Module 3
Louise tells the nurse that she will try the deep-breathing exercises but asks whether there is anything else that she can try to help her feel calmer. The nurse reviews several stress-reducing strategies with Louise. Which of these statements by Louise indicate a good understanding of stress-reduction techniques? Select all that apply. a) "I'll start going to bed 30 minutes earlier." b) "I'll limit my coffee to one cup in the morning." c) "I'll go to the gym at least three times a week after work." d) "I'll exercise just before bedtime to help improve my sleep." e) "A cup of hot tea will help me relax in the evening." f) "During my break at work, I can find a quiet place and focus on feeling calmer."
a) "I'll start going to bed 30 minutes earlier." b) "I'll limit my coffee to one cup in the morning." c) "I'll go to the gym at least three times a week after work." f) "During my break at work, I can find a quiet place and focus on feeling calmer." RATIONALE: People who are stressed are often fatigued; for this reason, going to bed 30 to 60 minutes earlier each night may be helpful. Reducing or even eliminating caffeine can help a person feel more relaxed, and both tea and coffee contain caffeine. Exercise can help reduce stress, but it is best to exercise at least 3 hours before going to bed. Exercising for at least 30 minutes three or more times a week is recommended. Meditation takes practice, but it can help produce a relaxation response by quieting the sympathetic nervous system.
A few weeks later, while under the care of a hospice program, Isabel dies peacefully at home. Her parents and her children, who have been at her side, are understandably upset. Which statements by the hospice nurse are appropriate at this time? Select all that apply. a) "It's OK to cry." b) "Everything will be fine." c) "I'll be here if you want to talk." d) "Don't cry. She wouldn't want that." e) "You need to be strong for your little brother." f) "Let me know if I can make any phone calls for you."
a) "It's OK to cry." c) "I'll be here if you want to talk." f) "Let me know if I can make any phone calls for you." RATIONALE: The nurse's statements should not minimize the family members' loss. The nurse must avoid trite statements such as "Everything will be fine," "Don't cry," and "You need to be strong." These statements are actually barriers to communication and do not demonstrate care and concern. The nurse should offer supportive statements, acknowledge the family's feelings, be ready to listen, remain present, and offer to help as needed.
The nurse is talking to a client in the mental health unit. The client says, "I'm really angry with my boyfriend about the things he says to me. Women always get put down, as if we don't matter or have anything important to offer." Which response is the most appropriate one for the nurse to make? a) "Tell me how you feel as a woman." b) "I know how you feel. I see that happening with some of my friends." c) "Yes, it's sad that women are treated that way. I guess we need to deal with it." d) "Many women's groups are developing ways to deal with this. I'll give you the names and contact numbers of some of these groups before you're discharged from the hospital."
a) "Tell me how you feel as a woman." RATIONALE: Focusing helps a client expand on a topic of importance. It also helps the client become more specific, move from vagueness to clarity, and concentrate on reality. The nurse should focus on the client's verbalization of concern. Agreeing with the client and avoiding the issue does not address the client's concern. Although the client may need to be provided with referrals to self-help or support groups before discharge, offering the names and contact numbers of women's groups is not the most appropriate response because it does not address the client's concern at the current time.
Suicide precautions are enacted for Joseph, and the nurse assigned to care for Joseph sits down to talk with him. During the conversation Joseph states, "I don't want to live if I can't see my son. He's the only thing that matters to me." Which response by the nurse will most likely promote therapeutic communication? a) "Tell me more about how important your son is to you." b) "Do you have other family members whom you enjoy spending time with?" c) "I'm concerned about you, Joseph. You need to look for other activities to occupy your free time." d) "I understand what you mean. I have a daughter, and I always look forward to seeing her when I get home from work."
a) "Tell me more about how important your son is to you." RATIONALE: The correct option focuses on Joseph's thoughts and feelings and encourages Joseph to talk about them. It also indicates that the nurse is listening to the client. The remaining statements are nontherapeutic, focus on other issues, and avoid the client's concern.
Louise reads an article about herbal therapies for stress relief and decides that she wants to try drinking tea made with kava. She calls the company nurse to ask about using kava. Which instructions should the nurse provide? Select all that apply. a) "You shouldn't use kava if you think you might be pregnant." b) "Herbal products are safe to use, because they aren't really medications." c) "This herb helps some people feel more relaxed and may help you sleep." d) "It's safe to drink a small glass of wine at night with this tea right before bedtime." e) "If you drink this tea long enough, you may notice a yellow discoloration of your skin."
a) "You shouldn't use kava if you think you might be pregnant." c) "This herb helps some people feel more relaxed and may help you sleep." e) "If you drink this tea long enough, you may notice a yellow discoloration of your skin." RATIONALE: Kava is commonly used to relieve anxiety and stress and to promote sleep. It may cause a temporary yellow discoloration of the skin, and it should not be taken with alcohol or psychoactive drugs or by women who are pregnant or breastfeeding. Even though kava is an herbal product, those who use it must be aware of potential side effects and contraindications.
A client is experiencing anxiety and requests help with using constructive coping mechanisms. When recommending coping mechanisms, the nurse should discuss which responses as most likely to be successful? Select all that apply. a) A response that is protective b) It is an effort to relieve anxiety. c) It may involve behaviors such as using relaxation techniques. A response that encourages relaxation techniques d) A response that involves repression of a painful experience into the unconscious. e) A response used by the individual to consciously confront a threat.
a) A response that is protective b) It is an effort to relieve anxiety. c) It may involve behaviors such as using relaxation techniques. A response that encourages relaxation techniques e) A response used by the individual to consciously confront a threat. RATIONALE: A coping mechanism is any effort to adjust and relieve anxiety. Constructive coping mechanisms are protective responses that an individual uses to consciously confront a threat. Constructive coping mechanisms can include distractions such as reading, praying, meditation; relaxation techniques; or seeking social support. Destructive coping mechanisms involve repression into the unconscious and tend to be ineffective. Examples of destructive coping mechanisms include withdrawal from social contacts, poor dietary habits, smoking, and alcohol and drug abuse.
With her parents beside her, Isabel carefully explains her situation to her children and outlines the plans for surgery and chemotherapy over the next few months. The children listen, in tears, and ask questions about what Isabel is facing. Later in the day, Regina starts to talk about looking forward to next summer's trip to Florida, a trip they have taken every year. Isabel says nothing about it but worries that her daughter may not fully understand her situation. Which stage of grief is Regina exhibiting at this time? a) Denial b) Bargaining c) Depression d) Acceptance
a) Denial RATIONALE: According to Elisabeth Kübler-Ross, a person who is undergoing a significant loss — the a person who is dying or people close to a dying person — will experience five stages of grief. The first of these stages is the denial stage, during which the person acts as if nothing has changed. The subsequent stages are anger, bargaining, depression, and finally, acceptance.
Which therapeutic nursing actions should the nurse use when dealing with the husband of a client who is dying? Select all that apply. a) Encouraging the husband to express his feelings and concerns b) Making decisions for the husband to lessen his burden of grief c) Determining how much the husband wishes to know about the care being provided to his wife d) Refraining from demonstrating emotion over the client's terminal situation in the presence of the husband e) Telling the husband that it will be easier to accept the loss if he avoids reminiscing and talking about his life with his wife
a) Encouraging the husband to express his feelings and concerns c) Determining how much the husband wishes to know about the care being provided to his wife RATIONALE: The nurse needs to assist the client, family, and significant others through the process of grief. The use of therapeutic communication techniques is important in promoting the process. It is important for the nurse to determine the needs of the family or significant other and how much information they wish to receive about the client's condition and the care being provided to their loved one. The nurse should also encourage reminiscing and the expression of feelings and concerns, which will help loved ones move through the grief process. The nurse should not make decisions for the family unless they specifically request that the nurse do so. Instead, the nurse should assist with the decision-making process if asked and avoid interjecting personal views or opinions. The nurse should acknowledge his or her own feelings. It is also acceptable for the nurse to express his or her own emotions with the family as appropriate.
The nurse is assigned to work with a client who has just been admitted to the mental health unit. Which action should the nurse plan to take in the orientation or introductory phase of the nurse-client relationship? a) Establish a contract with the client b) Increase the client's independence c) Promote the use of constructive coping mechanisms d) Refer and transfer the client to other sources of support
a) Establish a contract with the client RATIONALE: The tasks of the orientation or introductory phase of the nurse-client relationship are to establish trust, acceptance, open communication, and formulate a mutual contract with the client. The contract begins with the introduction of the nurse and client, the exchange of names, and the explanation of roles. Promotion of the use of constructive coping mechanisms and increasing the client's independence are tasks of the working phase. Referring and transferring the client to other sources of support is a task of the termination or separation phase.
The home care nurse making a visit to a client who is receiving hospice care understands that hospice care is intended to achieve certain outcomes. What are these outcomes? Select all that apply. a) Relief of symptoms b) Postponement of death c) Hastening of disease remission d) Facilitation of a peaceful death e) Provision of the best possible quality of life
a) Relief of symptoms d) Facilitation of a peaceful death e) Provision of the best possible quality of life RATIONALE: In hospice care, an interdisciplinary approach is used to assess and address the holistic needs of clients and families to ensure the best possible quality of life and a peaceful death. The holistic approach neither hastens nor postpones death, nor does it hasten remission of the disease; instead, it provides relief of symptoms.
Just before a session with the nurse, Katie receives a call from her boss. After the call, Katie is extremely upset and unable to sit down. She paces the room, crying and repeating, "I don't know what to do. He hates me!" Which nursing interventions will be most likely to be effective at this time? Select all that apply. a) Speaking to Katie in slow, firm, short statements b) Leaving Katie alone until she has settled down c) Assessing the need for medication at this time d) Exploring problem-solving strategies with Katie e) Moving Katie to a quiet setting and staying with her f) Using nonverbal cues, without speaking, to convey concern
a) Speaking to Katie in slow, firm, short statements e) Moving Katie to a quiet setting and staying with her RATIONALE: Katie is showing signs of a severe to panic level of anxiety. During this time it is important to keep her safe, meet her physical needs, and reduce anxiety. Moving to a quiet environment and speaking to her in slow, firm, short statements can help. Medication may be considered if other measures do not help. Persons who are experiencing severe anxiety are not able to solve problems; leaving Katie alone would not be safe, and she would be too upset to respond to nonverbal cues from the nurse.
Several family members are sitting at the hospital with a client who is dying of cancer of the bladder. The dying client's roommate is found waiting outside the room after visiting hours have ended. He tells the nurse that he wants to give his roommate's family privacy. Which action should the nurse take? a) Transferring the roommate to another room b) Reminding the dying client's family that visiting hours have ended c) Informing the dying client's family that the client may have just two visitors at a time d) Telling the roommate that he may return to his room and that the curtain will be drawn around the dying client's bed to provide privacy
a) Transferring the roommate to another room RATIONALE: When a client is dying, it is important for the client and family members to acknowledge their sadness and say goodbye. The client and family should be given privacy to express their feelings and comfort one another. However, the nurse should also consider the needs of nearby clients, such as the client's roommate. Because the client is dying, it is inappropriate to prohibit family from visiting or to require them to leave once visiting hours have ended. In this situation, it would be best to transfer the roommate to another room. This action will meet the needs of both clients.
The nurse is caring for a Muslim client who is dying of gastric cancer. Which specific request from the client's family might the nurse anticipate? a) "One of us must be present when he passes." b) "Can we please turn him to face the southwest?" c) "We are expecting the priest to come to administer sacraments." d) "We will need to cremate the body within 24 hours of his passing."
b) "Can we please turn him to face the southwest?" RATIONALE: At the end of life, the Muslim client or family may prefer the client face Mecca, which is in a south or southwest direction from the United States. Mecca is the birthplace of the prophet Muhammad and the spiritual center of Islam. Followers of Hinduism may wish for a relative to be present at death and request the body be cremated within 24 hours of passing. In the Catholic faith, the priest administers sacraments including Holy Communion and Reconciliation.
After 2 weeks, Isabel undergoes surgery to remove her ovaries and surrounding tissues. One week later, she visits her surgeon and gets the news that the cancer has spread to three lymph nodes in the area. "Not the best prognosis," she is told, "but we can still give it a good try." The nurse, helping Isabel get ready to leave, sees that she is sitting very still with her eyes closed. She tells the nurse, "I don't know how I'm going to get through this. I don't want to leave my children alone!" Which response to Isabel's statement is therapeutic? a) "If I were you, I'd get a second opinion before doing anything." b) "This must be a terrible time for you. Would you like to talk about it?" c) "It's too early to be upset. You haven't even had any chemotherapy yet!" d) "Don't worry. Everything will be all right. Dr. Smythe is the best oncologist in the area."
b) "This must be a terrible time for you. Would you like to talk about it?" RATIONALE: When a person who is experiencing grief or facing death wants to talk, the nurse needs to take the time to listen and avoid creating barriers to communication. Offering to take the time to listen to Isabel's concerns is a therapeutic response. Providing unsolicited advice is nontherapeutic. Telling Isabel that it's "too early to be upset" essentially denies her grief; telling her not to worry offers false reassurance. These three options are examples of barriers to communication.
A client tells the nurse that he is experiencing a great deal of work-related stress and is taking an anxiolytic medication. He tells the nurse that he read on the Internet that St. John's wort, an herbal product, is helpful in reducing stress and says that he would like to try taking it. Which is the best response for the nurse to give the client? a) "It's an herbal product made from a plant, so it's harmless." b) "You'll need to discuss the use of St. John's wort with your health care provider before taking it." c) "I read the same thing, and I know that you can buy St. John's wort at any health food store." d) "You should give it a try. I would suggest taking it every morning that you're scheduled to work."
b) "You'll need to discuss the use of St. John's wort with your health care provider before taking it." RATIONALE: The use herbal therapies in combination with other medications can result in significant and potentially dangerous medication interactions. The nurse should tell the client that he should discuss the use of St. John's wort with his health care provider. Therefore the other options are incorrect.
The nurse is providing physical care to a client who has recently been told that he has inoperable lung cancer with a poor prognosis. The client says to the nurse, "I am so scared of dying. You hear so many stories about death. If only someone could tell me what it is really like." Which response should the nurse give the client? a) "What stories have you heard?" b) "You're scared of dying. Let's talk about what makes you scared." c) "I've heard a lot of stories, too. I wish I could give you an answer to this one." d) "People who have died and been resuscitated say it's a beautiful experience."
b) "You're scared of dying. Let's talk about what makes you scared." RATIONALE: The nurse should use the therapeutic communication technique of paraphrasing and a response that is open-ended, which is also therapeutic. The nurse should restate the client's message and provide the client an opportunity to express his feelings, concerns, and fears. The responses in the incorrect options do not focus on the client's concern.
After several months and six rounds of chemotherapy treatments, Isabel begins to experience an aching pain in her back and hips. A bone scan reveals that the cancer has spread to her bones, and her oncologist tells her that her prognosis at this time is poor. He also tells her that she may have only weeks to live. Isabel again calls her family together and shares the news with them. She has been quietly working with an attorney to get her affairs in order, and her parents have agreed to serve as legal guardians of her children after her death. She has a living will and has included Regina in these discussions about the arrangements. Isabel has noticed that Regina has been quieter and has not talked to Isabel as much as usual. Isabel talks to the social worker at the oncology office about this, and the social worker suggests that Regina may be experiencing anticipatory grieving. Which examples are characteristics of anticipatory grieving? Select all that apply. a) The person experiences grief weeks after the actual loss. b) A family member begins to withdraw emotionally from the terminally ill person. c) A family member may choose to be with friends instead of staying with a dying family member. d) A person is overwhelmed by grief and cannot carry out day-to-day actions such as going to work. e) A family member is unable to sleep after a loss but does not connect the altered sleeping pattern to the loss.
b) A family member begins to withdraw emotionally from the terminally ill person. c) A family member may choose to be with friends instead of staying with a dying family member. RATIONALE: Anticipatory grief is the process of letting go that occurs before an actual loss (such as death) has occurred. It occurs when there is time for the person or family members to accept the reality of a terminal illness. However, some family members may actually begin withdrawing emotionally from the ill person as a self-protective mechanism, leaving the ill person with less support at the end of his or her life. Delayed grief occurs later, some time after the actual loss, instead of at the time of loss. Exaggerated grief is when a person experiences grief to such a degree that he or she cannot carry out daily functions. Masked grief is when a person is unable to recognize that the physical or emotional symptoms he or she is experiencing is a result of the loss that has been experienced.
The nurse employed in hospice care is reading the records of assigned clients. Which client does the nurse identify as being at risk for disenfranchised grief? a) The mother of a child who was killed in an automobile accident b) A same-sex partner of a client with acquired immunodeficiency syndrome c) A client with terminal cancer who is receiving a great deal of support from his wife d) A client with end-stage renal disease who relies heavily on religious beliefs for hope
b) A same-sex partner of a client with acquired immunodeficiency syndrome RATIONALE: Disenfranchised grief occurs when societal norms do not define a loss as a loss within its traditional definition. Basically, the survivor is not acknowledged for the loss and as a result is not given support by others. One example of disenfranchised loss is the death of a same-sex lover. In such a situation, grief may need to be hidden for the surviving partner to avoid negative social pressure. The mother of a child killed in an automobile accident, a client with terminal cancer, and a client with end-stage renal disease who relies heavily on religious beliefs for hope are not at risk for disenfranchised grief.
After a thorough mental health assessment, Joseph is transferred to the mental health unit in a voluntary admission. The nurse in the mental health unit reviews the emergency department notes in preparation for the interview with Joseph. Which would the nurse determine because Joseph has consented to voluntary admission? a) Joseph cannot request and be granted hospital discharge. b) Admission to the mental health unit was sought by Joseph. c) Admission to the hospital was made without Joseph's consent. d) Joseph will not be making decisions about his treatment or care.
b) Admission to the mental health unit was sought by Joseph. RATIONALE: Voluntary admission is generally sought by the client or by the client's guardian. Voluntary admitted clients have the right to request and be granted release from the hospital. Clients admitted to a mental health facility do not lose the right to informed consent or decision-making. Involuntary admission is made without the client's consent.
Which action on the part of the nurse would best help Katie in regaining her self-worth? a) Suggesting that she quit her job and find a new one b) Assisting Katie in exploring solutions to the problem c) Teaching Katie how to stand up to her boss when he reprimands her d) Encouraging Katie to use any defense mechanism necessary to deal with the problem
b) Assisting Katie in exploring solutions to the problem RATIONALE: A client who is experiencing anxiety may feel helpless and may be overwhelmed by feelings of inadequacy. The fact that the client has found it necessary to seek outside help may further increase feelings of inadequacy. Therefore, increasing the client's self-esteem and feeling of self-worth is important. The nurse would help Katie regain her feelings of self-worth by communicating confidence that she can find solutions to problems. The nurse would also convey the impression that Katie is a worthwhile person by listening to and accepting her feelings, being respectful, and praising her help-seeking efforts. Quitting her job and finding a new one is unrealistic. Use of any defense mechanism to deal with the problem is incorrect, because the use of nonconstructive defense mechanisms should be discouraged. Standing up to her boss might cause additional problems between Katie and the boss.
The nurse employed in the mental health unit of a hospital is leading a group psychotherapy session. Which is the nurse's role in the termination of stage of group development? a) Encourage problem-solving b) Encourage accomplishment of the group's work c) Acknowledge the contributions of each group member d) Encourage members to become acquainted with one another
b) Encourage accomplishment of the group's work RATIONALE: In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and help one another prepare for the future. Encouragement of problem-solving and accomplishment of the group's work is part of the working stage. Encouragement of members to become acquainted with one another is a task of the orientation stage.
A client is seen in the emergency department for complaints of chest pain and difficulty breathing. The results of laboratory and diagnostic tests are normal, indicating that there is no physiological basis for the complaints. On further assessment, the client tells the nurse that chest pain and difficulty breathing are the symptoms that his wife had before she died. Which type of defense mechanism does the nurse recognize in this behavior? a) Projection b) Introjection c) Rationalization d) Reaction formation
b) Introjection RATIONALE: Introjection is a type of identification in which the individual incorporates the traits or values of another into himself or herself. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. Reaction formation is the development of conscious attitudes and behaviors and acting out behaviors opposite of what one really feels.
The nurse teaches Louise deep-breathing exercises to help her relax and reduce stress. She tells Louise that she may perform these exercises while sitting at her desk and that she should perform them whenever she begins to feel stressed. Which observation by the nurse indicates that Louise is performing the breathing exercises correctly? a) Louise breathes in through her nose, holds her breath for 10 seconds, and then breaths out through her nose. b) Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. c) Louise breathes in through her nose, holds her breath for 15 seconds, and then breathes out quickly through her mouth. d) Louise quickly breathes in through her mouth, holds her breath for 10 seconds, and then quickly breathes out quickly through her nose.
b) Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. RATIONALE: To perform deep-breathing exercises, the client should shift to relaxed abdominal breathing. The client breathes in through the mouth, holds the breath for 3 seconds, and slowly breathes out through the nose. With every breath, the client should pay attention to the muscle sensations that accompany the expansion of the abdomen.
Joseph is discharged from the hospital, but his new mental health contract states that he will attend twice-weekly cognitive therapy sessions. During the working phase of the nurse-client relationship, what specific tasks does the nurse plan? Select all that apply. a) Establishing a rapport b) Promoting Joseph's problem-solving skills c) Gathering further data about Joseph's problems d) Summarizing the goals achieved in the relationship e) Discussion of problems and goals, and redefining as needed f) Helping Joseph explore how to practice alternative adaptive behaviors
b) Promoting Joseph's problem-solving skills c) Gathering further data about Joseph's problems e) Discussion of problems and goals, and redefining as needed f) Helping Joseph explore how to practice alternative adaptive behaviors RATIONALE: During the working phase of a nurse-client relationship, nurse and client work together to identify and explore issues that are causing problems in the client's life, then set goals for the sessions. It is also a time for data-gathering and identifying and promoting the client's problem-solving skills, as well as for exploring new behaviors for problem-solving. Establishing a rapport is part of the first phase of the nurse-client relationship, the orientation phase. Summarizing the goals that have been achieved is part of the termination phase.
During the assessment, Joseph discusses his feelings of self-harm with the nurse and hints that he even had a plan for carrying out his suicide if his life "got worse." Which methods of suicide are considered of lower risk, or "soft"? Select all that apply. a) Hanging b) Swallowing pills c) Inhaling natural gas d) Slashing one's wrists e) Staging a high-speed car crash into a cement wall
b) Swallowing pills c) Inhaling natural gas d) Slashing one's wrists RATIONALE: The evaluation of a suicide plan is extremely important in determining the degree of suicide risk. The lethality of a method in person's suicide plan indicates how quickly the individual would die if that plan were enacted. Guns, hanging, carbon monoxide, and car crashes are extremely lethal and are therefore considered higher-risk, or 'hard,' methods. Slashing the wrists, inhaling natural gas, and ingesting pills are lower-risk, or 'soft,' methods.
The nurse is evaluating the grief process for a woman whose husband died in an automobile accident 2 months ago. Which outcomes would the nurse identify as successful? Select all that apply. a) The client refuses to take on new responsibilities. b) The client demonstrates lengthening periods of stability. c) The client expresses positive expectations about the future. d) The client reports decreased preoccupation with the loss of her husband. e) The client's daughter reports that her mother has not paid any bills since the death of her husband.
b) The client demonstrates lengthening periods of stability. c) The client expresses positive expectations about the future. d) The client reports decreased preoccupation with the loss of her husband. RATIONALE: Grieving is a normal process in which people come to terms with losses. Successful outcomes associated with the grief process include the ability to tolerate intense emotions, reduced preoccupation with the deceased (loss), demonstration of increasing periods of stability, tending to previous responsibilities, taking on new roles and responsibilities, having the energy to invest in new endeavors, the expression of positive expectations about the future, and remembering positive as well as negative aspects of the deceased loved one. Refusing to take on new responsibilities and not attending to responsibilities are unsuccessful outcomes.
Isabel has begun outpatient chemotherapy. After each session, she goes home to rest, and she has been unable to care for her children. Her mother comes over in the afternoons to be there when the children come home from school and to cook dinner for the family. Trevor comes home one day with a note from his teacher. He has been rude at school, using "bad language" and talking back to the teacher. When asked about this, Trevor replies, "I'm fine. The teacher is stupid." Isabel calls the clinic nurse to talk about Trevor's behavior. Which statement by the nurse provides the best interpretation of Trevor's behavior? a) "Yes, he's being rude and insensitive, but he'll grow out of it soon." b) "Trevor needs to accept what's happening to you and stop acting out." c) "This may be his way of running away from the situation. Let's try to get him to talk about it." d) "The teacher just doesn't understand the difficult time that Trevor is going through right now."
c) "This may be his way of running away from the situation. Let's try to get him to talk about it." RATIONALE: For a school-age child, the realization of impending death and loss is a major threat to the child's sense of security and ego strength. At this age, children are likely to show their fear through verbal uncooperativeness —using rude or bad language or being impolite and stubborn. The nurse should recognize this as an attempt to "run away" from stress and should encourage Trevor to talk about his feelings. The incorrect options avoid the situation and do not address Trevor's behavior or feelings.
The hospice nurse is caring for a client with end-stage heart failure. The nurse should monitor the client for which signs of impending death? Select all that apply. a) Diarrhea b) Increased urine output c) Increased pain perception d) Decreasing blood pressure e) Irregular and noisy respirations f) Mottled and cyanotic extremities
d) Decreasing blood pressure e) Irregular and noisy respirations f) Mottled and cyanotic extremities RATIONALE: Some signs of impending death are decreasing blood pressure, irregular and noisy respirations, and mottled, pale, or cyanotic extremities. The client is more likely to experience constipation from decreased peristalsis. The urine output decreases, rather than increasing. Pain perception decreases.
The nurse is working with several clients who are using maladaptive defense mechanisms. Which situation is an example of the maladaptive defense mechanism known as identification? a) A client criticizes the nurse after his family fails to visit him. b) A married man flirts with his secretary and then brings flowers home to his wife. c) A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. d) A nursing student who fears failure on a final exam develops a terrible headache and is unable to take the exam.
c) A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. RATIONALE: Identification is an unconscious attempt to change oneself to resemble an admired person. A young boy's belief that a neighborhood gang leader who sells illegal drugs is someone to look up to is identification as a maladaptive defense. Displacement is a defense mechanism in which feelings toward one person are directed at another who is less threatening, thereby satisfying an impulse with a substitute object. The client who criticizes a nurse after his family fails to visit him is engaging in displacement. Undoing is engaging in behavior that is considered the opposite of a previous unacceptable behavior, thought, or feeling (e.g., a married man flirts with his secretary and then brings flowers home to his wife). Conversion is the expression of emotional conflicts through physical symptoms. A nursing student who fears failure on a final exam and develops a terrible headache becoming unable to take the exam is an example of conversion.
Katie, anxious about her work, is now afraid of her new boss. She dislikes going to work because she is afraid of being reprimanded, hates feeling inadequate and worthless, and fears demotion. Katie decides to seek help for her problem because she doesn't like taking her frustrations out on her children and makes an appointment to speak to the nurse at the mental health clinic. Which conclusion regarding Katie's defense mechanisms does the nurse make? a) They need restructuring. b) They must be used at work to deal with this situation. c) They are used to cope with the stress and to maintain self-esteem and ego integrity. d) They should not be used at all, because Katie must learn to deal with the situation on her own.
c) They are used to cope with the stress and to maintain self-esteem and ego integrity. RATIONALE: A defense mechanism is used to protect oneself from painful awareness of feelings that can provoke anxiety. Use of defense mechanisms help an individual cope with stressful situations and maintain self-esteem and ego integrity. The nurse would encourage the client to use constructive defenses and discourage the use of nonconstructive defenses. Returning the client to an earlier level of function, not the restructuring of defenses, is the goal of the nurse-client interaction.
Joseph has been undergoing therapy, and suicide precautions have been discontinued. Joseph asks the nurse about being discharged from the mental health unit. What information does the nurse keep in mind as he responds to Joseph? a) Administrative approval is required before discharge. b) Because of his admission status, Joseph may not request discharge. c) Voluntarily admitted clients have the right to request and be granted release from the mental health unit. d) Discharge will not be considered unless Joseph is able to move in with a relative or friend who can stay with Joseph full time for at least 1 month.
c) Voluntarily admitted clients have the right to request and be granted release from the mental health unit. RATIONALE: Voluntarily admitted clients have the right to request and be granted release from the mental health unit. Administrative approval is not required. Asking Joseph to move in with a relative or friend who will stay with him on a full-time basis for at least 1 month is incorrect and unrealistic.
The nurse provides information to a client about stress-management techniques. Which statement by the client indicates a need for further information? a) "Listening to music can be really soothing." b) "Getting enough sleep every night will help me deal with the stress." c) "I should get regular exercise as part of my stress-management program." d) "Everyone thinks that caffeine can make the stress worse, but that's a myth."
d) "Everyone thinks that caffeine can make the stress worse, but that's a myth." RATIONALE: Stress-management techniques include listening to music, having pets around, getting a massage, laughter and humor, participating in a regular exercise program, getting adequate sleep, and reducing or eliminating caffeine intake. Reducing or eliminating caffeine intake can yield more energy and help produce a relaxing feeling.
The family of a client at the end-of-life has requested their pastor visit the client in the hospital. Privately, the client tells the nurse, "He's not my pastor. My daughter is always trying to get me to go to her church. I don't want to see him." Which response by the nurse is most appropriate? a) "A crisis of faith is common at the end of life." b) "Have you shared your feelings with your family?" c) "Spiritual needs can be as important as the needs of the body." d) "I will communicate to your family that you do not want to see the pastor."
d) "I will communicate to your family that you do not want to see the pastor." RATIONALE: Care during the dying experience needs to be based on the client's wishes. Therefore, the nurse should recognize family dynamics and advocate on behalf of the client, who is in a vulnerable condition, and communicate the client's wishes to the family. By meeting separately with the family, the nurse may help the family understand how they can support the client's dignity and autonomy. The incorrect options are inappropriate and do not address the client's expressed wishes and needs.
Louise calls the firm's nurse's office and schedules an appointment. She tells the nurse that she is feeling tired and stressed and that she is experiencing palpitations every time one of the lawyers places a document on her desk. Louise tells the nurse that she has heard that taking ginseng will relieve the stress and asks whether it is safe to take. How should the nurse respond to Louise? a) "Many reports indicate that ginseng reduces stress." b) "Ginseng is a natural herbal substance and is safe to take." c) "It's a good idea to try ginseng, because it is so important to keep the stress level down to prevent illness." d) "It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you."
d) "It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you." RATIONALE: Herbal substances that have been used to relieve anxiety and stress include ginseng, St. John's wort, and kava. Contraindications to the use of these substances do exist. The client should be warned of this fact and advised to consult a health care provider regarding the use of herbal substances. Therefore the other responses are inappropriate.
Katie, very upset about her boss' comments, returns home from work to find her children sprawled on the couch, watching television and eating cookies and milk. She immediately yells at them, telling them to get off the couch and get their rooms cleaned and homework done. Which defense mechanism is exemplified by Katie's behavior toward her children? a) Introjection b) Dissociation c) Identification d) Displacement
d) Displacement RATIONALE: In using displacement, Katie directs her feelings toward one person (her boss) at another (or others; in this situation, her children) who is less threatening. Introjection is the incorporation or internalization of values, standards, or traits of another person with whom intense emotional ties exist. Dissociation involves the blocking off of an anxiety-provoking event or period from the conscious mind. Identification is an unconscious attempt to change oneself to resemble an admired person.
A client with claustrophobia is seen in the mental health clinic and is told that one treatment for the disorder is systematic desensitization. When the client asks the nurse to describe the treatment, what information does the nurse provide? a) It involves focus on the consequence of a behavior. b) A stimulus attractive to the client is paired with an unpleasant experience. c) The therapist will perform certain behaviors, and the client will imitate the behaviors. d) It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased.
d) It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased. RATIONALE: With systematic therapy, incrementally increasing exposure to a feared stimulus is paired with an increasing level of relaxation, helping reduce the intensity of fear to a more tolerable level. Operant conditioning is the manipulation of selected reinforcers to elicit and strengthen desired behavioral responses; the reinforcer refers to the consequence of the behavior, which is defined as anything that increases the occurrence of a behavior. Aversion therapy is a form of behavioral therapy in which negative reinforcement is used to change behavior; for example, a stimulus attractive to the client is paired with an unpleasant event in the hope of endowing the stimulus with negative properties, thereby dissuading the behavior. Modeling is a type of behavioral therapy in which the therapist acts as a role model for specific identified behaviors so that the client learns through imitation.
Two police officers arrive at the emergency department with a client who was been displaying violent behavior in a local park. The police report to the nurse that they tried unsuccessfully to reason with the client and that the client continued to direct violent behaviors at other individuals in the park. After a thorough psychosocial assessment of the client, the health care provider determines that the client requires emergency involuntary admission to the mental health facility. What determination does the nurse make with regard to this type of admission? a) It requires the client's consent. b) It takes away the client's right to informed consent. c) It is normally sought by the client or the client's guardian. d) It is necessary for a client who is a danger to self or others.
d) It is necessary for a client who is a danger to self or others. RATIONALE: Involuntary admission is made without the client's consent. Generally involuntary admission is necessary when the client is a danger to self or others, is in need of psychiatric treatment, or is unable to meet his or her own needs. Voluntary admission is usually sought by the client or by the client's guardian. Clients who are involuntarily admitted do not lose their right to informed consent.
The nurse is performing an assessment of a client who abuses alcohol. During the assessment, the client preaches about the evils of drinking. Which adaptive defense mechanism should the nurse recognize in the client's behavior? a) Projection b) Identification c) Rationalization d) Reaction formation
d) Reaction formation RATIONALE: Reaction formation is the development of conscious attitudes and behaviors and the acting out of behaviors that may conflict with what one really feels. The client's proclamations about the evils of drinking are an example of this adaptive defense mechanism. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Identification is an unconscious attempt to change oneself to resemble an admired person. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior.
The nurse providing information to the wife of a client who abuses alcohol encourages the woman to attend an Al-Anon support group. The wife tells the nurse that she is embarrassed by her husband's behavior and that it would be difficult for her to face other people. Which response should the nurse give the woman to help alleviate her concerns? a) The support group is always led by a nurse and health care provider. b) She will not know any of the members of the support group. c) She does not need to provide her name or any other identifying information to the group. d) The members of the group have experienced or are experiencing the same problem she is facing.
d) The members of the group have experienced or are experiencing the same problem she is facing. RATIONALE: Al-Anon is a support group for spouses and friends of alcoholics or addicts. Support groups are based on the premise that people who have experienced a particular problem are able to help others with the same problem. Although a nurse or other health care professional may be asked to speak at a support group meeting, the members of the group lead the group. The nurse cannot ensure that the wife will not know any of the members. Although the wife does not need to provide her name or any other identifying information to the group, this response is not helpful and will not alleviate the wife's concerns.
The nurse caring for Joseph discusses the plan of care with the psychiatrist, who tells the nurse that Joseph would benefit from cognitive therapy. What information does the nurse provide to Joseph about this type of therapy? a) Medication is the main treatment in this form of therapy. b) A reward will be given to Joseph for every hour in which he does not have a suicidal thought. c) The psychiatrist will function as a role model, helping Joseph learn to prevent thoughts of suicide. d) Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs.
d) Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs. RATIONALE: The therapeutic techniques of cognitive therapy are designed to identify, reality-test, and correct distorted conceptualizations and the dysfunctional beliefs underlying these cognitions. The client learns to master problems in situations he or she previously considered insurmountable by evaluating and correcting his or her thinking. Medication is not a primary component of cognitive therapy. In modeling, the psychiatrist or therapist acts as a role model for specific identified behaviors. In operant conditioning, a reward would be given for not having a suicidal thought.
