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VATI Psychosocial Integrity Quiz ; 25 Questions & Answers ( Graded A+)
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VATI Psychosocial Integrity Quiz ; 25Questions & Answers ( Graded A+)
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? - -a. Manifesting typical early symptoms of delirium.
b. Exhibiting evidence of asymptomatic pathology.
c. Experiencing side effects from a medication.
d. Restricting activities in response to disease symptoms. CorrectFrequently
older adults will minimize, deny, or underreport the impact of disease
symptoms which require alterations of daily activities in order to compensate
for the symptoms. In this case, the issue is not one of impaired cognition, but
rather the use of the coping mechanism of denial because of the difficulty in
performing self-care functions.
-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? - -a. "What is said in this room stays in this room."
b. "I cannot make that promise if it affects your or someone else's safety."
CorrectNurses 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.
c. "I feel that you should share this with your parents first."
d. "I am bound by the nurse-client relationship to keep your comments
private."
-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? - -a. This positioning has religious significance for the client
and family. CorrectAccording 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.
b. The nurse should support the family in their efforts to make the client
comfortable.
c. The religious practice of concealing the face of the dying client should be
supported.
, d. This positioning is preferred for a client with respiratory distress.
-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? - -a. Orient the client to the unit.
b. Stabilize the client's psychiatric needs.
c. Explain unit rules to the client.
d. Accept and make the client feel safe. CorrectClients 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? - -a. "Since you are the oldest
child, you have the responsibility to decide."
b. "If daddy were alive, he would be making these hard decisions, not us."
c. "It does not matter what we think, the living will says 'do not resuscitate'."
CorrectThe adult children need to have the concept of a 'do not resuscitate'
(DNR) clarified. The DNR in a living will expresses the wishes of the client in a
written form preceding the situation it addresses. It may also have additional
instructional statements with it that give further guidance for particular
situations. In any case, the DNR represents the wishes of the client, and does
not preclude decisions about care and death by the next of kin. And, despite
a DNR wish being expressed in an Advance Directive (sometimes called a
Living Will), it requires a healthcare provider order to put a DNR in effect.
d. "The doctors have told us that it is time for us to make some tough
decisions."
-A client diagnosed with schizophrenia and experiencing frequent auditory
hallucinations is admitted to an inpatient psychiatric unit. Which of the
following would be the most effective, initial strategy for the nurse to
implement? - -a. Agree with the client that the voices are audible.
b. Ask the client to describe the components of the hallucination.
CorrectInitially, the nurse should try to understand what the voices are
saying or telling the client to do. Suicidal or homicidal messages necessitate
initiation of safety measures for all members of the healthcare team as well
as the client. Once a client describes the hallucination or delusion, do NOT
dwell on it. Rather, focus conversation on more reality-based topics.
c. Explain to the client that the hallucination is not real.
d. Ask the client to rest in a quiet area until the voices are gone.
-A client expresses to the nurse that her husband is an alcoholic and has
trouble keeping a job for longer than three months. Which of the following is
the nurse's best response? - -a. "This seems to worry you. May I contact the
Hospital Chaplain?"
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