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Study guide · Psychosocial Integrity

Psychosocial Integrity

8 to 14% of the exam · 18 activity statements

Psychosocial Integrity covers how the practical nurse supports a client's emotional, mental and social wellbeing: therapeutic communication, coping, grief, end-of-life care, culture and spirituality, safety with aggression, substance use, abuse and neglect, cognitive impairment and mental health disorders. REx-PN items test whether you respond in a way that helps the client, notice the cue that signals risk, keep everyone safe and know when a finding goes to the RN, the primary health care provider or a mandated authority.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements the Test Plan lists for this category (18 of them), in our words; the official wording is in the Test Plan.

At a glance

Psychosocial Integrity
8 to 14%

of the exam (the Test Plan's range)

Activity statements
18
Key terms
8

What this guide covers, statement by statement

  1. Use therapeutic communication
  2. Judge how well a client is coping with big changes and offer support
  3. Manage the care of, and support, a client facing emotional or behavioural difficulties
  4. Judge the risk of violence or aggression and keep everyone safe
  5. Check for substance misuse, dependence, withdrawal or toxicity and act on it
  6. Care for someone whose senses or thinking are disturbed
  7. Build the client's culture and beliefs into the care you plan and give
  8. Care for someone who is dying
  9. Look for signs of mistreatment or neglect and respond
  10. Care for and support clients with short and long term mental illness
  11. Assess how the family functions to decide the care plan
  12. Read nonverbal signs of physical or emotional stress
  13. Support someone who is grieving a loss
  14. Help a client adapt when stress or a change in health hits
  15. Notice what is stressing the client and how it affects care
  16. Notice how staff stress affects client care
  17. Find out why a client is not following the treatment plan
  18. Care for a client with cognitive impairment

1Use therapeutic communication

  • Keep the focus on the client: open-ended questions, reflection of feelings, restating, clarifying and attentive silence invite the client to say more.
  • Blocks to avoid: false reassurance, giving advice, why questions, changing the subject, cliches, defending staff and talking about yourself.
  • With a delusion, respond to the feeling and state reality simply; do not argue with the belief or ask for more of its content.
  • With hallucinations, ask what the voices are saying so command hallucinations are found, and stay with the client.
  • Use plain words, an interpreter when the client's language differs (not a family member for health information) and confirm understanding.
  1. In practiceA client on a mental health unit says, "Nobody here gets it." The nurse answers, "Help me understand what it is like for you right now," and sits down at eye level. The open invitation keeps the focus on the client's experience instead of reassuring or defending staff.
  2. Where questions turnChoosing a soothing reassurance ("Everything will be fine") over a response that invites the client to explore the feeling.
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2Judge how well a client is coping with big changes and offer support

  • Life changes include a new diagnosis, loss of a body part or function, retirement, a move into long-term care and a change in role.
  • Ask how the client has coped with past changes and what supports they have; past strengths can be used now.
  • Effective coping: seeking information, using support people, problem solving, paced activity. Ineffective: prolonged denial, withdrawal, avoidance, substance use.
  • Accept the client's pace: refusing to look at a changed body part early on is common and is not forced.
  • Report signs of poor coping or depression, such as hopelessness, withdrawal or a change in sleep and appetite, to the RN.
  1. In practiceA resident who moved into long-term care two weeks ago stays in her room, sleeps through the day and says there is no reason to get dressed. The nurse sits with her, asks what she misses most and reports the signs of poor adjustment so the team can add support.
  2. Where questions turnReassuring the client that they will adjust soon instead of assessing how they are coping now.
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3Manage the care of, and support, a client facing emotional or behavioural difficulties

  • Set clear, consistent limits stated calmly; every staff member applies the same rule so manipulation stops working.
  • Behaviour plans use clear expectations, predictable consequences and prompt, specific praise for the wanted behaviour.
  • A compulsion relieves anxiety: early in treatment allow time for the ritual and meet basic needs, then limit it gradually with the team.
  • In severe anxiety or panic, stay with the client, use short calm sentences and a quiet space; teaching waits until anxiety lowers.
  • Never discuss one client's behaviour with other clients, and never punish without warning.
  1. In practiceAn adolescent asks several staff for a late bedtime, saying each time that another nurse already agreed. The nurse calmly repeats the unit rule, tells the team about the requests and everyone gives the same answer, so the behaviour no longer pays off.
  2. Where questions turnGranting an exception to build rapport, which rewards the manipulation.
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4Judge the risk of violence or aggression and keep everyone safe

  • The strongest predictor of violence is a history of violence; escalating cues are pacing, clenched fists, a loud voice, staring and threats.
  • Use a calm, low voice, short sentences and extra personal space; keep a clear exit for yourself and remove objects that could be thrown.
  • Call for help early as the facility's policy directs; a planned team response is safer than acting alone.
  • A threat against a named person is reported to the RN and team at once so assignments and observation can change.
  • Restraints and seclusion are a last resort under an order and the facility's least restraint policy, with close monitoring of circulation, skin, breathing and comfort.
  1. In practiceA client with a history of assault is pacing and clenching his fists after a phone call. The nurse speaks calmly from more than an arm's length, keeps the doorway clear, alerts the RN and asks other clients to move to the lounge.
  2. Where questions turnTouching or crowding an escalating client to calm them, which is felt as a threat.
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5Check for substance misuse, dependence, withdrawal or toxicity and act on it

  • Ask every client about alcohol, cannabis, opioids, stimulants and other substances in a matter-of-fact way, with the amount and the time of last use.
  • Alcohol withdrawal starts 6 to 24 hours after the last drink: tremor, sweating, anxiety, tachycardia, nausea; it can progress to seizures and delirium, so report early.
  • Withdrawal tools are scored by adding the item scores; the total guides reassessment and the prescribed protocol.
  • Opioid toxicity: slow breathing, pinpoint pupils and decreased consciousness; call for help, give naloxone and support breathing, then stay because naloxone can wear off.
  • Opioid withdrawal: runny nose, yawning, dilated pupils, goosebumps and cramps; uncomfortable but rarely fatal on its own.
  • Care in withdrawal: a quiet room with dim light, seizure precautions as policy directs, hydration and regular monitoring.
  1. In practiceA client admitted with a fracture last drank 30 hours ago and is now shaky, sweaty and anxious with a heart rate of 112/min. The nurse scores the withdrawal tool as the protocol directs and reports promptly so treatment can start.
  2. Where questions turnAttributing early withdrawal signs to pain or surgery and waiting to reassess.
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6Care for someone whose senses or thinking are disturbed

  • Delirium has an acute onset and a fluctuating course with inattention, often with visual hallucinations; it signals a physical cause such as hypoxia, infection, pain, retention or a medication.
  • Dementia develops gradually; a sudden change in a person with or without dementia is collected as data and reported.
  • Support orientation: a clock and calendar, glasses and hearing aids in place, consistent staff, familiar people and objects, and a day and night routine.
  • Sensory deprivation (isolation, low vision, hearing loss) and sensory overload (noise, constant light) both cause confusion.
  • Avoid restraints and sedation as first responses; they worsen confusion and increase injury.
  1. In practiceAn 81-year-old without dementia is suddenly confused the night after surgery and sees bugs on the wall. The nurse checks vital signs and oxygen saturation, looks for a full bladder and reports the acute change as possible delirium.
  2. Where questions turnCalling a sudden new confusion sundowning and leaving it until morning.
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7Build the client's culture and beliefs into the care you plan and give

  • Ask the client about practices and beliefs that matter for care (food, modesty, prayer, ceremonies, family roles, care after death); never assume from background.
  • Many Canadian facilities have policies for smudging and other ceremonies; follow the policy to make the practice possible.
  • Honour requests about the gender of caregivers when staffing allows, and record them in the plan of care.
  • A competent client decides who receives information and who takes part in decisions; ask the client privately.
  • Use a trained interpreter for health information, not family members or children.
  1. In practiceA client who identifies as First Nations asks for an Elder to hold a smudging ceremony before surgery. The nurse asks what is needed, follows the facility's smudging policy and lets the unit know when and where it will happen.
  2. Where questions turnRefusing a cultural or spiritual practice by citing a general rule without checking the facility's policy.
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8Care for someone who is dying

  • The goal is comfort: pain and breathlessness relief as prescribed, mouth care, skin care, positioning and a calm environment.
  • Thirst near death is relieved mainly by mouth care, moist swabs and lip moisturizer; intake falls naturally.
  • Noisy breathing from secretions: turn the client to the side, give gentle mouth care and explain the sound to the family; deep suctioning is not helpful.
  • Expected changes: cool, mottled extremities, irregular breathing with pauses, less urine, more sleep; prepare the family for them.
  • Respect the advance directive and DNR order, and the client's and family's spiritual and cultural wishes.
  1. In practiceA dying client's breathing becomes gurgling, and his wife is frightened. The nurse turns him onto his side, moistens his mouth and explains that the sound is common at this stage and does not usually distress him.
  2. Where questions turnChoosing an active treatment (deep suctioning, fluids, high-flow oxygen) when comfort measures are what the client needs.
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9Look for signs of mistreatment or neglect and respond

  • Signs of abuse: injuries in different stages of healing, patterned bruises, an explanation that does not fit the injury, fear of a caregiver, a caregiver who answers for the client.
  • Signs of neglect: poor hygiene, pressure injuries, weight loss, missed medications and an unsafe or unclean home.
  • Interview the client alone, document objective findings and the client's own words, and do not confront the suspected person.
  • Child abuse: in both British Columbia and Ontario the person with reasonable grounds to suspect it must report directly to child protection services; the duty is personal and proof is not needed.
  • Adult abuse and intimate partner violence: report to the RN or supervisor and follow the agency's policy; a competent adult decides about police involvement unless law or risk to others requires a report.
  1. In practiceA toddler has a spiral fracture and a story that keeps changing. The nurse makes a report to child protection services, tells the team and documents the injury and the parent's words exactly.
  2. Where questions turnPassing a suspicion of child abuse to someone else to report, when the duty to report belongs to the person with the suspicion.
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10Care for and support clients with short and long term mental illness

  • Ask directly about suicide when a client hints at it ("I won't be a problem much longer"); asking does not plant the idea. Report the answer at once.
  • Suicide precautions: remove means of self-harm, observe at the prescribed level, check that medications are swallowed and watch closely as energy returns.
  • Mania: high-calorie finger foods and drinks, a low-stimulus setting, simple limits and rest periods.
  • Psychosis: respond to the feeling, present reality simply, ask about command hallucinations and use reality-based activities.
  • Eating disorders: follow the meal plan, observe during and after meals as prescribed and monitor weight and reported electrolytes, especially in refeeding.
  1. In practiceA client with depression says she will not be a burden much longer. The nurse asks, "Are you thinking of killing yourself?" and, when she says yes, stays with her and reports to the RN at once.
  2. Where questions turnReassuring a client who hints at suicide instead of asking directly.
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11Assess how the family functions to decide the care plan

  • Family dynamics include roles, decision making, communication, conflict and how the family copes under stress.
  • Ask each member, including children and adolescents at their level, how care is shared now before suggesting changes.
  • A caregiver who refuses all help and looks exhausted is at risk of strain; assess her rest, beliefs about help and supports.
  • Stay neutral: do not take sides in a family disagreement.
  • Report findings so the team can involve the social worker or other supports.
  1. In practiceParents argue in clinic about who should give their teen's insulin. The nurse asks each of them and the teen how care works at home now and shares what she learns with the RN before any teaching changes.
  2. Where questions turnTaking one family member's side or giving a solution before assessing how the family works.
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12Read nonverbal signs of physical or emotional stress

  • When words and behaviour do not match, the nonverbal message is usually more accurate; name the mismatch gently.
  • Physical stressors show as grimacing, guarding, restlessness, rubbing a body part or changes in sleep and appetite.
  • Psychological stress shows as hand wringing, poor eye contact, short answers, pacing, regression in children or withdrawal.
  • A client who cannot speak (aphasia, dementia, intubation) communicates through behaviour; look for a cause such as pain or a full bladder.
  • Collect data on the cue, act within scope and report it.
  1. In practiceA client says he is fine before surgery while twisting his hands and avoiding eye contact. The nurse says, "You say you're fine, but you seem tense. What's on your mind?" and learns he is afraid of the anaesthetic, which she reports.
  2. Where questions turnAccepting "I'm fine" when the client's behaviour shows clear distress.
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13Support someone who is grieving a loss

  • Grief is individual; there is no fixed order or timeline, and culture shapes how it is expressed.
  • Support with presence, acceptance of tears and silence, simple words and time; let the person lead.
  • Sensing or briefly hearing the person who died is common in normal grief when the person is still functioning.
  • Loss includes a body part, function, role, home or pregnancy, not only a death.
  • Report signs that grief may be complicated or risky: hopelessness, inability to function over time, substance use or thoughts of suicide.
  • After a sudden death, prepare the body and the room and stay with the family when they view.
  1. In practiceA mother whose infant died six weeks ago says she hears the baby cry some nights but is caring for her other child. The nurse tells her many parents describe this and asks how she is coping and sleeping.
  2. Where questions turnTreating a normal grief experience as a psychiatric symptom, or offering a cliche that closes the conversation.
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14Help a client adapt when stress or a change in health hits

  • Crisis intervention focuses on the immediate problem: help the client name the most urgent need and one concrete step.
  • In a crisis, problem solving is narrowed; long lists and complex plans overwhelm.
  • Reinforce healthy strategies: relaxation and slow breathing, paced activity, sleep, talking with support people.
  • Discourage maladaptive strategies such as alcohol, isolation and suppressing feelings.
  • Mobilize supports (family, friends, community agencies, social work) and report ongoing distress.
  1. In practiceA client whose home burned down says he does not know what to do first. The nurse helps him decide that a place to sleep tonight comes first and contacts the social worker about emergency housing.
  2. Where questions turnGiving a person in crisis a long list of tasks or agencies to deal with all at once.
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15Notice what is stressing the client and how it affects care

  • Stressors that affect care include pain, language barriers, money, work, children, pets, housing and fear about the illness.
  • A client's refusal or poor participation often has a practical cause; ask about it.
  • Address what can be solved: arrange an interpreter, involve the social worker, report unrelieved pain.
  • Recognizing a stressor often resolves the behaviour more effectively than insisting on the routine.
  1. In practiceA client admitted overnight refuses her bath because her dog is alone at home. The nurse helps her reach a neighbour to care for the dog, and the client then accepts her care.
  2. Where questions turnInsisting on the unit routine or documenting a refusal without asking what is behind it.
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16Notice how staff stress affects client care

  • Fatigue, heavy workload, moral distress and critical events affect a provider's concentration and safety.
  • Signs in a colleague: errors, irritability, falling asleep, withdrawal, tearfulness after an event.
  • Nurses have a duty to report practice that puts clients at risk, first to the charge nurse or manager under workplace policy.
  • Support colleagues through debriefing, peer support and the employee assistance program.
  • Do not cover for a colleague or quietly take on an unsafe workload.
  1. In practiceA colleague who has worked several double shifts has made two medication errors and fell asleep on break. The nurse reports the safety concern to the charge nurse, who adjusts the assignment and offers support.
  2. Where questions turnCovering for a fatigued colleague, which hides a risk to clients.
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17Find out why a client is not following the treatment plan

  • Explore the reasons for nonadherence without judgment before teaching or warning.
  • Common reasons: side effects, cost, a delay before benefit, feeling better, stigma, beliefs about illness, missing how the illness felt (as with hypomania).
  • Avoid labels such as "noncompliant" and threats about consequences.
  • Report the client's reasons to the RN and primary health care provider so the plan can be reviewed with the client; the nurse does not change doses.
  1. In practiceA client stopped her antidepressant after two weeks. The nurse asks what led her to stop, learns she felt nauseated and saw no benefit yet, and reports this so the provider can review the plan.
  2. Where questions turnReteaching or warning the client before finding out why the treatment stopped.
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18Care for a client with cognitive impairment

  • Approach from the front, say your name, make eye contact and speak calmly in short sentences.
  • Give one-step instructions and limit choices to two.
  • Keep a consistent routine, caregiver and environment.
  • Respond to the feeling behind a confused statement and redirect, rather than repeatedly correcting reality.
  • For exit-seeking or agitation, look for an unmet need (toileting, hunger, pain, boredom) before anything else; restraints are a last resort.
  • Monitor how UCPs apply these approaches and update the plan of care.
  1. In practiceA resident with dementia goes to the exit saying she must make supper for her children. The nurse walks with her, asks about her children and guides her to help fold napkins in the dining room.
  2. Where questions turnRepeatedly telling a person with dementia the facts of their situation, which increases distress.
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Key terms

Therapeutic communication
Purposeful communication that keeps the focus on the client and helps the client express feelings and solve problems.
Delusion
A fixed false belief that is not changed by evidence.
Command hallucination
A hallucination that tells the person to do something, sometimes to harm themselves or others.
Delirium
An acute, fluctuating disturbance in attention and awareness caused by a physical condition.
Least restraint
The principle that restraints are used only as a last resort, under an order and policy, for the shortest time.
Duty to report
A legal obligation on a person with reasonable grounds to suspect child abuse to report it directly to child protection services.
Crisis intervention
Short-term help focused on the immediate problem when a person's usual coping is overwhelmed.
Complicated grief
Grief that remains intense and disabling over a long time and interferes with daily life.

After this guide: You should be able to choose the therapeutic response, recognize cues of suicide, violence, withdrawal, delirium and abuse, act safely within the practical nurse's scope and know when a finding goes to the RN, the primary health care provider or child protection services.

Practise Psychosocial Integrity