionals of the same gender touch the body. In this situation, observing the
position of the client would indicate that the spiritual needs of the client and family
were being met.
A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to
the mental health unit. The client is confused and disoriented. When developing a
plan of care, which of the following would be the priority intervention for this
client?
Select one:
a. Accept and make the client feel safe.
b. Explain unit rules to the client.
c. Orient the client to the unit.
d. Stabilize the client's psychiatric needs. Correct Answer: a. Accept and make the
client feel safe.
Clients in a mental health unit need to feel accepted and a client that is confused
needs to feel safe. Safety is the client's most basic need, making this the priority
intervention.
The nurse is assessing the family dynamics of a widow with end stage terminal
cancer. Which statement made between the adult children would best indicate the
need for further teaching?
Select one:
a. "It does not matter what we think, the living will says 'do not resuscitate'."
b. "Since you are the oldest child, you have the responsibility to decide."
ANSWERS ALL CORRECT
A nurse is assessing the health status of an older adult client. Although the client
denies a problem, the caregiver explains that the client is alert and oriented but
consistently has an unkempt appearance, body odor, and soiled clothing. The nurse
understands that the client's behavior is likely related to which of the following?
Select one:
a. Manifesting typical early symptoms of delirium.
b. Experiencing side effects from a medication.
c. Restricting activities in response to disease symptoms.
d. Exhibiting evidence of asymptomatic pathology. Correct Answer: c. Restricting
activities in response to disease symptoms.
During an assessment, an adolescent client whispers to the nurse, "I have to tell
you something, but you have to promise you won't tell anyone else." Which of the
following is the most appropriate response for the nurse to make?
Select one:
a. "I cannot make that promise if it affects your or someone else's safety."
b. "What is said in this room stays in this room."
c. "I am bound by the nurse-client relationship to keep your comments private."
d. "I feel that you should share this with your parents first." Correct Answer: a. "I
cannot make that promise if it affects your or someone else's safety."
Nurses should not promise what they cannot do. If a client admits to behaviors that
are dangerous to self or others, the nurse is obligated to report these behaviors.
A nurse is caring for a terminally ill client of the Muslim faith and observes the
client to be unconscious and having Cheyne-Stokes respirations. The family has
repositioned the bed so that the client is on the right side facing toward the wall.
The nurse does not question this action because of which of the following?
Select one:
, a. The religious practice of concealing the face of the dying client should be
supported.
b. This positioning is preferred for a client with respiratory distress.
c. This positioning has religious significance for the client and family.
d. The nurse should support the family in their efforts to make the client
comfortable. Correct Answer: c. This positioning has religious significance for the
client and family.
According to Muslim teachings, it may be comforting to the dying client and
family to turn the client on the right side to face Mecca. When death occurs, the
body must be kept covered at all times, and it is preferred that only healthcare
professionals of the same gender touch the body. In this situation, observing the
position of the client would indicate that the spiritual needs of the client and family
were being met.
A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to
the mental health unit. The client is confused and disoriented. When developing a
plan of care, which of the following would be the priority intervention for this
client?
Select one:
a. Accept and make the client feel safe.
b. Explain unit rules to the client.
c. Orient the client to the unit.
d. Stabilize the client's psychiatric needs. Correct Answer: a. Accept and make the
client feel safe.
Clients in a mental health unit need to feel accepted and a client that is confused
needs to feel safe. Safety is the client's most basic need, making this the priority
intervention.
The nurse is assessing the family dynamics of a widow with end stage terminal
cancer. Which statement made between the adult children would best indicate the
need for further teaching?
Select one:
a. "It does not matter what we think, the living will says 'do not resuscitate'."
b. "Since you are the oldest child, you have the responsibility to decide."
