Custom: Practice 6(Mental Health)
A nurse is reviewing data for a client who is manifesting symptoms related to a neurodevelopmental disorder. Which of the following tools should the nurse use to best screen the data for a neurodevelopmental disorder? Neurological assessment scale Medical history form Family composition questionnaire ADHD-FX
ADHD-FX The ADHD-FX is a helpful ADHD screening tool that uses a questionnaire to assess function in a variety of settings, such as academic, social, and at home.
A nurse is caring for a client who is grieving and has experienced sleep disturbances, weight loss, and often feels angry and irritable. The client also states that they feel depressed. Which of the following assessments is the nurse's priority? Spiritual practices Cultural practices Ability to function Social support
Ability to function Analysis of cues suggest the client has manifestations of prolonged grief disorder (PGD). Further assessment is needed to determine client's ability to function on a daily basis. Client safety and ability to care for themselves is the priority action for creating a plan of care.
A nurse is preparing to care for a client who is experiencing complicated grief. Which of the following actions demonstrates grief-informed care? Support the privacy of the client and do not discuss the loss. Contact the provider for directions on how to proceed. Stand when speaking to the client with door of the room open. Acknowledge and recognize that the client has experienced a loss.
Acknowledge and recognize that the client has experienced a loss. The nurse should take a grief-informed approach to care, which includes acknowledging and recognizing that the client has experienced a loss.
Which of the following roles is important for a nurse to undertake while working with a client who has a communication disorder? Speech therapist Advocate Diagnostician Legal representative
Advocate The role of advocate is a significant nursing role which helps maintain client dignity while supporting the best interests of the client.
A nurse is caring for a client who has cancer and is terminally ill. The nurse should recognize that the client and their family might be experiencing which of the following types of grief? Anticipatory Traumatic Complicated Disenfranchised
Anticipatory Anticipatory grief might be experienced by clients and their families when a client has a terminal illness and is still alive.
A nurse in a community health care clinic meets with a 14-month-old child whose older sibling has autism spectrum disorder (ASD). Which of the following actions should the nurse take? Assist the guardians in obtaining a neurological screening for the 14-month-old child. Refer the child to psychiatric services for medication therapy to prevent ASD. Reassure the guardians that they should not worry because ASD doesn't run in families. Tell the guardians they need to wait until the child is 2 or 3 years old before any screening will provide valid results.
Assist the guardians in obtaining a neurological screening for the 14-month-old child. The nurse's role includes advocating for early screening for neurodevelopmental disorders.
A nurse is providing an educational program about eating disorders to the local community. The nurse should include that which of the following groups has an increased risk for developing an eating disorder? Athletes Chefs Movie directors Musicians
Athletes Some of the high-risk groups correlated with eating disorders include models, dancers, and athletes, such as gymnasts, wrestlers, figure skaters, and horse jockeys.
The guardians of a school-aged child state that they run in circles in the classroom, interrupt others' conversations at home, and cannot focus when doing homework. The nurse should recognize that these behaviors can be indicative of which of the following disorders? Stereotypic movement disorder Attention-deficit/hyperactivity disorder (ADHD) Autism spectrum disorder (ASD) Dysgraphia
Attention-deficit/hyperactivity disorder (ADHD) ADHD is a neurological condition that impairs one's ability to listen, focus, and follow instructions. Individuals who have ADHD might be extremely active and impulsive which can negatively impact social interaction and academic performance.
Which of the following is a behavioral sign of a learning disability in a child? Avoiding homework Slow work pace Excessive focus on details Lack of attention to details
Avoiding homework This is a behavioral sign that may be indicative of a learning disability.
A nurse is participating in a hospital committee to discuss rationing of care and resources during a pandemic. The nurse should identify that which of the following behaviors is important in providing ethical and empathetic nursing care? Be honest, caring, and consistent Be transparent, honest, and credible Be transparent, collaborative, and consistent Be credible, collaborative, and consistent
Be transparent, collaborative, and consistent Being a nurse is a holistic role, and when rationing of resources is necessary, a nurse should be transparent, collaborative, and consistent in practice and care.
A nurse is providing an in-service about the prevalence of eating disorders. Which of the following information should the nurse include? The prevalence of eating disorders is decreasing. Anorexia nervosa is the most prevalent type of eating disorder. Binge-eating disorder is the most prevalent type of eating disorder. Bulimia nervosa is the most prevalent type of eating disorder.
Binge-eating disorder is the most prevalent type of eating disorder. Binge-eating disorder is the most prevalent type of eating disorder.
A nurse is talking with a newly hired nurse. The newly hired nurse states, "I really thought that I would easily transition from school to work. I am just exhausted, and now I wonder if I should even be a nurse." This statement that the nurse is experiencing which of the following types of stress? Grief Burnout Trauma grief Anxiety
Burnout This is an example of burnout because the newly hired nurse is experiencing a sense of powerlessness in the current situation.
Which of the following statements is true about children who have learning disabilities? Children who have learning disabilities might excel in reading skills. Children who have learning disabilities have below-average intelligence. Children who have learning disabilities have average or above-average intelligence. Children who have learning disabilities might excel in listening skills.
Children who have learning disabilities have average or above-average intelligence. This statement is true.
A nurse is caring for a client who has an eating disorder. The nurse should identify that eating disorders are challenging to treat due to which of the following factors? The treatment of an eating disorder depends primarily on psychotropic medication. Clients who have an eating disorder struggle with eating, which is necessary to live. Clients who have an eating disorder must be treated on an inpatient basis. Eating disorders have an abrupt onset.
Clients who have an eating disorder struggle with eating, which is necessary to live. The nurse should identify that eating disorders are challenging to treat because they involve a disruption in eating, which is necessary to live.
A nurse is precepting a newly hired nurse. The newly hired nurse asks, "Why is it important for me to attend a training on compassion fatigue and burnout?" Which of the following responses should the precepting nurse make? "Compassion fatigue can occur because nurses often experience trauma. We must learn to prioritize our self-care." "This is something that human resources requires. There has been a lot of patient feedback about care." "The patient experience must include compassionate nursing care." "This is a part of orientation, and you need complete all your required training during orientation."
Compassion fatigue can occur because nurses often experience trauma. We must learn to prioritize our self-care." Compassion fatigue (CF) can be experienced by nurses due to occupational stress and exposure to trauma, such as the death of clients. Education about CF and best practices, such as self-care practice, are important strategies to reduce CF.
A nurse is assessing a 10-year-old child who has an autism spectrum disorder. Which of the following findings are expected? Difficulties in mastering the rules of spelling Continuous rocking of the body Difficulty reading instructions for a game. Difficulties in remembering facts and numbers
Continuous rocking of the body This is a repetitive behavior that is a hallmark characteristic of ASD.
A nurse is assessing a client who has been diagnosed with prolonged grief disorder (PGD). The nurse should identify which of the following findings as an indication that the client has developed separation distress? Intense sorrow and emotional pain Continuous yearning for the deceased person Preoccupation with the person who died Preoccupation with the circumstance of the death
Continuous yearning for the deceased person Separation distress is a significant post-loss condition and is an attachment state that is expressed by the client's yearning.
Which of the following statements indicates a positive outcome for a client who has a stereotypical motor disorder? Calculates basic math problems Controls impulsive movements when excited Engages in conversation with peers Exhibits considerate behavior with family members
Controls impulsive movements when excited A client with a stereotypical motor disorder would have difficulty controlling impulsive movements when excited, so a good outcome statement to evaluate progress of interventions would be to control these movements effectively.
A teenage client who has autism spectrum disorder (ASD) tells a nurse, "I'm not doing well in all my classes. I am not learning as fast as everyone else." Which of the following actions should the nurse take? Recommend that the client consult with a psychologist. Refer the client to a neurodevelopmental specialist. Suggest the client undergo a neurological assessment. Coordinate a meeting with the client and school counselor.
Coordinate a meeting with the client and school counselor. A nurse can act as an advocate for a client in coordinating care, education, and skill development with teachers and school staff to promote good outcomes.
A client is experiencing complicated grief and has been diagnosed with prolonged grief disorder (PGD). Which of the following should the nurse include in the plan of care for a client who has PGD? Create a safe, confidential environment. Encourage the client to talk about their loss. Provide education regarding specialized treatment such as complicated grief therapy. Ask the client why their grief manifestations continue.
Create a safe, confidential environment is correct. Creating a safe and confidential environment is essential for client healing and positive client outcomes. Encourage the client to talk about their loss is correct. Encouraging a client to talk about their loss is essential for developing a trusting therapeutic relationship and an aspect of a grief-informed approach .Provide education regarding specialized treatment such as complicated grief therapy is correct. Client plan of care for PGD includes specialized treatment and education regarding specialized therapies should be include in a client's plan of care.
A nurse is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect? Lower than normal expected reference range of body weight Hyperkalemia Amenorrhea Dental decay
Dental decay The nurse should expect dental decay for a client who reports frequent self-induced vomiting because this causes tooth enamel to become eroded, causing dental decay.
Which of the following comorbidities would a nurse expect when caring for a client with Down syndrome? Tic disorder Developmental Coordination Disorder (DCD) Learning disorders Depression
Depression Individuals who have Down syndrome often have comorbid psychiatric conditions, including depression and anxiety
A nurse is caring for a client who has a history of angina. Nurses' Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air A nurse is caring for a client who has type 1 diabetes mellitus and recently experienced significant weight loss. The client states, "I have been skipping my insulin to help lose weight." The nurse should identify that this is an indication of which of the following conditions? Diabulimia Bulimia nervosa Avoidant restrictive food intake disorder (ARFID) Anorexia nervosa
Diabulimia Diabulimia is an eating disorder that involves someone who has type 1 diabetes mellitus reducing or ceasing insulin treatment to lose weight.
A nurse is teaching a client who has an eating disorder about mindfulness and distress tolerance skills. This is an example of which of the following treatment modalities? Humanistic therapy Interpersonal therapy Dialectical behavior therapy Cognitive therapy
Dialectical behavior therapy Dialectical behavioral therapy involves providing validation about what the client is experiencing and feeling. This therapy promotes mindfulness and distress tolerance skills.
Which of the following is an example of inattentiveness seen in an adolescent who has ADHD? Difficulty waiting their turn Difficulty completing their homework Difficulty staying seated in class Listening attentively
Difficulty completing their homework Completing homework requires attention and mental effort.
A nurse is caring for a client who has an eating disorder. Which of the following actions should the nurse plan to take during the orientation phase of the nurse-client relationship? Identify areas that are causing problems in the client's life. Perform self-reflection activities. Provide education about the eating disorder. Discuss the timeline of the relationship.
Discuss the timeline of the relationship. The nurse should establish a contract about the timeline of the nurse-client relationship during the orientation phase.
A nurse is preparing a presentation for newly hired nurses about self-care of the nurse. Which of the following examples of self-care routines should be included? Eating balanced and nutritious meals Exercising occasionally Taking time for relaxation Establishing healthy boundaries Taking a lunch break
Eating balanced and nutritious meals is correct. Self-care routines, such as eating balanced and nutritious meals, should be practiced at work and home to promote physical, psychological, emotional, and spiritual self-care. These focus on individual health and wellbeing. Taking time for relaxation is correct. Self-care routines are to include current practices at work and home regarding physical, psychological, emotional and spiritual self-care. These focus on individual health and wellbeing. Establishing healthy boundaries is correct. Healthy boundaries provides limits or rules within a nurse-client relationship which and helps protect the nurse's and client's person's health, self-esteem, and well-being. Taking a lunch break is correct. Self-care routines, such as taking a lunch break, should be practiced at work and home to promote physical, psychological, emotional, and spiritual self-care. These focus on individual health and wellbeing.
A nurse works in which of the following roles when providing care to a client who has a tic disorder? Educating client and caregivers Prescribing behavioral therapy Diagnosing neurological conditions Prescribing pharmacological interventions
Educating client and caregivers The nurse can help clients and caregivers be aware of the elements of tic disorders and the options for addressing the condition.
A nurse is monitoring a client who has ADHD. The client is demonstrating disruptive behavior due to overstimulation from being in a group setting. Which of the following actions should the nurse take? Ask the client to express how they feel to the group. Initiate physical restraints. Administer an SSRI medication. Escort the client to a quiet room.
Escort the client to a quiet room. A quiet, unlocked room with soft objects can provide a safe, unrestrained place for a client to escape from overstimulation.
Which of the following characteristics would a nurse expect to find in an adolescent who has ADHD? Taking multiple attempts in completing verbal sentences Manifestations of an anxiety related disorder Expressing difficulties in reading assignments at school Manifestations of a schizophrenia spectrum related disorder
Expressing difficulties in reading assignments at school Difficulties in reading words is associated with dyslexia.
A nurse is teaching a parent about communicating with their teenage child who has anorexia nervosa. This is an example of which of the following types of therapy? Behavioral therapy Cognitive behavioral therapy Family-based therapy Humanistic therapy
Family-based therapy Family-based therapy involves providing a framework for family and friends to communicate with a client about their condition in a way that does not trigger the client, while also not enabling them. This is a first-line treatment for adolescents who reside with their parents.
A nurse is caring for a client who has bulimia nervosa has a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which of the following medications should the nurse anticipate administering? Fluoxetine Valproate Naltrexone Olanzapine
Fluoxetine The nurse should identify that fluoxetine is an SSRI that is FDA approved for the treatment of bulimia nervosa.
A charge nurse is concerned by a nurse's recent behaviors. Which of the following behaviors by the nurse indicates that they are is experiencing burnout? Does not report known medication error Takes regular lunch breaks Frequently calls in sick Sets firm professional boundaries with clients
Frequently calls in sick Frequently calling in sick might be an expression of burnout or compassion fatigue, which is emotional exhaustion and a decreased ability to provide compassionate or empathic care.
A nurse is caring for a client who has ADHD. Which of the following findings should the nurse expect to observe? Hypohidrosis Hypoactivity Hyperactivity Hyperhidrosis
Hyperactivity Classic symptoms of ADHD include inattention, hyperactivity, and impulsivity.
A nurse is providing medication education to clinicians who provide care at a local community health center. A small number of clients who regularly attend the community center identify as being part of an underrepresented culture. Which of the following benefits does the provision of culturally competent care provide to the client? If the client is comfortable, they are more likely to continue to seek treatment. Providing culturally competent care can reduce the client's feelings that they are risking relationships and jobs by seeking care. Receiving culturally competent care can reduce the chance that the client will need psychotropic medications. Without culturally competent care, the client might pay more out of pocket for treatment.
If the client is comfortable, they are more likely to continue to seek treatment. Culturally competent care can make clients feel more comfortable and can reduce incidents of bias. This makes it more likely that clients will continue to seek treatment.
A nurse is caring for a client who has anorexia nervosa. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Introduce coping strategies to reduce anxiety associated with eating. Summarize the goals that were met during treatment. Gather information about the client's "fear foods." Identify treatment goals related to the client's body image.
Introduce coping strategies to reduce anxiety associated with eating. The nurse should introduce coping strategies during the working phase of the nurse-client relationship.
A nurse is caring for a client who has anorexia nervosa. Which of the following findings should the nurse expect? Swollen parotid glands Hyperglycemia Hyperkalemia Lanugo
Lanugo Lanugo is a fine, downy hair that may grow on the face, back, and arms as a protective response to keep the body warm. This is an indication of anorexia nervosa.
Which of the following comorbid conditions might a nurse expect to see in a client who has ADHD? Down syndrome Spinal stenosis Learning disabilities Schizophrenia
Learning disabilities Serious academic and learning deficits frequently occur in clients who have ADHD.
A nurse is assessing a client who is experiencing grief. The nurse should identify which of the following findings as an indication that the client has developed clinical depression? States that connecting with family is comforting Loss of interest in pleasurable activities Loss of appetite Has intense moments of sadness
Loss of interest in pleasurable activities Loss of interest in pleasurable activities
A nurse is setting goals for a client who has bulimia nervosa. Which of the following goals should the nurse identify as the priority? Establishing a therapeutic relationship Identifying the cause of the eating disorder Medical stabilization Interrupting the binge-purge cycle
Medical stabilization The nurse should identify that medical stabilization is the highest priority for a client who has bulimia nervosa.
A nurse is caring for a 10-year-old client who has sustained a life-threatening injury and is on life support. Discussion regarding the continuation of care and withdrawal of life-sustaining treatment have begun. The nurse should identify that which of the following people can be involved in making the decision to withdraw treatment? Dietitian Nurse Medical ethicist Provider Medical surrogate
Medical surrogate is correct. The family member or person who has medical surrogacy for the client should be involved in decision to remove life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Provider is correct. The medical provider who is directly involved in care of the client or is consulted should be involved in the decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Medical ethicist is correct. A medical ethicist may be consulted and is considered a member of the client's health care team involved with decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Nurse is correct. The nurse is a key member of the of the client's health care team involved with decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity .Dietitian is incorrect. The dietitian is not involved in decisions regarding the withdrawal of life-sustaining treatment.
A nurse is weighing a client who was recently admitted into the eating disorder program. Which of the following actions should the nurse take? Invite the client to predict their weight beforehand. Weigh the client each day after their evening meal. Demand that the client remove hidden objects from their clothing prior to being weighed. Monitor for any extra fluids the client may have consumed prior to being weighed.
Monitor for any extra fluids the client may have consumed prior to being weighed. The nurse should monitor the client's fluid consumption because they might attempt to fluid load prior to being weighed to manipulate the weight reading.
A charge nurse is teaching a new nurse about medical aid in dying, which is legal in their state. The new nurse states, "I have very mixed feelings about medical aid in dying. Do I have to participate in the client care?" Which of the following statements should the charge nurse make? "Medical aid in dying is controversial. The goal is to support the client and prevent pain and suffering." "Medical aid in dying is consistent with the client's right for self-determination. Why should that be a concern for you?" "Being involved in medical aid in dying within this state is a part of providing client-centered care. You will need to participate." "As a nurse, your involvement in the medical aid in dying process is not required. You can object to participation based on personal beliefs."
"As a nurse, your involvement in the medical aid in dying process is not required. You can object to participation based on personal beliefs." CORRECT The American Nurses Association clearly indicates that nurses may refuse to participate in medical aid in dying for personal or religious reasons.
A nurse is caring for a client who is experiencing grief. Which of the follow client statements are consistent with a diagnosis of prolonged grief disorder (PGD)? "I need my job; I have not missed a day of work in 2 years." "My sibling died 14 months ago. Every day since then has been horrible." "Before, I would love going fishing, but not anymore." "Sometimes, I wish it was me who was killed, not my sibling." "I just miss them every day and want to talk with them one more time."
"Before, I would love going fishing, but not anymore" is correct. This statement expresses a loss of pleasure in activities once enjoyed, which is consistent with PGD ."Sometimes, I wish it was me who was killed, not my sibling" is correct. This statement expresses blame or guilt and an expression of distress, which is consistent with PGD ."I just miss them every day and want to talk with them one more time" is correct. This statement expresses yearning for the client and distress in the loss, which is consistent with PGD.
A nurse is teaching a client who was diagnosed with prolonged grief disorder about the importance of cognitive behavioral therapy (CBT). which of the following client statements indicates an understanding of the teaching? "Cognitive behavioral therapy will help me make funeral and burial arrangements for my partner." "Cognitive behavioral therapy will teach me about what happened during my partner's medical treatment." "Cognitive behavioral therapy will help me answer all my questions about why my partner died." "Cognitive behavioral therapy will help me figure out how to live with the loss of my partner."
"Cognitive behavioral therapy will help me figure out how to live with the loss of my partner." Professional therapy, such as cognitive behavioral therapy, will focus on the client learning to adapt to life without their loved one as well as working on guilt or other feelings of grief.
Which of the following questions should a nurse ask when assessing a pediatric client's risk factors for autism spectrum disorder (ASD)? "Are the parents younger than 25 years of age?" "Does the child have a twin who has similar manifestations?" "Does the child have gastrointestinal (GI) disorders?" "Has the child received all their vaccinations?"
"Does the child have a twin who has similar manifestations?" If one twin has ASD, the other is likely to be affected 36% to 95% of the time.
A nurse is providing education to a group of clients about the health effects of eating disorders. Which of the following client statements indicates an understanding of the teaching? "Anorexia can cause hypertension." "Eating disorders do not affect the kidneys." "Eating disorders can prevent the onset of the menstrual cycle." "Bulimia has no long-term health effects."
"Eating disorders can prevent the onset of the menstrual cycle." Some clients diagnosed with an early age onset of anorexia nervosa have never had their menstrual cycle due to their percentage of low body fat and hormonal deficiencies.
A nurse is screening a young adult for an eating disorder using the SCOFF questionnaire. Which of the following questions by the nurse represents the "O" for this assessment tool? "Have you experienced trouble with overeating?" "Do you think of yourself as overweight, even when others say you are thin?" "Have you recently lost more than 14 pounds in a 3-month period?" "Do you feel like you are outgoing?"
"Have you recently lost more than 14 pounds in a 3-month period?" The "O" of the SCOFF questionnaire represents "one stone," which is a British unit of measurement equivalent to 6.35 kg (14 lb). Therefore, this question represents the "O" for this assessment tool.
A nurse is caring for child who was resuscitated after drowning, is intubated, and has met the legal criteria of death. The health care team and parents have decided to stop all treatment and extubate. Which of the following statements by the nurse reflects that they are experiencing moral distress? "I could never give up on my child. I feel sick to my stomach." "The child is only 4-years-old. They can't give up now." "I can't believe that the parents were so negligent and didn't have a fence around the pool." "My faith would never let me make this decision for my child." "I am just so angry. This is a beautiful child with so much living ahead of them."
"I could never give up on my child. I feel sick to my stomach" is correct. This is an expression of personal values. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse ."The child is only 4-years-old. They can't give up now" is correct. This is an expression of anger and frustration, which are manifestations of moral distress. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse. "My faith would never let me make this decision for my child" is correct. This is an expression of personal beliefs and values. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse ."I am just so angry. This is a beautiful child with so much living ahead of them" is correct. This is an expression of anger and shock, which are manifestations of moral distress. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse.
A nurse is performing an initial assessment of a client who has anorexia nervosa. Which of the following client statements should the nurse expect? "I like the way I look." "I hope I will be able to gain weight during my stay." "I feel hungry most of the day." "I feel fat."
"I feel fat." Clients who have anorexia nervosa have a distorted body image and often perceive themselves as overweight, even if they are severely underweight.
A nurse is assessing a newly admitted client who has bulimia nervosa. Which of the following client statements should the nurse expect? "I feel energized when I binge and purge." "I feel preoccupied about my body shape." "I feel confident in my abilities." "I feel in control of my life."
"I feel preoccupied about my body shape." Eating disorders involve intense preoccupation with weight and body image.
A nurse is caring for a client who has a binge-eating disorder. Which of the following statements should the nurse expect from this client? "My binges usually start off with feeling hungry." "I binge to reward myself for completing difficult tasks." "I feel so defeated and want to hide after I have binged." "I am able to control the pace of my bingeing when I start getting full."
"I feel so defeated and want to hide after I have binged." Binges are associated with emotional distress, including shame, disgust, and embarrassment.
A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa? "I feel an emotional high during my binge-purge episodes." "I only use the laxatives when I am feeling constipated." "I feel a sense of power by restricting my food intake." "I have binged and purged for years without my family or friends knowing."
"I have binged and purged for years without my family or friends knowing." Clients who have bulimia nervosa typically hide bingeing and purging behaviors from others.
A nurse is admitting a client who has anorexia nervosa. Which of the following statements should the nurse expect from this client? "I restrict myself to 2,000 calories per day." "I have certain foods, like pizza, that cause me a lot of fear." "I don't eat because I do not like the taste of food." "I don't bother to track the number of calories I eat in a week."
"I have certain foods, like pizza, that cause me a lot of fear." CORRECT Clients who have anorexia nervosa often have "fear foods" that produce feelings of anxiety.
A nurse is proving care for a client. Which of the following client statements suggests receptive language disorder? "I have trouble following instructions because I don't understand what people are telling me." "People accuse me of being happy when something bad happens because I often smile." "People don't understand me because I can't find the right words to say." "I have trouble understanding people because my mind wanders while they are talking."
"I have trouble following instructions because I don't understand what people are telling me." This statement would suggest the individual has a hard time comprehending what others say and has a difficult time applying information and following instructions.
A nurse has completed an assessment of a client whose parent recently died. Which of the following client statements is an indication that the client is experiencing death anxiety? "I have had trouble sleeping. I wake up and go to my parent's room to find them." "I just don't understand why this happened. My thoughts have been so mixed-up since they died." "I just can't stop thinking about my own death. Life is so short." "I am so sad. It is very hard to consider what holidays will be like."
"I just can't stop thinking about my own death. Life is so short." Death anxiety is an emotional response and feeling of insecurity and anxiety a person can experience when considering death or dying.
A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief? "I can't cry when I talk about my friend because soldiers aren't supposed to show emotions." "It has been more than a year, and I still don't want to leave the house." "I should have been the one who had been killed instead of my friend." "When I have flashbacks, it feels like my heart is going to beat through my chest."
"I should have been the one who had been killed instead of my friend." This statement indicates self-blame or guilt, which is a manifestation of traumatic grief. A client's response is often intensified by disbelief or shock, feelings of anger or numbness, self-blame or guilt, a sense of fear or danger, loss of meaning.
A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa? "I spend lots of time searching for new recipes." "I know I am skinny." "I enjoy wearing form-fitting clothes to show off my body." "I have so much energy."
"I spend lots of time searching for new recipes." Clients who have anorexia nervosa typically demonstrate a high interest in preparing food, but not in eating.
A nurse is providing teaching about eating disorders to a group of clients. Which of the following client statements indicates an understanding of the teaching? "There are very few people affected by eating disorders." "Since I have only had my eating disorder for a year, it is not that serious." "I will need to ask for professional help if I want to recover from my eating disorder." "I can overcome my eating disorder if I just start eating."
"I will need to ask for professional help if I want to recover from my eating disorder." Due to the complexity and seriousness of eating disorders, client's should seek professional help to support the recovery process. Therefore, this statement indicates an understanding of the teaching.
A nurse is caring for a client who has returned from a bereavement support group. Which of the following client statements demonstrates that the client is meeting the planned outcomes of treatment? "No matter how much I try, I can't forget the night they died. I wonder if I ever will?" "People never really understand what my partner's death means to me. I really miss them." "I will take the kids to the ocean. We had great times there as a family, and it's time for more memories." "Our time together was so short. I just wish I had shown them how much I appreciated them."
"I will take the kids to the ocean. We had great times there as a family, and it's time for more memories." Accepting the death of the loved one and the loss is evidence that bereavement care and therapy are working.
A nurse is teaching a group of students about the prevalence of eating disorders in the U.S. Which of the following statements by a student indicates an understanding of the teaching? "It is estimated that 10 million people in the United States have an eating disorder." "The prevalence of eating disorders in the United States is lower compared to other countries." "It is difficult to determine the prevalence of eating disorders due to the secretive nature of these conditions." "Eating disorders are over diagnosed due to dieting fads."
"It is difficult to determine the prevalence of eating disorders due to the secretive nature of these conditions." The prevalence of eating disorders is difficult to determine due to the secretiveness of these conditions. Many clients who are experiencing an eating disorder will deny that the condition exists and avoid seeking help.
A nurse manager is evaluating staff to determine if efforts to reduce occupational stress have been successful. Which of the following statements by a staff member indicates that the occupational stress on the unit has been decreased? term-119 "Lately, we have had many client deaths. Now, we will take a break or even a pause after the death." "We are constantly asking for help, some clients are readmitted every week, and nothing changes." "Work is nonstop: no breaks or lunch." "People call in sick, so most days you just have to put your head down and work on your own."
"Lately, we have had many client deaths. Now, we will take a break or even a pause after the death." This statement recognizes a cause of occupational stress, multiple client deaths, and provides an example of a strategy, taking a break, that allows the nurses to consider their own thoughts and feelings.
A nurse is presenting information about the epidemiological aspects of eating disorders at a community health fair. Which of the following statements from a participant indicates a need for further teaching? "Eating disorders have one of the highest death rates among mental health disorders." "Around 30 million Americans have experienced an eating disorder." "Someone dies due to an eating disorder every 15 minutes." "Less than half of people with eating disorders seek help for their condition."
"Someone dies due to an eating disorder every 15 minutes." This statement is inaccurate and indicates a need for further teaching. The nurse should reinforce that someone dies due to an eating disorder every 52
A nurse is meeting with a 15-year-old client who has ADHD The client and their parent state they would like their medications stopped due to the unpleasant side effects. Which of the following statements should the nurse make? "It is important to take the medication as prescribed." "I will go get the physician to discuss this situation." "Tell me more about what unpleasant effects you have been experiencing." "Stop taking the medication immediately."
"Tell me more about what unpleasant effects you have been experiencing." The nurse's role is to advocate for the best interest of the client. The nurse would further assess what adverse effects the client is experiencing. Advocacy also includes talking to the provider about changing the dose of medication or switching to a different medication to decrease negative effects.
A nurse is teaching a newly licensed nurse about eating disorders. Which of the following statements should the nurse include in the teaching? "There are many different types of eating disorders." "Eating disorders have a low mortality rate compared to other mental illnesses." "Eating disorders are primarily caused by a lack of information about nutrition." "Eating disorders only affect females."
"There are many different types of eating disorders." There are a variety of eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, among others
A nurse is conducting a psychoeducation group about the etiology of eating disorders. Which of the following statements should the nurse include? "Childhood trauma is the primary contributor to the development of an eating disorder." "There is a mix of biological and psychosocial determinants that contribute to the development of eating disorders." "A specific gene has been identified as the primary cause of eating disorders." "Western cultural values are the primary cause of eating disorders."
"There is a mix of biological and psychosocial determinants that contribute to the development of eating disorders." The cause of an eating disorder is multifactorial and best explained by the diathesis-stress model, which poses that there are environmental and psychosocial factors, as well as biological and genetic factors that contribute to the development of an eating disorder.
A nurse is educating a parent of an infant that has failed to reach specific developmental milestones. Which statement should the nurse include? "Usually a diagnosis of global developmental delay can be made when a child does not meet milestones. Then, when the child is older, more testing can be done." "When an infant fails to meet certain important milestones, an intellectual disability can be diagnosed by a pediatrician." "A diagnosis of any type of neurodevelopmental disorder cannot be provided until a child is old enough to take a critical thinking test." "Unless trauma or injury is suspected, a child should be monitored for neurodevelopmental progress for a few years before a diagnosis is made."
"Usually a diagnosis of global developmental delay can be made when a child does not meet milestones. Then, when the child is older, more testing can be done." Standardized developmental screenings at various intervals of well-child visits or whenever a parent or clinician expresses a concern, as well as autism-specific screening at 18 and 24 months of age and at any subsequent visits.
A nurse is caring for a client who has anorexia nervosa and expresses anxiety about the weight gain restoration program. Which of the following statements should the nurse make? "Why do you become so frightened about gaining weight?" "Everyone feels better after they have completed the program." "What are your feelings about the restoration process?" "You will need to accept that increasing weight is a natural part of the program."
"What are your feelings about the restoration process?" This question is therapeutic because it avoids referring to weight gain in a manner that might be distressing to a client who has anorexia nervosa. The use of the phrase "restoration process" is more sensitive to the client's feelings of fear about gaining weight.
A guardian is concerned that their child, who has autism spectrum disorder (ASD), is having difficulty at school despite being in a specialized learning environment. Which of the following statements should the nurse make? "Many children with ASD have to work harder at school, but your child can succeed with enough effort." "Your child may have a coexisting condition that is affecting school performance, so we can arrange an additional evaluation to determine the best actions." "I can speak to the pediatrician about increasing your child's medication, and this will likely help with school performance." "Your child may have an intellectual disorder, instead of ASD, that is causing difficulty with school work, so a different educational program may be needed."
"Your child may have a coexisting condition that is affecting school performance, so we can arrange an additional evaluation to determine the best actions." It is common for neurodevelopmental disorders to coexist with other conditions, so further evaluation should be done to identify the appropriate combinations of interventions that will provide the best outcomes.
A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to "eat clean." The nurse should identify that this is an indication of which of the following conditions? Anorexia nervosa Orthorexia Rumination disorder Pica
Orthorexia The nurse should identify that a client who has eliminated specific foods from their diet to "eat clean" may have orthorexia. Orthorexia is characterized by an obsession with "clean eating," which results in significant food restriction and malnutrition.
A nurse is caring for a client who has a prescription for a bone densitometry test. The nurse should identify that this test is used to assess for which of the following conditions? Osteopenia Hyperphosphatemia Hypocalcemia Bone fractures
Osteopenia A bone densitometry test is used to detect osteopenia/osteoporosis, which is a potential complication of anorexia nervosa.
A nurse is discussing the official American Nurses Association position on capital punishment with a coworker. Which of the following statements by the nurse indicates an understanding of the American Nurses Association's (ANA) position? The role of the nurse is to facilitate justice as defined by the United States and the state in which they are employed. Participation, directly or indirectly, in the execution of a human being goes against nursing core values. A prison nurse has specific duties, among which is the preparation and support of the individuals awaiting execution. A nurse must set aside personal values and provide care based on the setting in which they work.
Participation, directly or indirectly, in the execution of a human being goes against nursing core values. The American Nurses Association (ANA) opposes both capital punishment and nurse participation in capital punishment.
A nurse is preparing for a home visit with a client whose partner recently died by suicide. Which of the following actions should the nurse take first when preparing to provide client-centered care? Review current provider prescriptions. Read the client's progress notes. Review the client's history. Perform self-reflection.
Perform self-reflection. Performing self-reflection allows the nurse to consider their own beliefs, values, personal losses or grief, and any bias they might have. This is an important first step in preparing for client-centered care.
Which of the following risk factors should a nurse associate with ADHD? Hispanic ethnicity High birth weight Prenatal exposure to alcohol or tobacco High-sugar diet
Prenatal exposure to alcohol or tobacco Strong evidence supports that prenatal exposure to alcohol or tobacco is an identified risk factor for ADHD.
A nurse is discussing the plan of care with the guardians of a child recently diagnosed with a neurodevelopmental disorder. The guardians tell the nurse that they are opposed to any medication intervention. Which of the following actions should the nurse take? Recommend the use of nonpharmacological interventions to the child's provider Suggest that the guardians find a new health care provider that will comply with their wishes for treatment. Tell the guardians that medication intervention will be necessary to proceed with the child's care. Educate the guardians about the possible effects and tolerability of medication intervention for their child.
Recommend the use of nonpharmacological interventions to the child's provider Gardians' preferences should be considered when creating a treatment plan. If parents refuse a particular treatment, the nurse should investigate the reasons behind the refusal then work with parents to provide treatment that is acceptable to them.
A nurse is caring for a client who has autism spectrum disorder (ASD). Which of the following clinical manifestations should the nurse expect to observe? Making eye contact with peers Engaging in new activities Interacting with peers Repeating what others say
Repeating what others say Young children who have ASD often exhibit restricted, repetitive patterns of behavior, interests, or activities. This may include repeating the words and actions of others without reason or context.
A nurse is caring for a client who has binge-eating disorder. Which of the following actions should the nurse plan to take during the termination phase of the nurse-client relationship? Review treatment goals that have been accomplished. Gather data about the client's home situation. Provide personal contact information to the client for use in case of emergency. Introduce the concept of discharge planning.
Review treatment goals that have been accomplished. The nurse should plan to review treatment goals that have been accomplished during the termination phase of the nurse-client relationship
A nurse is admitting a client who has end-stage chronic obstructive pulmonary disease (COPD) and has been intubated on previous hospitalizations. The client refuses intubation and any invasive treatment. Which of the following client rights is the client exercising? Right to medical records Right of autonomy Right of justice Right of confidentiality
Right of autonomy The client is exercising their right to determine their own care and treatment. The nurse should advocate for the client and support the client's right of autonomy or self-determination.
A nurse is caring for a client who has bulimia nervosa. Which of the following findings should the nurse expect? Lanugo Hyperkalemia Russell's sign Sunken parotid glands
Russell's sign Russell's sign is the presence of bruising and calluses on the knuckles of the hands due to self-induced vomiting. It can be an indicator of purging, which is a manifestation of bulimia nervosa.
A nurse is contributing to the plan of care for a recently admitted client who has bulimia nervosa. Which of the following interventions should the nurse recommend including in the plan of care for the first week of hospitalization? Permit the client to select their own meals. Assign the client independent bathroom privileges. Supervise the client during mealtimes. Punish the client for purging behavior.
Supervise the client during mealtimes. A newly admitted client who has bulimia nervosa should be closely supervised during mealtimes to ensure they are not engaging in harmful behaviors related to eating.
A nurse is reviewing strategies with a client who has a neurodevelopmental disorder to help them become more independent. Which of the following phases of the nurse-client relationship does this represent? Exploitation phase Identification phase Orientation phase Termination phase
Termination phase An important final treatment goal for clients with neurodevelopmental disabilities is achieving, as much as possible, a degree of independent functioning.
A nurse is providing care to a client who has dyslexia. Which of the following findings would the nurse expect to observe? The client is unable to write in cursive. The client is unable to communicate through writing. The client has difficulty solving math problems. The client has difficulty reading.
The client has difficulty reading. Dyslexia is a specific learning disorder that impairs reading and comprehension. Individuals who have dyslexia might find it difficult to pronounce words, identify letters, and understand what they have read. Frequent and recurrent use of oral language skills and the contextualization of letters through writing and reading can help learners.
A nurse is caring for a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication of refeeding syndrome? The client reports a sudden increased energy level. The client reports increased appetite at bedtime. The client had a weight gain of 0.91 kg (2 lb) over 1 week. The client has peripheral edema of both legs.
The client has peripheral edema of both legs. Clients who have anorexia nervosa can experience heart muscle atrophy due to prolonged starvation. As a result, the heart can become overloaded with the restart of fluid and nutritional intake, leading to edema, severe electrolyte imbalances, and potential cardiac collapse. Edema is an early indication of refeeding syndrome that should be reported to the provider immediately.
A charge nurse is observing a newly hired nurse provide grief-informed care for a client. Which of the following actions by the newly hired nurse requires follow-up by the charge nurse? The nurse determines the effect the death or loss has had on the client. The nurse acknowledges that the client experienced a death or loss. The nurse asks the client why they require care or assistance. The nurse advocates for the client to receive bereavement support.
The nurse asks the client why they require care or assistance. "Why" questions can be interpreted as judgmental and do not represent a grief-informed approach. A grief-informed approach focuses on what occurred (trauma or loss), where the trauma or loss took place, and how the trauma or loss affects the client's current condition or situation.
A charge nurse is observing a newly hired nurse provide grief-informed care for a client. Which of the following actions by the newly hired nurse requires follow-up by the charge nurse? The nurse determines the effect the death or loss has had on the client. The nurse asks the client why they require care or assistance. The nurse acknowledges that the client experienced a death or loss. The nurse advocates for the client to receive bereavement support.
The nurse asks the client why they require care or assistance. "Why" questions can be interpreted as judgmental and do not represent a grief-informed approach. A grief-informed approach focuses on what occurred (trauma or loss), where the trauma or loss took place, and how the trauma or loss affects the client's current condition or situation.
A nurse in a pediatrician's office is caring for a preschooler. Nurses' Notes 3-year-old well-child visit Child checks in with guardian for annual physical exam. Guardian reports child has had no illnesses other than a mild upper respiratory infection 2 months ago. Child playing with toys in exam room and answers questions appropriately. Language and motor skills appropriate for age. 4-year-old well-child visit Child in exam room with guardian for annual exam. Child noted to be restless, unable to sit in chair for more than a minute or two before getting up. Child frequently interrupting conversation between nurse and guardian and requires frequent redirection. Guardian states the child "has always been a busy kid, but it seems that it is getting worse." Guardian reports the child began preschool a few weeks ago and the teacher has sent several notes home that the child is often interrupting class and has difficulty following directions. Flow Sheet 3-year-old well-child visit Height 95 cm (37.5 in) Weight 14.5 kg (32 lb) 4-year-old well-child visit Height 101.6 cm (40 in) Weight 14.5 kg (32 lb) Vital Signs 3-year-old well-child visit Heart rate 98/min BP 91/48 mm Hg Respiratory rate 22/m
The nurse should analyze cues and determine that the child is exhibiting manifestations of attention deficit hyperactivity disorder (ADHD). The nurse should further assess the child by performing a developmental screening using a standardized assessment tool. The nurse should then discuss behavioral interventions with the guardian when implementing interventions for addressing the child's behaviors at home and school.
A nurse is caring for an adolescent client whose close friend recently died by suicide. The client tells the nurse, "I should have called back when they texted me. If I had been there, my friend would still be alive." Which of the following information should the nurse understand from this statement? This is an expression of a lack of self-compassion, and the client needs to focus on being kind to themselves. This is an expression of delayed grief response, and the client is expressing their thoughts and feelings. This is an expression of emotional pain, and the client needs to be closely monitored. This is an expression of normal grief, and the client will respond well if they can just express their feelings.
This is an expression of emotional pain, and the client needs to be closely monitored. This is emotional pain and feelings of guilt from a traumatic loss. It is important for this client to be closely monitored for safety.
A nurse is caring for an adolescent client whose close friend recently died by suicide. The client tells the nurse, "I should have called back when they texted me. If I had been there, my friend would still be alive." Which of the following information should the nurse understand from this statement? This is an expression of delayed grief response, and the client is expressing their thoughts and feelings. This is an expression of a lack of self-compassion, and the client needs to focus on being kind to themselves. This is an expression of normal grief, and the client will respond well if they can just express their feelings. This is an expression of emotional pain, and the client needs to be closely monitored.
This is an expression of emotional pain, and the client needs to be closely monitored. This is emotional pain and feelings of guilt from a traumatic loss. It is important for this client to be closely monitored for safety.
A nurse is interacting with a client. The client repeatedly shrugs and yells out random words. The nurse recognizes that this finding is associated with which of the following disorders? Attention-deficit/hyperactivity disorder (ADHD) Autism spectrum disorder (ASD) Tourette syndrome Expressive language disorder
Tourette syndrome Clients who have Tourette Syndrome can have vocal tics or sounds that are not associated with purposeful communication.
A nurse in the emergency department (ED) is caring for a client. Laboratory Results 1130: Complete Blood Count: Hgb 9 g/dL (12 to 18 g/dL) Hct 28% (37% to 52%) Total WBC count 4,000/mm3 (5,000 to 10,000/mm3) Platelet count 130,000/mm3 (150,00 to 400,000/mm3) Basic Metabolic Profile: Creatinine 0.8 mg/dL (0.5 to 1.0 mg/dL) BUN 19 mg/dL (10 to 20 mg/dL) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Vital Signs 1500: Heart rate 52/min Respiratory rate 28/min Blood pressure 74/50 mm Hg Temperature 36.1° C (97° F) SaO2 90% on 2 L/min via nasal cannula Nurses' Notes 1515: Client arrived at the ED via ambulance. Emergency medical technicians (EMTs) state the client fainted at place of employment while walking down a flight of stairs. Client fell and rolled down several steps. Coworkers called for an ambulance. Client was awake upon EMTs arrival. Client oriented to person, place, time, but appears lethargic. Reports dizziness and headache. No injury noted from fall. Client states, "I think I just haven't eaten enough today. That must be why I passed out." Client states they have passed out numerous times in the past month. Reports only eating one meal a day for the past few months because they have been
Using the airway, breathing, circulation (ABC) priority framework, the nurse should first take action and address the client's oxygenation status of labored respirations, an SaO2 below the expected reference range, and the client's report of shortness of breath by increasing the amount of supplemental oxygen they are receiving. The client's complete blood count indicates the client is experiencing anemia, which can account for their compromised respiratory status. The next finding the nurse should address is the client's blood pressure, which indicates hypotension. The client's fainting and report of dizziness may be a result of the hypotension they are experiencing. The client will require the initiation of IV fluids to replace their low circulating fluid volume.
A nurse is caring for a client who is receiving life-sustaining treatmen Medical History Day of admission: A 10-year-old client was hit by a car while riding their bike in their neighborhood. Sustained skull fracture, subdural basal hematoma, multiple fractures to both lower extremities, and ruptured spleen. Splenectomy performed, fractures set, and client placed in pediatric ICU on mechanical ventilator. Non-responsive. Vital signs stable. Initial electroencephalogram (EEG) shows no evidence of brain activity. Day 2: No change in status. Unresponsive to tactile stimuli. No purposeful movement noted. No spontaneous breaths. Day 3: Repeat Magnetic Resonance Imaging (MRI) reveals epidural hematoma and generalized cerebral swelling. Unresponsive to tactile stimuli. No purposeful movement noted. No spontaneous breaths. Decreased heart rate and widened pulse pressure consistent with increased intercranial pressure. Repeat EEG flat - no brain activity. Day 4: Client remains nonresponsive. Blood pressure dropping and heartrate decreasing over last 24 hr. Pupils fixed and dilated. No attempt at spontaneous breathing noted. Third EEG flat - no brain wave activity noted. Family conference called t
When analyzing cues, the nurse should anticipate experiencing feelings of grief and moral distress. The nurse should share these feelings in a debriefing meeting with other nursing staff. Debriefing can be beneficial to the nurse by providing a space for the nurse to express their feelings with the support of their peers. Withdrawing treatment when caring for a client can be emotionally and morally difficult and draining on the nurse.
A nurse in a pediatrician's office is caring for a preschooler. Nurses' Notes Initial visit Parent brought child in for evaluation at recommendation of preschool teacher. Parent reports that the teacher has concerns about the child's inability to sit still, focus on conversation, and complete simple tasks without distraction. The child is noted to be restless in the exam room and frequently interrupts during conversation. Discussed behavioral interventions to address behavior, parent voices understanding. 2-month follow-up visit Child remains restless and is easily distracted. Child often does not notice when being spoken to due to distractions and frequent talking to self. Parent reports using recommended behavioral interventions regularly but has seen no change in the child's behavior. Vital Signs Initial visit Heart rate 108/min Respiratory rate 22/min Temperature 36.7° C (98° F) 2-month follow-up visit Heart rate 112/min Respiratory rate 24/min Temperature 37.1° C (98.8° F) Which of the following medications should the nurse identify as being a potential treatment for this child? Methylphenidate Atomoxetine Clonidine Dextroamphetamine Selegiline
When analyzing cues, the nurse should identify that the child is exhibiting manifestations of attention deficit hyperactivity disorder, or ADHD. Manifestations of ADHD include hyperactivity, distractibility, inattention, and impulsive behaviors. Psychostimulant, selective norepinephrine reuptake inhibitors (SNRIs), and alpha-2 adrenergic agonists are types of medications used to treat ADHD. Methylphenidate and dextroamphetamine are psychostimulants, atomoxetine is an SNRI, and clonidine is an alpha-2 adrenergic agonist. Therefore, the nurse should identify these medications as potential treatments for this child.
A nurse is providing care to a client who experienced the loss of their partner. Vital Signs Day 1 0730: Temperature 36.6° C (97.8° F) Pulse rate 74/min Respiratory rate 16/min BP 118/74 mm Hg Day 2 0730 Temperature 36.9° C (98.4° F) Pulse rate 92/min Respiratory rate 18/min BP 98/72 mm Hg Medical History Day 1 0900: A 58-year-old client admitted for evaluation, accompanied by family members. Client has become more isolated over the last 15 months since their partner was killed in a motor-vehicle crash. Client acknowledges they just, "can't snap out of this funk." Client says most days they have severe longing for their partner and cannot imagine life without them. Client states, "my heart is broken and sometimes I just cannot catch my breath." Client refuses to discuss circumstances surrounding the death of their partner, but does keep pictures and other mementos as reminders of their partner close by. Nurses' Notes Day 1: Disheveled and wearing clothes that are soiled with food. Flat affect, disinterested in surroundings. Keeps eyes downcast and answers questions in a low voice volume. Day 2: Sitting in room. Refused to shower this morning. Consumed only a few bites of breakfast a
When analyzing cues, the nurse should identify that the findings of the client's statement of identify, their reaction to the visit from their adult children, and their statement of the desire to join their deceased partner indicate the client is experiencing prolonged grief disorder. These findings, combined with the client's self-care deficits, poor appetite, and depressed mood persisting 15 months following the death of their partner are unexpected findings and require additional evaluation and treatment.
A nurse is assessing an adolescent Nurses' Notes 12-year-old well-child exam Adolescent alert and pleasant. Makes good eye contact and has strong language skills. Adolescent reports participating in several extracurricular activities at school and that they are also active in their church youth group. Adolescent denies any current concerns regarding health, school, or relationships with peers and family. 13-year-old well-child exam Denies any change in health since last exam one year ago. Adolescent answers questions appropriately and appears well-groomed. During interview, adolescent noted to frequently blink rapidly and clear throat. Denies manifestations of respiratory tract infection or allergies. Adolescent reports starting menstrual cycle approximately 4 months ago, with irregular cycles occurring every 20 to 40 days. Also reports mild cramping with menstruation that is managed with over-the-counter analgesics. Flow Sheet 12-year-old well-child exam Height 155 cm (61 in) Weight 47.6 kg (105 lb) 13-year-old well-child exam Height 160 cm (63 in) Weight 49.9 kg (110 lb) Vital Signs 12-year-old well-child exam Heart rate 100/min Respiratory rate 22/min BP 96/58 mm Hg SaO2 98% on room
When analyzing cues, the nurse should identify that the frequent rapid blinking and clearing of the throat are unexpected findings that should be reported to the provider. These findings are manifestations of a tic disorder and require further evaluation. Tic disorders can start suddenly and worsen during times of stress. Most tic disorders resolve within a year from time of onset.
A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Vital Signs December 1: Heart rate 48/min Respiratory rate 24/min Blood pressure 78/52 mm Hg Temperature 35.6° C (96° F) SaO2 93% on room air December 15: Heart rate 55/min Respiratory rate 20/min Blood pressure 84/50 mm Hg Temperature 36° C (97° F) SaO2 96% on room air History and Physical December 1: Height 163 cm (64 in) Weight 34.5 kg (76 lb) BMI 13 Pale, cold extremities, dry skin, thinning hair Weak pulse Respirations slightly labored, chest clear Bowel sounds hypoactive x 4 quadrants Concentrated urine December 15: Height 163 cm (64 in) Weight 37.2 kg (82 lb) BMI 14.1 Pale, cold extremities, dry skin, thinning hair Pulses palpable Respirations even, unlabored, chest clear Bowel sounds active x 4 quadrants Clear yellow urine Laboratory Results December 1: Basic Metabolic Profile: Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Sodium 128 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) December 15: Basic Metabolic Profile: Creatinine 0.9 mg/dL (0.5 to 1.0 mg/dL) BUN 22 mg/dL (10 to 20 mg/dL) Sodium 130 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5
When evaluating outcomes, the nurse should identify that the findings of increased weight, improved respiratory assessment, and a creatinine level that is now within the expected reference range are indications of a therapeutic response to the treatment plan.
A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Vital Signs December 1: Heart rate 48/min Respiratory rate 24/min Blood pressure 78/52 mm Hg Temperature 35.6° C (96° F) SaO2 93% on room air December 15: Heart rate 55/min Respiratory rate 20/min Blood pressure 84/50 mm Hg Temperature 36° C (97° F) SaO2 96% on room air History and Physical December 1: Height 163 cm (64 in) Weight 34.5 kg (76 lb) BMI 13 Pale, cold extremities, dry skin, thinning hair Weak pulse Respirations slightly labored, chest clear Bowel sounds hypoactive x 4 quadrants Concentrated urine December 15: Height 163 cm (64 in) Weight 37.2 kg (82 lb) BMI 14.1 Pale, cold extremities, dry skin, thinning hair Pulses palpable Respirations even, unlabored, chest clear Bowel sounds active x 4 quadrants Clear yellow urine Laboratory Results December 1: Basic Metabolic Profile: Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Sodium 128 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) December 15: Basic Metabolic Profile: Creatinine 0.9 mg/dL (0.5 to 1.0 mg/dL) BUN 22 mg/dL (10 to 20 mg/dL) Sodium 130 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5
When evaluating outcomes, the nurse should identify that the findings of increased weight, improved respiratory assessment, and a creatinine level that is now within the expected reference range are indications of a therapeutic response to the treatment plan.
A nurse is caring for a client who is dying. Nurses' Notes Day 1 1000: Client resting quietly in bed. Client's partner in bedside chair. Partner has been providing comfort measures and non-pharmacologic interventions. States that they feel overwhelmed at times when providing care and becomes very emotional when talking about the future. Day 2 1030: Client's partner overheard crying in the bathroom. States that the impending death is too much to bear right now and the decisions that must be made are exhausting. They are not sleeping well at night and their appetite is significantly decreased. Verbalizes feelings of anxiety. Hospice care arranged for client's upcoming discharge. Respite care discussed with the client's partner. Day 3 1300: Client alert and oriented x4. Client discharged to home with hospice care. Partner will be providing care to the client at home. A nurse is planning self-care education for the caregiver of a client who is dying. Which of the following recommendations should the nurse include? Select all that apply. Increase recommended daily caloric intake. Walk for at least 30 min each day outside. Limit leisure activities for the caregiver. Establish a sleep routine
When generating solutions, the nurse should encourage the caregiver to walk outside for 30 minutes each day and establish a routine of at least 7 hr of sleep per night. The nurse should identify that a self-care routine that includes daily physical exercise is recommended for caregivers to support their physical and mental well-being. Adults require 7 to 9 hours of sleep each night and getting adequate sleep can enhance the caregiver's emotional and physical health.
A nurse in a mental health clinic is caring for a client who is grieving. Nurses' Notes 1000: Client presents to the mental health clinic and is tearful and angry. They recently experienced the loss of a child due to illness. Information provided to client about group therapy and individual therapy. 1100: Client is continuing to sob and states, "I can't go on living without my child." Current list of home medications reviewed. Client states they have not been taking the prescribed medication "because it will not help." 1300: Client spoke in group therapy session regarding feelings and prescribed treatment. Acknowledges the role of the therapist and expectations of support group, yet confides, "My anger and sadness are still very Medication Administration 1000: Sertraline 100 mg PO BID Vital Signs 1015: Temperature 36.8° C (98.4° F) Heart rate 85/min Respiratory rate 15/min BP 147/86 mm Hg Oxygen saturation 99% A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply. Statement regarding outlook on living. Statement related to feelings of sadness and anger. Knowledge of expectations durin
When recognizing cues, the nurse should identify that the client's statements about their outlook on living and their use of pharmacological treatment are the priority findings to address. The nurse should identify that safety is a priority and suicidal thoughts or expressions require immediate intervention. The nurse should also recognize that pharmacological treatment can help in relieving the symptoms of depression, anxiety, and post-traumatic stress that is related to grief. The client's statement indicates a lack of understanding of this treatment modality.
A hospice nurse is providing support to the partner of a client who is dying. Nurses' Notes 1300: Client appears asleep. Client's partner is in bedside chair. 1400: Crackles noted upon auscultation of bilateral lung fields. Head of bed elevated to facilitate drainage. 1500: Client's partner crying and holding the client's hand. Client exhibiting irregular respiratory rate with periods of apnea and hyperventilation noted. Vital Signs 1300: Temperature 38° C (100.4° F) Pulse rate 62/min Respiratory rate 14/min B/P 104/64 mm Hg Oxygen saturation 96% 1400: Temperature 37.9° C (100.3° F) Pulse rate 45/min Respiratory rate 12/min B/P 95/55 mm Hg Oxygen saturation 95% Which of the following actions should the nurse take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Nursing Action Indicated Nonessential Contraindicated Offer to remain in the room. Call the provider to get a prescription for the partner. Inform the partner that the client is not in any pain. Encourage the client's partner to express their sorrow. Encourage the client's partner to stay awake as long as the client is al
When taking action for the partner of a client who is dying, the nurse should anticipate offering to remain in the room with the client and partner and encouraging the partner to express their feelings of sorrow. The nurse should identify that the partner is experiencing anticipatory grief and providing a therapeutic presence can help create a safe environment for grieving. Encouraging the partner to express their thoughts and feelings is therapeutic and promotes acceptance and healing in the grieving process. The nurse should identify that calling the provider to request a prescription for the partner is nonessential. The partner is experiencing anticipatory grief and requesting a medication prescription will not decrease the feelings of loss the partner is experiencing. The nurse should identify that informing the partner the client is not in pain and encouraging the partner to remain awake as long as the client is alert are contraindicated interventions. The nurse should not provide false reassurance to the partner as this is nontherapeutic. The nurse should also encourage the partner to rest as needed, since grief can cause somatic manifestations, such as disturbances in sleep and appetite.
