Psychosocial

Integrity
Archer Review

© USMLE Galaxy LLC

Psychosocial Integrity
(RN 6 - 12%)
(PN 9 - 15%)

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Key Topics
▪ Abuse (Risk factors/Intervention)
▪ Crisis management
▪ Coping
▪ Grief/loss/end of life
▪ Substance abuse
▪ Communication/environment
▪ Family dynamics (RN only)
▪ Stress Management
▪ Mental health - watch on demand video for mental health
▪ Culture & Religion - watch on demand video for culture

Abuse

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 Types/Assessment of Abuse
● Physical Abuse
○ Being violent towards others to the point that injury occurs
● Sexual Abuse
○ Sexual conduct without consent from both parties
● Verbal/Emotional abuse
○ Verbal is a form of emotional abuse - meant to control/harm another
● Neglect
○ Basic needs are not meant - poor hygiene/lack of clean clothing, child absent from school
often
● Financial Abuse
○ Abuse of finances which is more common in fully dependent on someone else
● Elderly Abuse
○ Risk factors:
■ Alzheimer’s Disease / Dementia / Isolation / immobility

Assessments
● Story doesn’t match the injury
● Multiple broken bones in different stages of healing
● Burns
○ Scalding on bottom of feet
○ Cigarette burns
○ Area the client couldn’t reach/burn themselves
○ Clear line of demarcation, no splash marks
○ Zebra pattern
● Child
○ Spiral fractures
○ Retinal bleeds
○ Bruises in places that don’t make sense for the child’s developmental stage
○ Parent hovering over child/won’t allow the child to speak

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Interventions for Abuse
Report abuse if

● Child
● Vulnerable Adult

Ensure that clients physical needs are stabilized then report the abuse

Non vulnerable adult - their choice to report, our priorities include

● Safety need
○ Going back to abuser: safety plan
● Physiological need:
○ Leaving abuser: helping locate a shelter

NCLEX Question
A 78-year-old woman is brought to the emergency department (ED) for evaluation of an arm injury.
During the assessment, the nurse notices bruises in varying stages of healing covering the client's
chest and legs. When the nurse asks how the bruises were sustained, the client reluctantly states
that her son frequently hits her "if supper is not ready when he gets home from work." Which of the
following is the most appropriate nursing response?

A. "Oh? Let me talk to your son."

B. "I appreciate your honesty, but I need to inform you that I am a mandated reporter, and I am required
to report this."
C. "Let's talk about how you can manage your time to prevent your son from getting upset."
D. "Do you have friends who can help you or keep you safe until you resolve these important issues with
your son?"

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Answer: B
Choice B is correct. Under specific state and/or federal laws, nurses are mandated reporters, required to report any
suspicion of child or elder abuse. Additionally, depending on the applicable jurisdiction, state law may mandate the
nurse to report gunshot injuries, dog bites, specific criminal acts (i.e., rape, etc.), and certain infectious diseases (i.e.,
HIV, tuberculosis, monkeypox, etc.). The nurse should explain to the client that applicable state and/or federal law(s)
require the nurse to report the suspected abuse to a specific entity or authority as outlined in the applicable law.

Choice A is incorrect. Confronting the client's son does not rectify the issue, nor does the response address any of
the safety concerns of the client moving forward. As a mandated reporter, the nurse must also report the elder abuse
suspicions/allegations to the proper authorities.

Choice C is incorrect. Teaching the client time management skills would erroneously imply that the client is at fault
for this abuse and should therefore be avoided. This statement does not address the fact that the nurse is a
mandated reporter of elder abuse.

Choice D is incorrect. The client's friends do not have a duty to keep the client safe, nor does the client need to
"resolve . . . important issues" with her son. Additionally, this statement does not address the fact that the nurse is a
mandated reporter of elder abuse.

Coping/Crisis Management

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 Response to Role Changes
● Role strain
○ Single role stress
● Role conflict
○ Multiple roles that contend with one another
● Role overload
○ Multiple roles without adequate ability to fulfil them
● Intra-role conflict
○ Single role conflict (can be religious/moral/ect)
● Inter-role conflict
○ Conflict between the multiple roles

NCLEX Question
Which of the following nursing diagnosis is appropriate for your client when your client
is not coping with a progressive disease in an adaptive manner?

A. Ineffective coping related to fear secondary to a progressive disease

B. Ineffective coping related to role ambiguity secondary to a progressive disease
C. Ineffective coping related to role changes secondary to a progressive disease
D. Ineffective coping related to role conflict secondary to a progressive disease

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Answer: C
Choice C is correct. “Ineffective coping related to role changes secondary to a progressive disease” is the nursing
diagnosis that is appropriate for your client when your client is not coping with a progressive disease adaptively.

Choice A is incorrect. “Ineffective coping related to fear secondary to a progressive disease” is not correct because
there is no indication that this client is affected by fear.

Choice B is incorrect. “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur
when the client with a progressive disease is not sure about what is expected in their sick role. Still, there is no
indication that this client is affected by this uncertainty.

Choice D is incorrect. “Ineffective coping related to role conflict secondary to a progressive disease” is also not
appropriate because there is no information in this question that indicates that the client has a role conflict.

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Altered Body Image
● Alopecia
○ Hair loss
○ Psychological Need:
■ May suggest client pick out a wig before losing their hair
● Amputation
○ Mirror Therapy
■ Have client look in mirror at residual limb
○ Verbalize feelings
○ Support Groups
● Burns
○ Scarring can cause a change in appearance
○ Work with a rehabilitation team
○ Avoid sun exposure to the healing tissues

Grief/loss/end of life

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 End of Life Care
● Hospice
○ Life expectancy 6 months or less
○ Focused on making the client comfortable
○ Support offered for both client and family
● Palliative Care
○ Diagnosis of terminal illness
○ Focus is on symptom management
○ Support offered to both client and family

● Ensure to care and educate both the patient and their loved ones.

Types of Grief
● Normal
○ Sorrow/overwhelming emotions due to some change
● Anticipated
○ Grief due to a change that is expected
■ Examples
● Loved ones getting put on hospice
● Changes role in career after birth of a child
● Dysfunctional
○ Lasts longer than 6 months
○ Affects day to day functioning

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 Kubler Stages of Grief
● Denial
○ Avoidance, Shock, Confusion
● Anger
○ Anxiety, irritability
● Bargaining
○ Negotiates with self or higher power (ex: God)
● Depression
○ Feeling of hopelessness and helplessness
● Acceptance
○ Moves on

Clients may go through stages multiple times and in any order

Nurse’s Role In Grief

● Make sure to establish rapport with the client
○ Open ended questions
○ Allow client to remain the focus of the conversation
○ Explore feelings of the client
● Help client with effects of the grieving process
○ Physical
○ Social
○ Spiritual
● Use of the interprofessional team
● Work on developing coping skills

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 Communication/Environment

The DO’s of Therapeutic Communication

- Use open ended questions
- Use therapeutic silence
- Use therapeutic touch
- Remain focused on the client
- Present reality

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The DON’Ts of Therapeutic Communication

- Ask WHY
- Dismiss a client’s feelings
- Give false reassurance
- Give personal opinion
- Pass it off to someone else
- Argue with the client
- Make assumptions

Milieu/Therapeutic Environment
● Prioritize - client safety
○ Works on the physical environment
○ Works on the social environment
○ Structured form of therapy
● Client is the center of their therapy
○ Sets individual goals
○ May also participate in group sessions
● May use other members of the healthcare team
● Focus on structure and consistency
● The treatment as well as the surroundings (furniture, paint colors, etc) are
structured to be beneficial for the client

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NCLEX Question
The husband of a client diagnosed with a brain tumor tells the nurse, "I don't think I
can make it if something happens to my wife. I love her so much." What is the most
appropriate response from the nurse?

A. “Let me call the chaplain to come and talk to you.”

B. “Do you have any family support to be with you?”
C. “What makes you think you won't be able to make it?”
D. “Do not worry, everything will be alright. You are a strong man.”

Answer: C
Choice C is correct. This is an appropriate response and encourages the client's husband to
express himself, as it is an open-ended question. Further, the therapeutic communication
technique of clarification was used, which shows that the nurse utilized active listening.

Choices A, B, and D are incorrect. These statements are not therapeutic because they are
closed-ended or divert the client's immediate concern to another individual. The client's husband
expressed discontent, and the nurse should directly respond to the client's husband. Allowing the
client to express himself may alleviate some of his apprehension.

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 Substance Abuse

Nicotine - CNS Stimulant

Intoxication (poisoning): Withdrawal:

● Think sped up ● Headache

● Diarrhea ● Nervousness
● Cramping ● Hunger
● Vomiting ● Weight gain
● Diaphoresis ● Anger
● Dizziness ● Poor Concentration
● Arrhythmias ● Restlessness

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Cocaine - CNS Stimulant
Intoxication: Withdrawal:

● Hypertension ● Dysphoric mood

● Tachycardia ● Fatigue
● Paranoia ● Insomnia or Hypersomnia
● Mydriasis ● Psychomotor agitation
● Increase in energy ○ Vivid dreams
● Seizures ● Chills
● Death ● Depression/Anxiety

Opioids - CNS Depressant

Intoxication: Withdrawal:

● Drowsiness ● Insomnia
● Slurred speech ● Fever
● Respiratory depression - ● Goosebumps (piloerection)
give antidote ● Yawning
● Cyanosis ● High blood pressure
● Pinpoint pupils ● Tachycardia
● Skin cold and clammy ● Anxiety

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Heroin - CNS Depressant
Intoxication: Withdrawal:

● Drowsiness ● Agitation
● Euphoria ● Diaphoresis
● Sedation ● Vomiting
● Bradypnea - respiratory arrest ● Diarrhea
● Confusion ● Rhinorrhea
● Ataxia ● Tachycardia

Alcohol - CNS Depressant

Intoxication: Withdrawal:

● Slurred Speech ● Agitation

● Unsteady Gait ● Delirium
● Depression ● SEIZURES
● Loss of inhibition ● Tremors
● Drowsiness ● Delirium tremens
● Ataxia ● Headache
● Disorientation

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NCLEX Question
The nurse is educating community members on the signs and symptoms of substance abuse
intoxication. Which information should the nurse include?

Select all that apply.

A. Cocaine may cause increased pulse, low blood pressure, and paranoia
B. Inhalants may cause slurred speech, loss of motor coordination, and nausea
C. Heroin may cause increased alertness, paranoia, and increased respirations
D. Alcohol may cause drowsiness, slurred speech, and difficulty walking
E. Marijuana may cause a slowed reaction time and problems with balance and memory

Answer: B, D, and E
Choices B, D, and E are correct. Depending on the inhalant, an individual may experience a loss of inhibition, headache,
nausea, poor muscle coordination, and slurred speech. Alcohol may cause drowsiness, loss of inhibition, and difficulty
walking. Marijuana may cause a slowed reaction time, difficulty with learning and memory, and hallucinations.

Choices A and C are incorrect. Cocaine is a stimulant and produces significant blood pressure and pulse increases.
Psychotic symptoms such as paranoia are also common. Heroin has depressant effects during intoxication and may
produce drowsiness, euphoria, sedation, and worse respiratory arrest from decreased respiration.

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 Family Dynamics

Changes in Family Dynamics

● Divorce
● Illness of Spouse
● Death
● New additions to the family
● Blended family

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 Parenting Styles
● Authoritarian
○ Strict Rules
○ Parent make all decisions
● Authoritative
○ Problem solves together
○ Clear rules
● Permissive
○ Rules are rarely present/kept
○ Gives into child to avoid conflict
● Uninvolved (Neglectful)
○ Parent is not involved with child
○ No rules

Family Therapy
● Works to define family roles
● Can be long or short term
● Nurses Role
○ Assessment
○ Teaching/education

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 Stress Management

Nonverbal Cues of Stress

● Emotional
○ Irritation
○ Anxiety
○ Anger
● Physical Assessment
○ Headaches
○ Heart rate increased
○ GI upset
○ Rapid respiratory rate
● Other
○ Difficulty concentrating
○ Unable to sleep
○ Avoiding responsibilities

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Interventions for Stress
● Reduce environmental stimuli
○ Noise
○ Turn off television
○ Bring client to their own room/away from others
● If experiencing severe anxiety or panic attack the nurse should REMAIN with
the client

Stress Management
● Relaxation techniques
○ Guided imagery
■ Imagine a different place using the senses
● e.g., on a beach (hear the waves coming up the beach, smell the ocean, etc)
○ Meditation
■ Redirects focus
● Adequate sleep
○ This looks different for everyone
○ Assess client functioning
● Exercise
○ Regular moderate exercise

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Wrap-up NGN Question!

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Question
➢ For each client need, click
to specify the potential
nursing intervention that
would be appropriate for
the client's care. Each
category must have at least
one option selected.

Question
➢ For each client need, click
to specify the potential
nursing intervention that
would be appropriate for
the client's care. Each
category must have at least
one option selected.

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