Psychosocial Integrity: A
Comprehensive Guide to Patient-
Centered Care
A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is
the nurse's best response?
1. "What do you think you should do?"
2. "Absolutely, I think you should tell your parents."
3. "Don't you think your parents have the right to know about your sexuality?"
4. "I do not think now is the right time to tell your parents. Wait until you are 21."
TERM
Image
1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on
options and does not have the nurse tell the client what to do. It is much more therapeutic to help
the client make the decision for themselves, instead of the nurse. This prevents any biases from
impacting the outcome.
2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
DEFINITION
The nurse is caring for a client who presents to the mental health unit following a violent altercation
with the spouse. The client has numerous bruises on the face, chest, and back. There is one
laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood
of the perpetrator in this situation?
1. Extreme anger
2. Anxiety
3. Kindness
4. Irritability
TERM
Image
,3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the
honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the
tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts
and promises of love.
1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger
building stage is called tension building stage and is characterized by minor incidents like pushing,
shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it
getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn
to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering
stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings.
After the beating the client is calm and described as "in shock" or have have amnesia of the event.
You also see extreme anger in the escalation/de-escalation stage.
2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger
building stage is called tension building stage and is characterized by minor incidents like pushing,
shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it
getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn
to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering
stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings.
After the beating the client is calm and described as "in shock" or have have amnesia of the event.
You also see extreme anger in the escalation/de-escalation stage.
4. Incorrect: Irritability would
DEFINITION
A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack
occurs. What would be the nurse's best response to the client?
1. "I understand that you feel anxious. But you must stop this behavior."
2. "The feelings that you described can occur in individuals with asthma. You may find that learning
relaxation exercises may help."
3. "I am concerned that feeling anxious during an asthma attack means you need more education
about asthma."
4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage
your asthma."
TERM
Image
2. Correct: This statement acknowledges the client's feelings and then provides a suggested strategy
that has been found to be useful in clients with anxiety and fear associated with asthma.
1. Incorrect: The nurse states understanding but then tells the client to stop the behavior without
providing any helpful suggestions.
3. Incorrect: This response is disagreeing with the client's feelings and psychosocial response by
stating that more education about asthma will prevent anxiety during an asthma attack.
,4. Incorrect: This response dismisses and belittles the client's feelings and psychosocial response
associated with asthma. By stating "everyone with asthma", the nurse is making a stereotypical
response. This does not promote expressions of feelings by the client.
DEFINITION
Which nursing intervention should the nurse include when caring for a client with Alzheimer's
disease being admitted to a long term care facility?
1. Offer multiple environmental stimuli at the same time to provide distraction.
2. Encourage the client to participate in activities such as board games.
3. Restrain the client in a chair to prevent falls when sundowning occurs.
4. Involve the client in supervised walking as a routine.
TERM
Image
4. Correct: A regular routine and physical activity help client's with Alzheimer's disease maintain
abilities for a longer period of time. Physical activities promote strength, agility and balance. The
client's walking should be supervised for client safety issues.
1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's Disease. The client
can become agitated and/or more disoriented with an increase in environmental stimuli.
2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory
impairment. Board games require complex cognitive actions.
3. Incorrect: Restraints should be avoided because they increase agitation. The client may become
agitated by the restriction of he restraints. Also the client may perceive the restraints as a threat.
DEFINITION
An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days
later, the client decides to leave the hospital against medical advice. What is the priority nursing
intervention at this time?
1. Hide the client's clothes so that he cannot leave.
2. Administer the ordered sedative.
3. Place restraints on the client.
4. Determine why the client wants to leave.
TERM
Image
4. Correct: Always assess why the client wishes to leave first. This will provide an opportunity to
attempt to fix the problem and possibly revise the client's decision.
1., 2. & 3. Incorrect: Confining a client against his or her wishes, except in an emergency situation,
may be considered false imprisonment. Actions that may invoke these charges include: locking an
, individual in a room, taking a person's clothes for the purposes of detainment against his or her will,
and retaining in mechanical restraints a competent voluntary client who demands to be released.
DEFINITION
A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client
refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine."
Which nursing response is appropriate?
1. "Do you think people want to kill you with rays?"
2. "You don't have to worry that someone is going to kill you."
3. "I don't want you to talk about the x-ray technicians."
4. "Where did you get the idea that someone was trying to kill you?"
TERM
Image
1. Correct: By restating the client's primary idea this reinforces to the client that statement has been
heard. This allows the client to clarify the statement or realize that the nurse has understood the
comment. This is the therapeutic communication technique of restating.
2. Incorrect: The nurse is using the nontherapeutic communication technique of giving reassurance.
The nurse is stating that the client has nothing to worry about. The client may feel the nurse is
moderating their intense concern of the possibility of being killed.
3. Incorrect: The nurse is disregarding the client's concern about possibly being killed. The nurse is
redirecting the conversation about the client to concern for the x-ray technicians. The nurse is
preferring the conversation to be focused on another topic. This is an example of the nontherapeutic
communication technique of introducing an unrelated topic.
4. Incorrect: Demanding a reason from the client about their thoughts or feelings is an example of
the nontherapeutic communication technique of requesting an explanation. This is a direct question.
The client will need to defend their feelings or thought. The client may feel intimidated and stop
communicating with the nurse.
DEFINITION
A client had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I
am worried that the pathology report will indicate cancer." Which response would the nurse initiate
to assist the client in reducing their anxiety?
1. "You are anxious about the pathology report?"
2. "Would you like me to recommend a movie for you to watch?"
3. "I will notify your daughter that you are concerned about the pathology report."
4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"
TERM
Image
Comprehensive Guide to Patient-
Centered Care
A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is
the nurse's best response?
1. "What do you think you should do?"
2. "Absolutely, I think you should tell your parents."
3. "Don't you think your parents have the right to know about your sexuality?"
4. "I do not think now is the right time to tell your parents. Wait until you are 21."
TERM
Image
1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on
options and does not have the nurse tell the client what to do. It is much more therapeutic to help
the client make the decision for themselves, instead of the nurse. This prevents any biases from
impacting the outcome.
2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to
behave which implies that the nurse knows what is best and that the client is not capable of making
any decisions.
DEFINITION
The nurse is caring for a client who presents to the mental health unit following a violent altercation
with the spouse. The client has numerous bruises on the face, chest, and back. There is one
laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood
of the perpetrator in this situation?
1. Extreme anger
2. Anxiety
3. Kindness
4. Irritability
TERM
Image
,3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the
honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the
tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts
and promises of love.
1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger
building stage is called tension building stage and is characterized by minor incidents like pushing,
shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it
getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn
to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering
stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings.
After the beating the client is calm and described as "in shock" or have have amnesia of the event.
You also see extreme anger in the escalation/de-escalation stage.
2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger
building stage is called tension building stage and is characterized by minor incidents like pushing,
shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it
getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn
to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering
stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings.
After the beating the client is calm and described as "in shock" or have have amnesia of the event.
You also see extreme anger in the escalation/de-escalation stage.
4. Incorrect: Irritability would
DEFINITION
A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack
occurs. What would be the nurse's best response to the client?
1. "I understand that you feel anxious. But you must stop this behavior."
2. "The feelings that you described can occur in individuals with asthma. You may find that learning
relaxation exercises may help."
3. "I am concerned that feeling anxious during an asthma attack means you need more education
about asthma."
4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage
your asthma."
TERM
Image
2. Correct: This statement acknowledges the client's feelings and then provides a suggested strategy
that has been found to be useful in clients with anxiety and fear associated with asthma.
1. Incorrect: The nurse states understanding but then tells the client to stop the behavior without
providing any helpful suggestions.
3. Incorrect: This response is disagreeing with the client's feelings and psychosocial response by
stating that more education about asthma will prevent anxiety during an asthma attack.
,4. Incorrect: This response dismisses and belittles the client's feelings and psychosocial response
associated with asthma. By stating "everyone with asthma", the nurse is making a stereotypical
response. This does not promote expressions of feelings by the client.
DEFINITION
Which nursing intervention should the nurse include when caring for a client with Alzheimer's
disease being admitted to a long term care facility?
1. Offer multiple environmental stimuli at the same time to provide distraction.
2. Encourage the client to participate in activities such as board games.
3. Restrain the client in a chair to prevent falls when sundowning occurs.
4. Involve the client in supervised walking as a routine.
TERM
Image
4. Correct: A regular routine and physical activity help client's with Alzheimer's disease maintain
abilities for a longer period of time. Physical activities promote strength, agility and balance. The
client's walking should be supervised for client safety issues.
1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's Disease. The client
can become agitated and/or more disoriented with an increase in environmental stimuli.
2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory
impairment. Board games require complex cognitive actions.
3. Incorrect: Restraints should be avoided because they increase agitation. The client may become
agitated by the restriction of he restraints. Also the client may perceive the restraints as a threat.
DEFINITION
An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days
later, the client decides to leave the hospital against medical advice. What is the priority nursing
intervention at this time?
1. Hide the client's clothes so that he cannot leave.
2. Administer the ordered sedative.
3. Place restraints on the client.
4. Determine why the client wants to leave.
TERM
Image
4. Correct: Always assess why the client wishes to leave first. This will provide an opportunity to
attempt to fix the problem and possibly revise the client's decision.
1., 2. & 3. Incorrect: Confining a client against his or her wishes, except in an emergency situation,
may be considered false imprisonment. Actions that may invoke these charges include: locking an
, individual in a room, taking a person's clothes for the purposes of detainment against his or her will,
and retaining in mechanical restraints a competent voluntary client who demands to be released.
DEFINITION
A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client
refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine."
Which nursing response is appropriate?
1. "Do you think people want to kill you with rays?"
2. "You don't have to worry that someone is going to kill you."
3. "I don't want you to talk about the x-ray technicians."
4. "Where did you get the idea that someone was trying to kill you?"
TERM
Image
1. Correct: By restating the client's primary idea this reinforces to the client that statement has been
heard. This allows the client to clarify the statement or realize that the nurse has understood the
comment. This is the therapeutic communication technique of restating.
2. Incorrect: The nurse is using the nontherapeutic communication technique of giving reassurance.
The nurse is stating that the client has nothing to worry about. The client may feel the nurse is
moderating their intense concern of the possibility of being killed.
3. Incorrect: The nurse is disregarding the client's concern about possibly being killed. The nurse is
redirecting the conversation about the client to concern for the x-ray technicians. The nurse is
preferring the conversation to be focused on another topic. This is an example of the nontherapeutic
communication technique of introducing an unrelated topic.
4. Incorrect: Demanding a reason from the client about their thoughts or feelings is an example of
the nontherapeutic communication technique of requesting an explanation. This is a direct question.
The client will need to defend their feelings or thought. The client may feel intimidated and stop
communicating with the nurse.
DEFINITION
A client had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I
am worried that the pathology report will indicate cancer." Which response would the nurse initiate
to assist the client in reducing their anxiety?
1. "You are anxious about the pathology report?"
2. "Would you like me to recommend a movie for you to watch?"
3. "I will notify your daughter that you are concerned about the pathology report."
4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"
TERM
Image
