MH4

The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement?

"A daily, half-mile-long, brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

"Tell me more about what causes you to feel like the rape just occurred."

The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse would make which therapeutic response to the client?

"Tell me more about what happened that causes you to feel like the rape just occurred."

The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse would avoid choosing which client as a roommate for the client with anorexia nervosa?

A client with pneumonia

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which community group?

Alcoholics Anonymous

The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present?

Amenorrhea

The nurse is caring for a client dying of cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing?

Bargaining

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic, if identified by the student, indicates a need for further teaching about the disorder?

Body weight well below ideal range

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

A client's spouse becomes distraught when thinking about his wife's terminal prognosis. Which action would the nurse implement to best assist the spouse?

Encourage development of realistic goals.

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?

Examine and treat the wound sites.

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply.

Grief Anxiety Altered body image

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

The nurse is working with a client diagnosed with anorexia nervosa. As the nurse plans care, which would be focused on as the primary problem?

Impaired nutritional status

Which data indicates to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply

Looks at old snapshots of family Visits the spouse's grave once a month Visits the senior citizens' center once a month

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives at the unit?

Place the client on one-to-one suicide precautions.

The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates which actions the parents should take?

Planning a non-food-related activity

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the registered nurse and pediatrician regarding necessary follow-up because this infection can be associated with which finding?

Possible sexual abuse

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions would the nurse take to provide end-of-life psychological care? Select all that apply.

Provide privacy to the client and family. Encourage the family to talk with and reassure the client. Encourage visits by appropriate spiritual services as desired.

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions would be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a DVD and a cherished autographed picture of the performer.

The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?

The client reports nightmares involving being stalked when alone at night.

The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care?

The client verbalizes stages of grief and plans to attend a community grief group.

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by which event?

The death of a loved one

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on which information?

The physical condition of the client

A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse would focus the initial data collection on which information?

The presence of existing suicidal thoughts

The nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. Which interpretation would the nurse make of these behaviors?

They are expected reactions to a devastating event.

A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse?

"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse?

"Can you tell me more about your feelings?"

An assistive personnel (AP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the AP indicates to the nurse that the AP understands suicide?

"Discussing suicide with a client is not harmful."

During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response?

"Have you shared your concerns with the police?"

The nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse would be therapeutic?

"How do you feel about this surgery?"

The nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use, and what effect does it have on you?"

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?

"I don't feel like hurting myself anymore."

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

"I drink hot chocolate before bedtime." "I plan out my goals for work for the next day"

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance."

The nurse employed in a primary health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

The nurse is having a therapeutic discussion with a client and knows that which statements by the client would be immediately reported to the charge nurse? Select all that apply.

"I hid my silverware from dinner last night." "I know that by this time tomorrow all my troubles will be over."

A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed?

"I know that I won't become depressed again."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?

"I no longer feel that I deserve the beatings my husband inflicts on me."

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

"I'm going to do whatever it takes to get better." "I'll go and participate as much as I can in the group discussions."

A client has been hospitalized and has participated in substance abuse therapy group sessions. The client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response?

"It must be hard to accept that she has passed away."

The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feel regret?"

A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make?

"It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response?

"It sounds as though you are feeling all alone right now."

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

"My husband always brings me flowers and apologizes after he hits me." "I have bruises all over my body. I am frequently clumsy and fall a lot." "My boyfriend yells and accuses me of having an affair if I am late after work."

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse would make which therapeutic response to the client?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be which statement?

"What do you find difficult about this situation?"

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?

"What do you mean by that?"

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?

"What do you mean by that?"

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?

"What is causing you to become agitated?"

The nurse is collecting data on a client in crisis. Which question would the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

"What leads you to seek help now?"

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask?

"What leads you to seek help now?"

A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse?

"When I tell my child to do something once, I don't expect to have to repeat it."

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse would give which reply?

"Within a few hours"

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response?

"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?"

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response?

"You don't think you can ever do anything right?"

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work, and they feel isolated and fearful. The nurse would suggest which to the mother?

"You should seek community after-school programs or activities for your children."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse would make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?"

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure!' I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response would the nurse make to the client?

"You're feeling angry that your family continues to hope for you to be 'cured?'"

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?

"You're feeling angry that your family is hoping for a cure?"

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Alzheimer's disease

The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and terminal cancer

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse would consider which about a crisis response?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.

A high achiever Personality changes Lanugo over the back and extremities

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse would avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is therapeutic?

Assist her to express feelings.

The nurse prepares to discharge a fifty-year-old client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve the primary developmental task?

Assist the client resume her familial role.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?

Autonomy vs. shame and doubt

The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention?

Contracts and immediate available crisis resources

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

Provide safety for the client and other clients on the unit.

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse knowing that which action is necessary?

Reporting the case to legal authorities

The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline on the bed. Which assessment has priority?

Respirations

The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions would be included? Select all that apply.

Respond to requests from the client and family promptly. Support the client's decision-making in order to promote client control. Provide information about what to expect during the dying process to the client and family.

A registered nurse has administered a dose of naloxone intravenously to a client with intravenous opioid overdose. The licensed practical nurse assigned to assist in monitoring the client ensures that which equipment is available in the immediate vicinity of the client?

Resuscitation equipment

The nurse is assisting in caring for a client who is receiving a dose of nalmefene intravenously to treat opioid overdose. The nurse plans to have which supplies available as supportive equipment in case it is needed?

Resuscitation equipment

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.

Severe suicidal tendencies Extremely unstable medical and psychiatric conditions Desire for punishment of client or convenience of staff Delirium or dementia leading to inability to tolerate decreased stimulation Severe drug reactions or overdoses or need for close monitoring of drug dosages

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?

Showing the client the cast cutter and explaining how it works

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would take which action?

Stay with the client at all times.

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment?

Suggest that the mother's boyfriend move out of the home.

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Teaches about the effects of cocaine on the heart and offers referral for further help

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the primary health care provider will be contacted regarding discharge.

The nurse is caring for a pediatric client who sustained physical injuries following a bombing. Which actions by the nurse would help put the child at ease and decrease the child's and family's stress level? Select all that apply.

Tell the truth about the child's status. Communicate an attitude of confidence. Encourage family caregivers to stay with the child. Establish a trusting relationship with the child and the parents.

The nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which data would indicate that the client is a very high risk for suicide?

The client has an immediate plan for a suicide attempt.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation would the nurse make of this behavior?

The client is displaying typical behaviors that can occur during termination.

The nurse working in an emergency department is collecting data on a female client that is a victim of domestic violence. The nurse understands that which of the following assessment findings are characteristics of the emotional effects of abuse? Select all that apply.

The client states, "I always feel like I have no energy." The client states, "I feel so hopeless about the future." The client states, "I struggle to find the motivation to get my work done."

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?

The client verbalizes stages of grief and plans to attend a community grief group.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma.

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance.

A client with suspected opioid overdose has received a dose of nalmefene. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which statement is true?

These are signs of opioid withdrawal.

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?

When the last alcoholic drink was consumed

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client?

Provide authority, action, and participation.

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action would the nurse implement?

Remain with the client at all times.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety?

Assign a staff member to the client who will remain with him or her at all times.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the primary health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate?

Remain with the client until the anxiety decreases.

The nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse would distinguish which attribute of normal adolescents from an adolescent with depression?

Adolescents like to stay up late but rarely have insomnia.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures will most likely promote coping? Select all that apply.

Ask a member of the local ostomy club to visit with the client before discharge. Ask the enterostomal nurse specialist to consult with the client before discharge. Ask the client to begin doing one part of the ostomy care each day and increase tasks daily.

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Report the case in which the abuse is suspected.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

Which factors would the nurse consider when developing a critical incident stress debriefing (CISD) plan for employees of a level 1 trauma center? Select all that apply.

CISD promotes effective coping strategies. CISD occurs in small group settings for staff. CISD may help prevent posttraumatic stress disorder. CISD is only one component of a much larger stress management program.

A depressed client is found unconscious on the floor in the dayroom of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. What is the immediate action of the nurse?

Call a rapid response.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse would take which action?

Call for the registered nurse.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

Call the nursing supervisor.

The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?

Check the wound sites.

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

Client threatened to commit suicide. Client threatened to kidnap his spouse.

The nurse is caring for a client who has been admitted for alcohol abuse and knows that which medications may be prescribed in the treatment of this disorder? Select all that apply.

Diazepam Disulfiram Chlordiazepoxide

Following an airplane crash that had only a few survivors, the nurse would anticipate which survivor responses to stress? Select all that apply.

Difficulty sleeping Feeling vulnerable Feeling blame or guilt Feeling numb or in disbelief

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication would the nurse explain is available for this purpose?

Disulfiram

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Extend touch, and hold the client or family member's hand if appropriate. Be honest and truthful, and let the client and family know that you will not abandon them.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding?

Evidence of the client's altered and distorted body image

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse would take which nursing action first?

Examine the neck area and assess the airway.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client?

Explaining equipment and procedures on an ongoing basis

When caring for a client who has been raped, which intervention should the nurse implement during the examination?

Explaining procedures to be completed and why the procedures are necessary

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply.

He expresses his anger at God and the primary health care providers for allowing this to happen. He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

Hypertension, disorientation, hallucinations

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions

The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?

Indicates that facial puffiness will be a permanent problem

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time?

Initiate confinement measures.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply.

Irritability Hypertension Gastrointestinal disturbances

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason?

Protection from the risk of intimacy

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

Lanugo Amenorrhea

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.

Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils Ensuring that her diet consists of bland, easy-to-digest foods and beverages

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.

A client is admitted to the emergency department with a diagnosis of drug-induced anxiety related to over-ingestion of his prescribed antipsychotic medication. Which important piece of information would the nurse obtain initially?

Name of the ingested medication and the amount ingested

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

No charge will be made against the RN because the RN's actions are reasonable.

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?

Notify the social worker to investigate the situation.

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?

Observe for excessive exercise.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention would the nurse include in the plan of care?

One-to-one suicide precautions

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.

Punishment (e.g., punishment applied after the client has had an alcoholic drink) Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus.

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply.

Receiving assurance Receiving information Having support available Remaining near the client

A client that is postgastrectomy being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I may lose my job." Based on the client's statement, the nurse would determine that at this time, it is most appropriate to discuss which topic?

Reducing stressors in life

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?

Reexperiencing recollections of the trauma

The nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a concern about her appearance as a result of alopecia. The nurse plans to tell the client which information about hair loss and regrowth to assist the client in coping with this possible change?

Regrown hair may have a different color and texture.

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions would the nurse take? Select all that apply.

Remain calm and reassuring. Convey caring behaviors towards the client. Establish rapport and actively listen to the client.