Passpoint- Unit 4 review

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements.

A 47-year-old client has been taking prescribed medication for an intestinal ulcer. During a routine office visit for blood pressure monitoring, the client reports he is no longer able to have sexual intercourse with his spouse. The nurse determines that this is most likely the result of:

ulcer medication.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He's doing too much. I told him to let me help, but he won't let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, what should the nurse do?

Direct the body and eyes at the wife and client.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse?

Explore other ways to control symptoms and address the family's concerns more effectively.

Which of the following client behaviors indicates the nurse-client relationship is in the working phase?

The client makes an effort to describe his or her problems in detail.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a graphic sheet

A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that

it is normal for the child to want to sleep with them at night.

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

previous coping skills

A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating which stage of separation anxiety?

protest

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

reorienting the client to time and place

A client is receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug?

"Do you have less pain in the legs?"

After an episode of severe pain, a client says to the nurse, "The pain really frightened me. I thought I was going to die." Which statement is the most appropriate response from the nurse?

"I understand that pain can be a frightening experience."

Which client statement indicates that the client has gained insight into his use of the defense mechanism of displacement?

"Now when I am mad at my wife, I talk to her instead of taking it out on the kids."

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response?

"Please explain that to me."

The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which statement by the mother indicates that she understands her daughter's illness and management?

"Tasks as simple as getting out of bed and showering in the morning may be difficult for her."

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly."

At the admission interview, the father of a 4-year-old boy with attention deficit hyperactivity disorder (ADHD) says to the nurse, "I know that my wife or I must have caused this disease." What is the nurse's best response?

"ADHD is more common within families, but there is no evidence that problems with parenting cause this disorder."

A nurse is explaining electroconvulsive therapy (ECT) to members of a depression support group. Which statement would indicate understanding?

"ECT treatments are given for severe depression when other meds have failed."

In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement?

"I get so angry at times that I have to have a couple of drinks before I sleep."

The son of an older adult client who has cognitive impairments approaches the nurse and says, "I'm so upset. The health care provider says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment?

"I want the social worker to make this decision so Dad won't blame me."

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or healthcare facilities. What is the nurse's best response?

"It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?"

A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply.

-Keep in contact with other family and friends. -Attend memorial or religious services. -Use relaxation techniques and physical activities. -Attend community meetings with others who have lost loved ones.

The nurse is caring for an adolescent client. What is the best way for the nurse to obtain data related to the client's spirituality?

Ask the client if there are aspects of the client's life they consider spiritual.

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. Which of these best describes a subculture?

a unique cultural group that exists within the larger culture

A client recovering from a drug overdose is interacting with the nurse and recounting her exploits at numerous parties she has attended. Which action is most therapeutic?

directing the conversation to realistic concerns

While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience?

fear of the unknown

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first?

medication compliance

A client brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He's fine except for this irrational belief that we'll remarry." When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time?

referral to an outpatient therapist

Which discharge instructions would the nurse give to the client with acute pancreatitis? Select all that apply.

-Report any twitching or muscle spasms. -Eat a high-carbohydrate, low-protein, low-fat diet.

A 12-year-old African-American client has experienced significant blood loss and may require a blood transfusion. The child's mother, father, and sisters are currently present at the child's bedside in the emergency department. How should the nurse direct questions and teaching about the client's condition and treatment?

Assess who is the dominant member of the family and then address that person.

The parent of a school-age child with autism asks the nurse how she should tell her son that he has autism. Which response by the nurse is most therapeutic?

"Explain the definition of autism and emphasize your child's strengths as well as his areas of challenge."

An obstetric ultrasound reveals that the client's fetus has spina bifida. The mother is concerned about raising a child with a congenital abnormality and starts to cry. Which response by the nurse is best?

"I know this must be overwhelming. I'm here to sit with you and support you."

A nurse is providing education to a client recently diagnosed with schizoaffective disorder. Further teaching is necessary when the client makes which statement?

"I will need to get my blood drawn daily to check the levels of the antipsychotic medications."

The nurse is caring for a client who has been physically abused. Which statement by the nurse expresses empathy for this client?

"It must be difficult what you have been going through."

An adolescent client is admitted to a psychiatric day treatment program due to severe lower back pain since her mother's death 3 years ago. Medical examinations have not discovered a physical cause for her pain. She cares for her four younger siblings after school and on weekends because of her father's long work hours. Which predischarge statement indicates that treatment for her condition has been successful?

"My back pain is worse on weekends with more responsibility and homework."

A client is readmitted to the acute care facility. During the admission assessment, the client reports not taking the medication as prescribed. What is the best response by the nurse?

"Please tell me about how you take your medications?"

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

"When my moods fluctuate, I'll increase my dose of lithium."

Which response is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?

"When you interrupt others, they leave the area."

The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.

-Reorient frequently to time, place and situation. -Arrange for familiar pictures or special items at bedside. -Spend time with the client, establishing a trusting relationship.

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. What are purposes of the "read-back" requirement? Select all that apply.

-to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information -to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information

The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family?

Contact the hospice agency to provide grief support for the family.

Identify a command center at which activities are coordinated.

Discuss feelings of anger with staff.

A nurse is evaluating a fetal monitor strip and finds the fetal heart rate accelerated 20 beats per minute for 15 seconds. What is the nurse's best action?

Reassure the client that all is well with the fetus.

A charge nurse is making shift assignments when a staff nurse requests to not be assigned to a particular child because of the quantity of time the child requires. The charge nurse knows that the child and family have bonded with the staff nurse. What should the charge nurse do next?

Talk with the staff nurse about the assignment and the concerns voiced.

An adult client diagnosed with anxiety disorder becomes anxious when she touches fruits and vegetables. What should the nurse do?

Teach the woman to use cognitive behavioral approaches to manage her anxiety.

What client behaviors would be most important for the nurse to consider in deciding to institute suicide precautions because of high-risk behavior?

The client recently attempted suicide with a lethal method.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?

taking hold

When assessing a 17-year-old client with depression for suicide risk, which question would be best?

"Are you thinking about killing yourself?"

Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my spouse." How should the nurse respond?

"Can you tell me more about what your goals for a sexual relationship with your spouse are?"

A client with Alzheimer's disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which statement?

"Dad said that what he missed most while he was here was using his aftershave."

After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in stable condition. While standing by the crib, the mother says, "Perhaps if I had brought my baby to the hospital sooner, the surgery could have been avoided." What is the nurse's best response?

"Do you think that earlier hospitalization could have avoided surgery?"

After a client reveals a history of childhood sexual abuse, what question should the nurse ask first?

"Does your abuser still have contact with young children?"

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

A client with a diagnosis of major depression and a history of several suicide attempts tells a nurse, "I have no reason to live. Nobody cares about me." Which response by the nurse is most therapeutic?

"How long have you been feeling like this?"

A nurse is approached by an adolescent who has been admitted to the hospital for headaches. She confides that she is being sexually abused by a family friend. What should be the nurse's best initial response?

"I believe you; you were right to tell me."

A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

The nurse is preparing to administer oral medication to an 8-year-old child who is resistant to taking the medication. Which is the most effective statement made by the nurse that would encourage the child to take the medication?

"I have your medication. Swallow these please."

An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which response by the nurse is the most appropriate?

"I understand your concern. I'll call the physician to review the results with you."

The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship?

"I'm sorry this is happening to you."

A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?

"It sounds like that offers you a sense of security."

A client is being treated for injuries sustained in a motor vehicle collision for which the client was at fault and that resulted in the death of two children. The client does not want to ambulate in the hallway because the client thinks that all the nurses will judge the client for what happened. What is the most appropriate response by the nurse providing care?

"It sounds like you fear being judged by the staff. Can you tell me more about that?"

The mother of a client with schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which response by the nurse is most appropriate?

"She may have stopped taking her medications. I'll check on her."

A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be most appropriate?

"Tell me more about where you found this information that you gave me."

During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. What is the best response by the nurse?

"Tell me more about your feelings on this."

A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response?

"That's a difficult question to answer, and this must be very frightening for you."

A client with severe and persistent depression is debating undergoing electroconvulsive therapy (ECT). The client's family asks a nurse to convince the client that this treatment would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make?

"The client, treatment team, and family can meet to discuss this treatment option."

A client with substance abuse and bipolar disorder has recently stabilized after experiencing a crisis resulting from a psychotic episode. The client tells the nurse, "I want to live in the community again." What is most important for the nurse to communicate with the healthcare provider if advocating for the client's discharge into the community?

"There's extensive documentation to support the client's improved functioning level."

The nurse providing health promotion education to the parents of a 6-year-old child should include which statements about 6-year-old children in the education?

"They are very sensitive to criticism."

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate?

"This subject seems to be troubling you. Let's walk to the activity room."

A client with depression has not responded to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). Which statement should the nurse add when explaining the procedure to the client?

"This treatment has been proven to be effective, and we expect a positive outcome."

As the nurse helps the client prepare for discharge, the client says, "You know, I've been in lots of hospitals, and I know when I'm sick enough to be there. I'm not that sick now. You don't need to worry about me." What would be the most therapeutic response by the nurse?

"We're concerned about you. How can we help you before you leave?"

An adolescent client is diagnosed with borderline personality disorder (BPD). The client has an eating disorder behavior consisting of eating and then purging. Which of the following questions by the nurse is the best way to assess the client's nutritional status?

"What do you eat in a day?"

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?"

A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. Which question would be appropriate for the nurse to ask to assist the client?

"What have you done so far to try to solve this problem?"

A client with two young children is diagnosed with breast cancer. The client says, "This is the worst time in my life. How can I adjust to all of this without losing it?" What is the nurse's best response?

"What ways have you used to help reduce stress and cope with significant events in your life?"

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse?

"You have a right to withdraw consent. Can you share more about your decision?"

A client admits to having thoughts of suicide. He is lethargic, withdrawn, and irritable. In conversations with the nurse, he stresses his faults. When he starts to point out the things he cannot do, which response by the nurse is best?

"You were able to write a letter to your friend today."

The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." How should the nurse respond?

"You're frightened. This is a hospital and these people are staff members. You're safe here."

The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my partner? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply.

-"Encourage your partner to rest in between contractions." -"Continue to praise your partner and give her encouragement." -"Stay by your partner's side. It is important that she knows you are there to support her."

A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply.

-"I will develop a list of questions to use in interviewing potential midwives." -"I understand the complications that could occur in a home birth setting." -"I realize that I may need to be transferred to a hospital if complications develop."

The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply.

-"If I am having trouble sleeping or eating, I will call the mental health center." -"I can't drink even one or two beers." -"Anxiety makes it more likely I will hear voices."

A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which the client lost both legs. The client states, "I will never be able to work again or live a normal life." Which responses by the nurse would be considered therapeutic? Select all that apply.

-"Losing both legs is hard to accept, how are you feeling now?" -"The occupational therapist will teach the use of adaptive equipment promoting independence." -"I am here to help you. Let's devise a plan so that you are working toward your goals."

An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply.

-"Our child is just trying to get attention." -"Our child would not do this again." -"Our child will be fine in a couple of days."

The nurse is witnessing a surgical consent for an adult client. What nursing considerations should the nurse should keep in mind while witnessing the consent? Select all that apply.

-Ask the client for permission to discuss the surgery with visitors. -Refrain from witnessing the client's signature because the client decided to refuse the surgery. -Alerts the surgeon to the client's questions prior to witnessing the consent.

Which are culturally appropriate actions on the part of the nurse when caring for a non-English-speaking client? Select all that apply.

-Ask the client specific and direct questions. -Direct questions to the culturally appropriate decision maker. -Arrange for an interpreter who speaks the client's dialect.

A client with a diagnosis of metastatic breast cancer asks the nurse, "Why has God done this to me? I need to see a minister and go back to church." What interventions would be most helpful to the client at this point in time? (Select all that apply.)

-Discuss feelings related to the illness. -Address the use of spiritual resources. -Encourage communication about religious beliefs.

While providing care to a client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on the arms and trunk. When the nurse asks about these bruises, the client responds, "I tripped." What actions would the nurse take? Select all that apply.

-Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. -Assist the client in developing a safety plan for times of increased violence. -Provide the client with telephone numbers of local shelters and safe houses.

A nurse is collecting an initial assessment for a client in early labor. During the health history portion of the assessment, the client tells the nurse that they had an elective abortion, but they do not want their spouse to find out. How should the nurse proceed? Select all that apply.

-List the elective abortion under past surgeries in the client's chart. -Uphold the client's wishes and ensure the client's confidentiality.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

-Provide explanations and support to the client. -Attend to the client's physical needs. -Report any signs of abuse to appropriate agencies.

A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply.

-The parents may be at different stages in dealing with the child's death. -The dying child may become clingy and act like a toddler. -The death of a child may have long-term disruptive effects on the family. -The child does not fully understand the concept of death.

A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply.

-asking the client about original spiritual beliefs -identifying current or past spiritual supports -exploring factors that are creating conflict with client's beliefs

The hospice nurse is assessing a new client to prepare to support the client's reaction to and expression of grief. What assessment(s) should the nurse include? Select all that apply.

-developmental age -family role and supports -socioeconomic factors -religious beliefs -type of terminal illness

A nurse is caring for a client who exhibits behaviors that tests the nurse-client relationship. When discussing this behavior at a multidisciplinary team conference, which behaviors would the nurse provide as examples? Select all that apply.

-placing the nurse in the role of parent -requesting personal information from the nurse -stating information to try to shock the nurse -violating the nurse's personal space

A nurse is caring for a spiritually distressed client. Which are the factors affecting spiritual distress? Select all that apply.

-self-alienation -chronic illness -sociocultural deprivation

A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply.

-set realistic goals for each day -practice relaxation techniques -balance sleep, rest, and exercise

The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply.

-unhealthy personal boundaries -abuse and neglect

A 2-year-old child is brought into the clinic with an upper respiratory tract infection. The nurse is concerned about abuse with this child. Which findings should prompt the nurse to evaluate for suspected child abuse? Select all that apply.

-welts or bruises in various stages of healing on the trunk -circular, symmetrical burns on the lower legs -a parent who is hypercritical of the child and pushes the frightened child away

A client is grieving following a spontaneous abortion (miscarriage). She unexpectedly becomes pregnant again very quickly after the miscarriage, and is quickly able to move through her grief and become excited and happy about this pregnancy. Which type of grief did the client likely experience for her miscarriage?

Abbreviated grief

An older adult client has received a terminal lung cancer diagnosis. The client's adult children are tearful and afraid to leave their parent's bedside. What type of grieving is this family most likely experiencing?

Anticipatory

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question?

Arrange for a person with an ostomy to visit the client preoperatively.

The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma?

Clients can recover from mental illness if they have willpower.

The nurse is providing care for a client who immigrated three months ago. The nurse observes that the client is reluctant to make eye contact when responding to the nurse's questions. What is the nurse's best response?

Consider the norms around nonverbal communication in the client's culture.

The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client.

Which interaction is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client?

Equal sharing of time for discussion of problems so there is mutuality in the relationship

A child is newly diagnosed with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first to help the parents?

Evaluate and assess parents' stress and anxiety levels.

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent?

Get help to handle the situation safely.

When assessing a client's level of stress caused by significant life events, the nurse should use:

Holmes and Rahe's theory.

During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption?

Observe how the client and the client's family interact with each other and with other staff members

A nurse is caring for a client in a multicultural community. The nurse knows that it is important to give the client meaningful spiritual care within the healthcare context. What is the best action made by the nurse?

Provide care that is congruent with the client's beliefs.

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do?

Tell the physician about the pain so that its cause can be determined.

A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on bupropion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior?

The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior.

The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse use to evaluate the effectiveness of such a program?

a reduction in the total number of restraint procedures

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client?

a security window in the door or a room camera

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. The nurse should:

allow her to verbalize her feelings and concerns.

A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest?

charting by exception

A client has just been diagnosed with cancer. During the initial stage of adaptation to the diagnosis and its treatment, the nurse can facilitate the client's adaptation by using which strategy?

encouraging the client to maintain her usual role

When discussing spirituality with a parent of an 8-year-old child, the nurse instructs the parent that children of this age

enjoy lore and legends of religious groups.

`The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse?

ensuring relevance to, and quickly refocusing upon, the client's experience

A client with major depression is frequently irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach?

firmness

When planning the care of a client experiencing aggression, the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which measure should the nurse consider to be the most restrictive?

haloperidol given intramuscularly

Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which intervention should the nurse expect to implement to accomplish this goal?

having the mother stay with the infant

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make?

hearing loss

A nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor should the nurse most likely consider?

inadequate diet

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor?

lacking understanding of body integrity

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication?

lorazepam

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

making a copy of the incident report for the client

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Fowler

A client is being discharged from the acute inpatient unit but needs further continuous supervision that is less intense than inpatient hospitalization. The nurse should refer the client to which setting?

subacute unit

A client walks into the clinic and tells the nurse she has run out of money for crack, has crashed, and wants something to help her feel better. Which factor is most important for the nurse to assess?

suicidal ideation

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern?

suicide potentialq

A hospitalized client craves a drink after withdrawing from alcohol. Which measure is the best way to help the client resist the urge to drink?

support from other alcoholic clients

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should

take measures to ensure privacy during the counselor's visit.

A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling?

the nurse's comfort and knowledge level related to the process of spiritual counselling

The nurse is preparing to take a meal tray to the client. The nurse understands that the client follows a kosher diet. Which foods noted on the tray would be of a concern to the nurse?

turkey and cheese sandwich

Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?

using gestures to express desires

The nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors?

preventative vaccinations

The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take?

Call a break in the meeting and talk to the nurse in a private place.

The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the health care provider (HCP)?

The child reports having a previous surgery for a ruptured appendix.

A client with impulsive behavior, unstable yet intense interpersonal relationships, and substance use disorder expresses anger to staff and other clients in a psychiatric unit. What is the priority action by the nurse?

Give positive reinforcement when the client uses appropriate ways to express anger.

A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

spiritual alienation

A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent?

"All visitors should wash their hands before they leave or enter the room."

Members of which religious tradition are likely to have the most stringent restrictions and parameters placed on their medical care?

Christian Scientist.

The nurse is working on a psychiatric unit with new admissions with suicidal ideation. What characteristic is being described by a client who states, "I want to live, but maybe the answer is to die"?

ambivalence

A nurse is caring for a terminally ill client in the home. The family wants to know how to respond when the client asks whether the client is dying. Which is the best response by the nurse?

"Answer truthfully in a caring, gentle manner."

A nurse is admitting a client with barbiturate abuse. Which drug is most likely to increase the client's depression?

amitriptyline hydrochloride

The nurse is meeting a client on the mental health unit. When beginning a therapeutic relationship, which nursing actions are appropriate? Select all that apply.

-Help the client explore different problem-solving techniques. -Encourage the practice of new coping skills.

A nurse working in an alcohol rehabilitation program is teaching staff how to give clients constructive feedback. Which statement given as an example illustrates that the staff member understands the nurse's teaching regarding the use of constructive feedback?

"You interrupted twice in 4 minutes."

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response?

"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."

A 3-year-old child of Vietnamese descent with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, welt-like lesions on the child's upper back and chest. Which question should the nurse ask next?

"Can you tell me about any cultural practices in your family?"

On admission for a bronchoscopy, a client reports managing hypertension for the past year with a type of biofeedback device. What is the nurse's best response?

"Explain to me how it works for you."

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?

"I understand my pain will feel worse when I am worried about my divorce."

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. How would the nurse respond?

"Is there anyone else I can call to support you at this time?"

A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, "You're going to tell me who did this to you. What's his name?" Which is the nurse's best response?

"Please come with me, sir. I need some important information."

The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?

"There is not enough blood circulating to the kidneys."

A client being admitted to hospital is asked to sign a statement confirming that the client understands the rights to communicate information related to life support and resuscitation. The client asks the nurse why signing such a statement is necessary. What is the best response by the nurse?

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."

A laboring client at 28 weeks gestation is in preterm labor. Her partner gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse?

"You and your partner have been through a lot with this pregnancy. Let's talk about this further."

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client?

"You may want to have an abortion if you find out you are pregnant."

A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate?

"You seem upset. Having your child hospitalized must be difficult."

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. "He knows who we are, but that's about it. We don't know what to say to him." What should the nurse tell the family? Select all that apply.

-"Answer his questions simply, honestly, slowly, and clearly." -"Occasionally remind him of the time, day, and place when he doesn't remember." -"Include him in your conversation, instead of talking about him while he's present."

A client is admitted to the psychiatric unit following a suicide attempt. The client has suffered identity theft through the Internet and states, "My savings, checking, and retirement accounts are empty. I have nothing left to pay my bills or buy food and medicines. The only thing left is to die." After 1 week, the nurse would conclude that the client has been helped upon hearing which statements? Select all that apply.

-"I realize that I still can get monthly public assistance benefits." -"I filed identity theft claims with the bank, my retirement account, and the government authorities." -"With all the help I got here, I think I may be able to survive after all."

On an oncology unit, the nurse hears noises coming from a client's room. The client is found throwing objects at the walls and has just picked up the phone and is screaming, "How can God do this to me? It's the third type of cancer I've had. I've gone through all the treatment for nothing." In what order of priority from first to last should the nurse make the interventions? All options must be used.

-"Please put the telephone down so we can talk." -"I can hear how upset you are about the cancer." -"Tell me what you are feeling right now." -"I wonder if you would like to talk to a member of the hospital clergy."

Which preoperative instructions should the nurse include while teaching a client scheduled for spine surgery? Select all that apply.

-An incentive spirometer will be used following surgery. -The client should be turned every two hours after surgery using a logroll technique. -The client will be using a pain rating scale to rate pain.

In developing a plan of care for a client who has had previous episodes of angry verbal outbursts, the nurse plans to take an educational approach to the problem. Arrange the following steps the nurse should take from first to last. All options must be used.

-Help the client identify triggers for anger. -Assist the client to recognize the early cues of anger. -Identify alternate ways to express anger. -Practice with the client appropriate ways to express anger.

A client who has been chronically unemployed with a history of explosive anger and depression is now experiencing significant hopelessness. What would be most appropriate for the nurse to include in the client's treatment plan? Select all that apply.

-Identify personal goals. -Gain insight into feelings. -Assess for suicidal ideation.

A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply.

-Take a seat next to the client and sit quietly to reflect on what was said. -Say to the client, "You're feeling upset about the news you got about the transplant."

A nurse is working on a medical unit at a hospital with an ethics review board. Which situation(s) would be appropriate for the nurse to forward for ethics committee review? Select all that apply.

-The child of Jehovah Witness parents being refused lifesaving blood transfusions. -A client whose last drink was 4 months ago placed on the liver transplant list. -The comatose client with a feeding tube and no advanced directive whose children want it removed and spouse does not.

A nurse is working in a rural health clinic that serves a large Amish population. The nurse is developing a program to address common health promotion strategies. Which aspect would be most important for the nurse to integrate into the program to promote its success? Select all that apply.

-importance of the extended family in providing support -focus on being in tune with nature for health maintenance -need to ask for permission before physically touching a client

A couple is speaking with a nurse about their ambivalence about sending their adult son with schizophrenia to residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What should the nurse keep in mind when planning to discuss this situation with the family? Select all that apply.

-investigating all potential care options -reviewing the client's treatment history

A client is remanded by the courts for psychiatric treatment. The police record, which dates to the client's early teenage years, includes delinquency, running away, auto theft, and vandalism. The client dropped out of school at age 16 and has been living alone then. This history suggests maladaptive coping, which is associated with:

antisocial personality disorder.

A parent brings a 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the parent and infant, the nurse should observe them:

as the parent feeds the infant.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you don't take your medication, you'll be put into seclusion." The nurse's statement is an example of which legal concept?

assault

What is the most appropriate long-term goal for an outpatient client with schizophrenia who has been withdrawn from friends and family for 3 weeks?

attending day therapy three times a week

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting?

charting by exception

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client?

checking that the restraints have been applied correctly

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication?

checklists

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which is a characteristic of rituals?

common and observable expressions of culture

Which approach by the nurse would most likely foster a therapeutic relationship with a client who tries to manipulate people?

consistency

A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The most therapeutic nursing intervention would be to

continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis.

An adolescent client with depression and a suicide attempt is admitted to an inpatient unit. The nurse notes that the client describes a recent breakup of a dating relationship with an emotionless tone and a flat facial expression. What will the nurse do next?

Ask the client if there is a plan in place for suicide.

The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." What should the nurse do next?

Ask the social worker to find financial assistance for the client.

A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?

Assess urine for excessive bleeding.

A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program?

creating a safe environment for sharing information

A father tells the nurse that his adolescent son spends lots of time in his room, his grades are falling, and he has given away a few of his favorite video games. What is the most appropriate action for the nurse?

Make a same-day appointment for the adolescent with his usual health care provider.

Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what?

cultural blindness

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which problem?

delusion

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child?

Define behaviors that are acceptable and behaviors that are not permitted.

A hospital client has told the nurse that their religion involves the burning of incense and has asked permission to do so on the unit. The nurse is aware that this practice would violate the hospital's fire regulations. What is the nurse's best action?

Dialogue with the client about alternative rituals or the possibility of performing the ritual outdoors.

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client?

Discuss secondary gains that are unconsciously driving the client's behavior.

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which is the best action for the first nurse to take?

Discuss the conversation directly with the other nurse.

A nurse observes another nurse making social plans with a client and disclosing information of a personal nature. What would the observing nurse do in this situation?

Discuss the observation directly with the nurse.

A client with dementia is eating off of other clients' meal trays. After the client with dementia is asked to stop, which action should be taken?

Distract the client.

An older adult client shares with the nurse having never gotten over the grief of losing a parent 22 years ago. The client states that the parent completed suicide and the client found the parent and called for emergency assistance. The nurse assesses that the client is experiencing which type of grief?

Dysfunctional

A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client has decided to continue the pregnancy based on religious beliefs and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate?

Explore the nurse's own feelings about the issues of anencephaly and organ donation.

A nurse meets frequently with a depressed client. The client stays mostly in his room and speaks only when addressed, answering briefly and abruptly while keeping his eyes on the floor. Initially, the nurse should focus on the client's ability to do which function?

Express himself verbally.

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective?

having the client discuss needs with the staff person assigned

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which intervention is the nursing priority?

Explain procedures and unit routines to the client, as well as checking orientation.

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety?

Explain the surgical procedure to the client and what happens before and after surgery.

A nurse implements a healthcare facility's disaster plan. Which action should be performed first?

Identify a command center at which activities are coordinated.

In the hospital setting, the child of a client who is dying tells the nurse, "It is hard to just sit here for hours and not say or do anything." As the nurse responds to the child's statement, what issue is most important for the nurse to focus on during their discussion?

Know that being present with the person is important.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care?

Involve the client in usual at-home activities.

An IV infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?

It may be necessary to remove a small amount of hair from the infant's scalp.

While the nurse is transferring a confused client from the chair to the bed, the client bites the nurse on the arm. Out of frustration, the nurse slaps the client across the face, leaving a large bruise. The nurse's behavior is reported to the nurse manager. What is the most appropriate action for the nurse manager to take?

Support the claim of battery brought by the client's family.

An adolescent becomes increasingly withdrawn, is irritable with family members, and has been getting lower grades in school. After giving away a stereo and some favorite clothes, the adolescent is brought to the community mental health agency for evaluation. Which aspect of the adolescent's behavior is most suggestive of suicide?

The adolescent has a suicide plan.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse?

Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan.

An older adult client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line, and I've had it!" Which action should the nurse take?

Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act.

On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend abuses inhalants. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, what is the most important factor for the nurse to consider?

The boys probably fear punishment.

A client of Hispanic ethnicity has recently immigrated to this country and has been admitted for depression. The nurse documents that the client has poor eye contact during the medication teaching session. What is the most likely reason for the client's behavior?

The client is demonstrating respect for the nurse.

In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is

self-disclosure.

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the mother and partner to do?

Relate to each twin individually to enhance the attachment process.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

Based on a client's history of violence toward others and inability to cope with anger, what should the nurse use as the most important indicator of goal achievement before discharge?

verbalization of feelings in an appropriate manner

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

Parents of a 5-year-old child call the clinic to tell the nurse that they think their child has been abused by the daycare provider. What should the nurse advise them to do first?

Schedule an immediate appointment with their healthcare provider.

The nurse notes that the client seems anxious. Which strategy should the nurse use to enhance communication?

Sit down to talk with the client.

An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt.

The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best?

Spend brief intervals with the client each day.

A client often does the opposite of what she is requested to do. For example, if asked to stand up, she sits down; if asked to dress, she undresses. In view of the client's negativism, which action would be best for the nurse to take to get the client to the dining room for meals?

Tell her it is time for lunch, and guide her to the dining room.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially?

The client will discuss her feelings related to her losses.

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason?

The action indicates nonverbal agreement with the client's false ideas.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications.

When reviewing a client's chart, the nurse reads the progress note below. 10/151130Client, age 28, admitted to unit with diagnosis of antisocial personality disorder and suicide attempt after cutting his right wrist. Right wrist dressing appears dry and intact. Client states, "I don't want to be here and I'm not following your treatment plan or any of your rules. I'm going to tell everyone here not to follow your rules."—Barbara Jones, RNWhich statement, about the client's condition, is most accurate?

The client is not motivated to change his behavior or his lifestyle.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior?

The client's anger is not intended personally.

Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse should address which factor?

The emotional responses may be similar to those of other crime victims.

qWhich statement best explains why the nurse should acknowledge differences between the nurse's culture and the client's culture?

The nurse may hold values that could influence the care of the client.

A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure?

The nurse should contact the person identified as the healthcare power of attorney.

A client who has paranoid personality disorder is participating in a treatment group. Which behavior should the nurse observe for as the client participates in the group?

hypervigilance

A 22-year-old client is admitted to room 13. He states that he does not want to remain in the room because the number will bring him bad luck. The nurse should:

move the client; his fears, even when unfounded, can impede recovery.

When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions?

naming another client as his adversary

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms?

negative symptoms

A nurse is caring for a newly admitted client on the psychiatric unit. The nurse would most hinder therapeutic communication by performing what action?

offering advice and opinions

The nurse is caring for a child with cystic fibrosis. What behavior exhibited by the parents of a child with a chronic illness may indicate feelings of guilt about the child's illness?

overindulgence

The nurse has recently accepted a position in a community with an ethnically and culturally diverse population. What action should the nurse first perform in order to enhance cultural competence?

Thoughtfully reflect on the characteristics of their own culture.

The nurse is planning care for a newly admitted client on the psychiatric unit. Which action by the nurse is most important?

To establish trust and rapport by using the client's name and maintaining eye contact

A client with a fetal demise at 40 weeks asks the nurse, "How could God let this happen?" An appropriate goal for the client with a nursing diagnosis of Spiritual distress related to infant loss as verbalized by the client would be that the client will

participate in supportive spiritual practices.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?

pulse deficit

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness?

repression

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families?

role stereotyping

When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue?

safety

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include?

Use a caring approach to maintain close observation of the client

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the physician's and nurse's names.

What is a generally accepted criterion of mental health?

self-acceptance

A client is having trouble adjusting to a colostomy surgically created 4 days ago. The nurse prioritizes which nursing diagnosis?

altered body image

The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest?

alternative ways to manage the adverse effects

Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse?

a person who says, "I've found a solution for this mess

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which intervention should the nurse employ as the first step?

eliminating distracting stimuli such as turning off the television

A major role in crisis intervention is getting a client's family and friends involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize what information?

emergency resources and when to use them

A client scheduled to have a surgery for a hernia the next day is anxious about the procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skill is the nurse demonstrating?

interpersonal skills

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action would the nurse include in the care plan?

involving the client and family in planning care

A client suspects the end of life is near. However, others talk about only pleasant matters and maintain a persistently cheerful facade. The nurse plans care for this client by recognizing that these behaviors will most likely cause the client to experience which feeling?

isolation

A nurse may use self-disclosure with a client if:

it achieves a specific therapeutic goal.

A college student visited the health center almost daily during the second half of the semester, before course examinations. Physical causes for these visits have been eliminated. Based on the following progress note entry in the client's chart, the nurse should suspect2/10/20171600Throughout the semester, this student presented at the walk-in clinic an average of twice per week reporting a variety of symptoms. A full work-up was done to rule out mononucleosis, influenza, colitis, pregnancy, kidney infection, and chronic fatigue. The student presented in a dramatic and worried manner with each new complaint. She did not question any of the findings, seeming to simply suffer a repeat of a previous malady or present with a new set of symptoms. It is recommended that the client have a consult to mental health services.

somatic symptom disorder

A nurse has attended an in-service workshop to address the phenomenon of ageism in the healthcare system. Which practice is indicative of ageism?

speaking to older adults in a way one would with clients who have mild cognitive deficits