Mental Health Quiz 3

A nurse cared for a terminally ill patient for over a month and always looked forward to spending time with the patient. When the patient died, the nurse experienced sadness and felt mildly depressed. Eventually, the nurse explains these feelings to a mentor. The mentor should counsel the nurse: a. about stress-reduction strategies. b. to seek therapy for dysfunctional grief. c. about the experience of disenfranchised grief. d. to consider taking a leave of absence to pursue healing.

C) About the experience of disenfranchised grief.

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

C) Honeymoon Feedback: The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

An adult who was widowed 18 months ago says, "I can now remember good times we shared without getting upset. Sometimes I even think about the disappointments. I've become accustomed to sleeping in our bed alone." The work of mourning: a. Is beginning b. Is progressing abnormally c. Is at or near completion d. Has not begun

C) Is at or near completion

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to: a. promote integration of self-concept. b. provide inpatient treatment for the child. c. reduce loneliness and increase self-esteem. d. improve language and communication skills.

C) Reduce loneliness and increase self-esteem. Feedback: Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Sibutramine (Meridia) D. Pemoline (Cylert)

C) Sibutramine (Meridia) Feedback: The nurse should teach the client that Sibutramine (Meridia) is an anorexiant medication prescribed for morbidly obese patients. The mechanism of action in the control of appetite appears to occur by inhibiting the neurotransmitters serotonin and norepinephrine. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

C) Sleep disturbances and weight loss Feedback: The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

C) The client demonstrates healthy coping mechanisms that decrease anxiety. Feedback: The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

C) The nurse who refuses to engage in power struggles related to food consumption. Feedback: The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

A recently widowed patient tells the health care provider, "I have so much epigastric discomfort. I wonder if I have an ulcer." Diagnostic tests are negative. The symptom demonstrates: a. early reorganization behavior b. disorganization and depression c. preoccupation with the deceased d. normal phenomenon of mourning

D) Normal phenomenon of mourning

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

D) Physical injuries Feedback: The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

D) These programs allow clients to maintain control. Feedback: Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

A physician informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day the patient says to the nurse, "My doctor said I have breathing problems, right?" Which nursing diagnosis is applicable? a. Denial related to acceptance of new diagnosis b. Chronic sorrow related to unresolved life conflicts. c. Situational low self-esteem related to stress of new diagnosis. d. Acute confusion related to metastatic changes to cerebral function.

A) Denial related to acceptance of new diagnosis.

The spouse of a patient in hospice care angrily tells the nurse, "The care provided by the aide and other family members is inadequate, so I must do everything myself. Can't anyone do things right?" The palliative care nurse should: a. provide teaching about anticipatory grieving. b. assign new personnel to the patient's care. c. arrange hospitalization for the patient. d. refer the spouse for crisis counseling.

A) Provide teaching about anticipatory grieving.

An individual was killed during a store robbery 2 weeks ago. The widowed spouse, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about the death. Which is the nurse's most therapeutic comment? a. "I'm worried about how much you're crying. Your grief over your spouse's death has gone on too long." b. "The unexpected death of your spouse must be so painful. I'm glad you're able to talk to me about your feelings." c. "This loss is harder to accept because of your mental illness. Let's refer you to the partial hospitalization program." d. "Your crying shows me you aren't coping well. I made an appointment for you to see the psychiatrist for medication adjustment."

B) "The unexpected death of your spouse must be so painful. I'm glad you're able to talk to me about your feelings."

An emergency department nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services? A. "We do not believe in immunization of our children." B. "This child is always creating problems for the family." C. "Our child would rather play alone than with other children." D. "We homeschooled our children in order to include religious education."

B) "This child is always creating problems for the family." Feedback: The acute injury, coupled with bruises of different ages, suggest that the child may be abused. Abusive parents may perceive the child as bad or evil or project blame. The nurse is required to report suspicions of abuse to child protective services.

The school nurse assesses four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity? A. 5'2" tall; weight 104lbs B. 5'7" tall; weight 110lbs C. 5'5" tall; weight 114lbs D. 5'8" tall; weight 127lbs

B) 5'7" tall; weight 110lbs Feedback: Body mass index (BMI) is used to gauge the level of severity, degree of functional disability, and need for supervision for persons diagnosed with anorexia nervosa. BMI is calculated as weight in kilograms divided by height in meters squared. Ideal BMIs are between 19 and 25. A person whose BMI is over or equal to 17kg/m2 meets one criterion for anorexia nervosa with mild severity. The BMI for the correct response is 17.2.

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

B) Altered nutrition: less than body requirements R/T inadequate food intake. Feedback: Based on Maslow's hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

Shortly after a man's wife dies, the man approaches the nurse who cared for his wife during her final hours of life and says angrily, "If you had given your undivided attention, she would still be alive." Which analysis applies? a. The comment summarizes the nurse's inadequacies. b. Anger is a phenomenon experienced during grieving c. The patient had ambivalent feelings about his spouse. d. In some cultures, grief is expressed solely through anger.

B) Anger is a phenomenon experienced during grieving.

The mourning process is more difficult when the bereaved: a. was relatively independent of the deceased. b. has experienced a number of previous losses. c. accepts that death is expected for older adults. d. had few unresolved conflicts with the deceased.

B) Has experienced a number of previous losses.

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

B) Remain with the client for at least 1 hour after the meal. Feedback: A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

B) Secure additional resources for the mother's evening and night care. Feedback: The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

Psychotherapy for individuals at risk for complicated grief focuses on which goals? Select all that apply. a. Identifying ways to break bonds with the deceased b. Exploring emotional responses to a loss c. Solving problems related to moving forward in life d. Learning about the stages and symptoms of grieving e. Using antipsychotic medications for dysfunctional grief

B, C, D

A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? A. "I look good because whenever I overeat, I purge myself." B. "I love sweets. I make myself throw up so I can eat more." C. "I've lost 60 pounds but I am still a size 2. I want to be a size 0." D. "I've hidden my eating disorder from everyone, even my parents."

C) "I've lost 60 pounds but I am still a size 2. I want to be a size 0." Feedback: Thought processes that accompany anorexia nervosa include a terror of gaining weight, viewing oneself as fat even when emaciated, and judging one's self-worth by one's weight or size.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice?

- This therapy will increase the client's motivation to gain weight. - This therapy will reward the client for perfectionist achievements. - This therapy will provide the client with control over behavioral choices. - This therapy will protect the client from parental overindulgence.

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

A) "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." Feedback: The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.

After being notified that her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, "He'd still be alive if you'd given him your undivided attention!" Select the nurse's best response. a. "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes." b. "Your husband's heart was severely damaged and could no longer pump. There's nothing anyone could have done." c. "I will call the nursing supervisor to discuss this matter with you." d. "It will be all right if you cry. Crying is a normal grief response."

A) "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes."

A terminally ill patient says, "I know I'm not going to get well, but still..." and the patient's voice trails off. Which response by the nurse would be therapeutic? a. "What do you hope for?" b. "No, you're not going to get well." c. "Do you have questions about what is happening?" d. "I'm happy you are being realistic about your future."

A) "What do you hope for?"

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

A) An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child. Feedback: The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

A university football coach invited the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include? A. Appropriate behavior with intimate partners B. University resources for counseling and support C. The importance of role modeling for children and teens. D. Public recognition of children with life-threatening illnesses

A) Appropriate behavior with intimate partners. Feedback: While the nurse may include any of the topics, appropriate behaviors with intimate partners has priority. Characteristics of the game of football, the physical power required to be a player, and the risk for drug or alcohol misuse among this age group are factors that increase the risk for intimate partner violence.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

A) Chronic low self-esteem, related to negative feedback from parents. Feedback: The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

A) Dementia Feedback: Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

A) Expresses frustration verbally instead of physically. Feedback: The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

A) History of family violence. Feedback: An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty relating to others b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities

A) Impaired social interaction related to difficulty relating to others. Feedback: Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.

Sixteen years ago a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parents' behavior? a. Mourning b. Bereavement c. Complicated grief d. Disenfranchised grief

A) Mourning

A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

A) Name two community resources that can be contacted. Feedback: The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

A) Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision. Feedback: The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

A) The client will identify two alternative methods of dealing with isolation by day 3. Feedback: The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

A) The emesis produced during purging is acidic and corrodes the tooth enamel. Feedback: The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

A, B Feedback: The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

A, B, C Feedback: An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by "yes" or "no."

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

A, B, C Feedback: Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

A, C, E, F, G Feedback: The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

Which statements by a patient who is terminally ill give the nurse information relevant to spiritual assessment? Select all that apply. a. "I feel an inner peace with my decision to use hospice services." b. "I trust my health care provider to prescribe enough medication to keep me free of pain." c. "I have prepared advance directives to spare my children the need to make difficult decisions." d. "I plan to use these last weeks to experience the process of dying as fully as I experienced the richness of living." e. "Listening to hymns helps deepen my relaxation and the relief I get from my pain medication."

A, D, E

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

B) "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." Feedback: The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how close he is to death or how sad I am." Which response by the nurse would be most therapeutic? a. "You're right to protect him at a time when he is so vulnerable." b. "He might be more reassured than disturbed by your tears." c. "It's important for you to know that time is running out." d. "You definitely need to be honest about your feelings."

B) "He might be more reassured than disturbed by your tears."

After the death of his wife, a man tells the nurse, "I can't live without her. She was my whole life." Which is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "Remember, she's no longer suffering." d. "Your friends will help you cope with this."

B) "Her death is a terrible loss for you."

Which finding indicates the successful completion of an individual's grieving process? a. For 2 years, a person has kept the deceased spouse's belongings in their usual places. b. After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse. c. Three years after the death, a person talks about the spouse as if the spouse were still alive and weeps when others mention the spouse's name. d. Eighteen months after the spouse's death, a person says, "I never cry or have feelings of loss even though we were always very close."

B) After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

B) Child and siblings are experiencing neglect. Feedback: The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

As death approaches, a patient diagnosed with acquired immunodeficiency syndrome (AIDS) says, "I don't want to see a lot of visitors anymore. Just my parents and my sibling can come in for a while each day." What action should the nurse take? a. Ask the patient to reconsider the decision because many interested and caring friends can be sources of support. b. Discuss the request with the parents and sibling. Suggest that they explain the patient's decision to friends. c. Suggest that the patient discuss these wishes with the health care provider. d. Place a "no visitors" sign on the patient's door.

B) Discuss the request with the parents and sibling. Suggest that they explain the patient's decision to friends.

A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

B) Have the patient fill out an abuse assessment screen. Feedback: In this situation, the nurse should consider the possibility that the patient is a victim of domestic violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

A person whose spouse died two years earlier tells friends, "I think I'll start going out socially, maybe even take someone to dinner." This comment best demonstrates that the individual is: a. Denying the significance of the loss. b. In a period of resolution of grief. c. Actively working through grief d. Experiencing intrusion

B) In a period of resolution of grief. Feedback: Reduction in emotional swings and a sense of self-coherence and readiness for new relationships, ability to experience positive states of mind.

An emergency department nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? A. Leathery facial tone B. Injuries in a bikini pattern C. Reluctance to be examined D. Lack of eye contact with the nurse

B) Injuries in a bikini pattern Feedback: The majority of victims of reported intimate partner violence are women. Intimate partner violence is the number one cause of emergency department visits by women. Patterns of damage are often in locations that cannot be noticed easily, such as the torso, back, upper arms, upper legs, inside body orifices, and under the hair.

A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? A. Another beating by the abusive partner B. Love, gifts, and praise from the abusive partner C. A brief period during which the partners ignore each other D. The abusive partner leaves the relationship for a short time.

B) Love, gifts, and praise from the abusive partner. Feedback: The cycle of violence consists of three phases: (1) tension-building phase, (2) acute battering phase, and (3) honeymoon phase. The question scenario shows acute battering, so a period of loving calm is likely to follow.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

B) Report the suspected abuse or neglect according to state regulations. Feedback: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

B) Risk for injury, related to partner's physical abuse when intoxicated. Feedback: Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

B) Risk of domestic abuse Feedback: The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for domestic violence.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

B) Strong negative feelings interfere with assessment and judgment. Feedback: Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

B) Sympathy for the victim and anger toward the abuser. Feedback: Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

A nurse who has worked for a community hospice organization for 8 years says, "My patients and their families experience overwhelming suffering. No matter how much I do, it's never enough." Which problem should the nursing advisor suspect? a. The nurse is experiencing spiritual distress b. The nurse is at risk for burnout and compassion fatigue. c. The nurse is not receiving adequate recognition from others. d. The nurse is at risk for overhelping, which creates dependency.

B) The nurse is at risk for burnout and compassion fatigue.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

B) To emphasize that the client is capable of consuming food without purging. Feedback: By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

A nurse manager notices that a staff member spends minimal time with a patient diagnosed with AIDS who is terminally ill. The patient says, "I'm having intense emotional reactions to this illness. Sometimes I feel angry, but other times I feel afraid or abandoned." The nurse manager can correctly hypothesize that the most likely reason for the staff member's avoidance is: a. high risk for infection transmission. b. feelings of inadequacy in dealing with complex emotional needs. c. knowledge that the patient needs time alone with family and friends. d. belief that the patient's former lifestyle included high-risk behaviors.

B) feelings of inadequacy in dealing with complex emotional needs.

A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

C) "How did this happen to you?" Feedback: Obtaining the victim's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? A. "You need to gain weight to become healthier." B. "Your world would not change if you gained a few pounds." C. "Tell me how your world would be different if you were fat." D. "Your attractiveness is not defined by a number on the scales."

C) "Tell me how your world would be different if you were fat." Feedback: Cognitive distortions with underlying emotions of anxiety, dysphoria, low self-esteem, and feeling lack of control are often present in persons suffering with eating disorders. In this instance, the adolescent is catastrophizing. The nurse should first help the patient to identify the fears. Cognitive distortions are consistently confronted by all members of the interdisciplinary team in preparation for carefully planned challenges to the patient later in treatment.

A nurse talks with a person whose spouse died suddenly while jogging. Which is the appropriate statement for the nurse? a. "At least your spouse did not suffer." b. "It's better to go quickly as your spouse did." c. "The loss of your spouse must be very painful for you." d. "You'll begin to feel better after you get over the shock."

C) "The loss of your spouse must be very painful for you."

A patient diagnosed with metastatic brain cancer says, "I'm dying, but I'm still living. I want to be in control as long as I can." Which reply shows the nurse was actively listening? a. "Our staff will do their best to help you feel comfortable." b. "Most people do not know how to help and are afraid of death." c. "Your mind and spirit are healthy, although your body is frail." d. "You want people to stop focusing on your weaknesses."

C) "Your mind and spirit are healthy, although your body is frail."

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 m

C) 15mL Feedback: 20mg of Prozac multiplied by three results in the calculated 60mg daily dose ordered by the physician. Each 5mL contains 20mg. 5mL multiplied by three equals the liquid dosage of 15mL.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

C) Bite marks Feedback: Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

A patient's fiancé died in an automobile accident several days ago. The patient reports crying and experiencing feelings of guilt and anger. This behavior is characteristic of which stage of acute grief? a. Denial b. Reorganization c. Development of awareness d. Preoccupation with the lost object

C) Development of awareness Feedback: Guilt, crying and blaming the staff are common in this stage.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

C) Emotional Feedback: Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

C) Holds the parent's hand while walking. Feedback: Holding the hand of another person suggests relatedness. Usually, a child with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

Which factor presents the highest risk for a child to develop a psychiatric disorder? a. Having an uncle with schizophrenia b. Being the oldest child in a family c. Living with an alcoholic parent d. Being an only child

C) Living with an alcoholic parent. Feedback: Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Being in a middle-income family and being the oldest child do not represent psychosocial adversity. Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family offers a greater risk.

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this client's symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

C) Metabolic acidosis Feedback: Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this client's fainting to the loss of alkaline stool due to laxative abuse which would lead to a relative metabolic acidotic condition.

A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which medication will the information focus on? a. Paroxetine (Paxil) b. Imipramine (Tofranil) c. Methyphenidate (Ritalin) d. Carbamazepine (Tegretol)

C) Methyphenidate (Ritalin) Feedback: CNS stimulants are the drugs of choice for treating children with ADHD: Ritalin and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.

An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

C) Physical Feedback: The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, " I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? A. report the clinical observation to the nursing supervisor B. ask the psychiatric technician, "What did you mean by that comment?" C. privately discuss the importance of sensitivity with the psychiatric technician D. immediately interrupt the interaction between the patient and psychiatric technician

C) Privately discuss the importance of sensitivity with the psychiatric technician. Feedback: The comment by the psychiatric technician trivializes the patients' problems. Low self-esteem and self-doubts about personal worth are characteristic features of persons who have eating disorders. The comment contributes to these aspects of self-perception.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy

C) Social skills group Feedback: Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

C) The client will gain 2 pounds prior to the next weekly appointment. Feedback: The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, measurable, and also include a time frame.

A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

C) The client will perceive an ideal body weight and shape as normal. Feedback: The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

C) The home environment is overprotective and demands perfection. Feedback: The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the rationale for scheduling group therapy at this time? A. To shift the clients' focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

C) To promote the processing of anxiety associated with eating. Feedback: When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

C) Women's shelter Feedback: Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

Which actions by a nurse contribute to protecting the rights of patients who are terminally ill? Select all that apply. a. Maintain hope for a positive prognosis. b. Hug the patient when sadness is expressed. c. Offer choices that promote personal control. d. Provide interventions that convey respect. e. Support the patient's quest for spiritual growth.

C, D, E

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

D) "I am angry at my mother. I can only get her approval when I win competitions." Feedback: This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influences the development of this disorder. Families who are overprotective and perfectionists can contribute to a family member's development of anorexia nervosa.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. "I do not use any laxatives or diuretics to lose weight." B. "I am losing lots of hair. It's coming out in handfuls." C. "I know that I am thin, but I refuse to be fat!" D. "I don't know why people are worried. I need to lose this weight."

D) "I don't know why people are worried. I need to lose this weight." Feedback: When the client states, "I don't know why people are worried. I need to lose this weight," the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance? A. "Sometimes I get so discouraged and frustrated with my job." B. "It's incredible that anyone could hurt a child or elderly person." C. "The abuser was probably a victim of abuse at some point in life." D. "I hope the abuser gets victimized so they know what it feels like."

D) "I hope the abuser gets victimized so they know what it feels like." Feedback: Nurses must be self-aware, particularly in highly charged situations. Wishing harm on an abuser may be understandable, but it is an indicator of the nurse's need for guidance.

A nurse leads a bereavement group. Which participant's comment best demonstrates that the work of grief has been successfully completed? a. "Our time together was too short. I only wish we had done more things together." b. "I know our life together was a blessing that I did not deserve. I wish I had said 'I love you' more often." c. "Other people knew my loved one as a good and helpful person. I hope people see me in the same way." d. "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

D) "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

A family of a terminally ill patient asks the nurse, "What can we say when our family member mentions death is coming soon?" Which response could the nurse suggest? a. "We think you will be around for a long time." b. "We don't want you to give up trying to get well." c. "We don't think we're ready to talk about this yet." d. "We feel so sad when we think of life without you."

D) "We feel so sad when we think of life without you."

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for: a. Communication disorder b. Stereotypic movement disorder c. Intellectual development disorder d. Attention deficit hyperactivity disorder

D) Attention deficit hyperactivity disorder Feedback: Excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mg/dL Phosphate 3.0 mg/dL The nurse should take which action next? A. Measure the patient's body temperature B. Inspect the patient's skin and sclera for jaundice C. Assess the patient's mucous membranes for erosion D. Auscultate the patient's heart rate, rhythm, and sounds.

D) Auscultate the patient's heart rate, rhythm, and sounds. Feedback: The laboratory results show hypokalemia and hypocalcemia, which is likely to affect cardiac function, producing bradycardia, arrhythmias, and/or murmurs.

A widow grieving her husband's sudden death tells the nurse, "I'm not feeling well. Yesterday, I saw my husband walk through the door, stop, and smile at me. Then he just faded away." Which is the nurse's most appropriate action? a. Assess for recent substance use. b. Suggest a referral to the mental health clinic. c. Arrange for an evaluation for antidepressant medication. d. Counsel the widow that visualizations are a normal part of grieving.

D) Counsel the widow that visualizations are a normal part of grieving.

An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

D) Document injuries with a body map. Feedback: Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

After the death of a spouse, an adult repeatedly says, "I should have made him go to the doctor when he said he didn't feel well." This individual is experiencing: a. Preoccupation with the image of the deceased. b. Sensations of somatic distress. c. Anger. d. Guilt.

D) Guilt

A patient newly diagnosed with pancreatic cancer says, "My father also died of pancreatic cancer. I took care of him during his illness. I can't go through that." Select the highest priority nursing diagnosis. a. Anticipatory grieving b. Ineffective coping c. Ineffective denial d. Risk for suicide

D) Risk for suicide

A recently widowed adult says, "I've been calling my neighbors often but they act like they don't want to talk to me. I just need to talk about it, you know?" What is the nurse's best action? a. Say to the person, "You may call me anytime you need to talk." b. Ask the person, "What do you mean by 'I just need to talk about it'?" c. Educate the person about the importance of finding alternative activities. d. Tell the person the location and time of a local bereavement support group.

D) Tell the person the location and time of a local bereavement support group.

A nurse working with a person whose spouse recently died uses cheer and humor to lift the person's spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct? a. The nurse's technique was successful b. Use of humor should be added to the plan of care. c. Approach may prove useful in other, similar situations. d. The nurse needs supervision; the communication technique was not appropriate.

D) The nurse needs supervision; the communication as not appropriate.

A child drowned while swimming in a local lake four years ago. Which behavior indicates that the parents are effectively coping with their loss? The parents: a. prohibit their other children from going swimming. b. keep a place set for the dead child at the family dinner table. c. keep their child's room exactly as the child left it 4 years ago. d. throw flowers on the lake at each anniversary date of the accident.

D) Throw flowers on the lake at each anniversary date of the accident.

A grieving patient tells a nurse, "It's been eight months since my spouse died. I thought I would feel better by now, but lately I feel worse. I have no energy. I am lonely, but I don't want to be around people. What should I do?" What is the nurse's best counsel? a. Seek psychotherapy b. Become active in a church c. Attend a bereavement group d. Understand this is a normal response

D) Understand this is a normal response.

Children of a widowed parent confer with the nurse; their surviving parent repeatedly relates the details of finding the deceased parent not breathing, performing cardiopulmonary resuscitation, going to the hospital by ambulance, and seeing the pronouncement of death. The family asks, "What can we do?" The nurse should counsel the family: a. they should share their feelings with the surviving parent and ask for the retelling to stop. b. retelling the story should be limited to once daily to avoid unnecessary stimulation. c. retelling memories is to be expected as part of the aging process. d. repeating the story is a helpful and a necessary part of grieving.

D) repeating the story is a helpful and a necessary part of grieving.

A terminally ill patient tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity with willpower. I always gave my best and expected things to turn out well. I intend to die as I lived: optimistically." The nurse planning care for this patient recognizes a critical need to: a. provide aggressive pain and symptom management. b. help the patient reassess and explore existing conflicts. c. assist the patient to focus on the meaning in life and death. d. support the patient's use of personal resources to meet challenges.

D) support the patient's use of personal resources to meet challenges.