study set 1 med surg

a 40 year old patient cries and has tantrum when the health care provider refuses to give her a prescription for diet pills. the nurse realizes that this is the use of which defense mechanism

regression (behavior that reflects to an earlier form of coping)

when assisting the older adult who is despondent about the need to leave his home, what technique should the nurse use

reminisce with the patient and review his life

what should nurse do when suspecting a coworker of abusing drugs while at work

report observations to a supervisor

what should the entire health team focus on during the rehabilitation phase

abstaining from drug use

a confused and disoriented client is admitted to the pschiatric unit diagnosed with PTSD. the nurse initially plans to take which action with this client

accept the client as a person and make the client feel safe

what coping mechanism demonstrated by a patient should indicate to the nurse that the patient is seeking ways to deal with and resolve stress

adaption

the nurse cares for a client with antisocial personality disorder. what common characteristics of this disorder might the nurse observe in this client

aggressive actions toward other clients, - impulsive behaviors, - a history of repeated arrests

what should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy

arrange for transportation to and from the appointment

a 60 year old man was admitted for cholecystitis that resulted in a cholecystectomy. on his third day of hospitalization, he begins to sweat profuself, tremble, and has a blood pressure of 160/100. based on these findings, what focused assessment should the nurse compete

withdrawal problems

a client who has just received a diagnosis of asthma says to the nurse, this condition is just another nail in my coffin" which response by the nurse is therapeutic

you seem very distressed over learning you have asthma

what must a patient in the late stages of dependence do in order to recover

receive treatment for substance abuse

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

increasing the level of suicide precautions

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

inquiring about the clients feelings that may affect coping

the home health nurse assesses a patient who creates elaborate excuses for not leaving home. further questioning reveals the patient had not left home for 6 months. how should this be documented?

agoraphobia (high level of anxiety in which an anxiety attack could occur in individuals who avoid other people)

the nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement

all my difficulties are related to my drinking

a client is scheduled to have electroconvulsive therapy. which information would the nurse tell the client

amnesia of events occurring near the period of the therapy is common

The nurse is sensitive to the fact that patients lose control over their lives when admitted to the hospital. In what does this loss of control frequently result?

anxiety

the nurse alters the care plan for a patient with epression to include what type of activity

group outing to view wildflowers

a nurse places a client with an intentional overdose of narcotics on suicide precautions with 1:1 monitoring. which intervention by the nurse is appropriate when caring for a client on suicide precatuions?

the nursing assist helps with 1:1 monitoring - the nurse removes sharp objects from the room

the nurse cautions a patient to watch his step. what response indicates concrete thinking

the patient fixedly begins to watch his feet

what should the nurse do to decrease the patient disorientation at night during the detoxification period

use night lights and remove extra furniture from the room

what action by a student before taking a test should indicate to a nursing instructor that the student is demonstrating signs of a moderate anxiety

vomits

a patient seems bewildered when he confides in the nurse that all of his friends and leisure time have been centered on a drugs culture. which would be the best response by the nurse

what other sort of activities might you enjoy

laboratory work is prescribed for a client who has been experiencing delusions. when the laboratory technician approaches the client to obtain a specimen of the clients blood, the client begins to shout "you're all vampires. let me out of here" the nurse present at the time would respond with which question or statement

are you fearful and think that others may want to hurt you

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

assist the client resume her familial role

for the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. today, the patient tearfully refuses to dress or get out of bed. the nurse recognizes these behaviors as evidence of which psychiatric disorder

bipolar disorder

A nurse tearfully confides to the head nurse that being assigned to care for eight patients is stressful and overwhelming. What demonstrates the use of a healthy coping mechanism?

delegating appropriate care assignments to unlicensed assistive personnel

a fmaily is informed that the brain damage to their daughter is irreversible. the father is later overheard making vacation plans and discussing what the family will do when his daughter leaves the hospital. the nurse recognizes the father is in which crisis stage

denial

a client experiencing a severe major depressive episode is unable to address activities of daily living. which is the appropriate nursing intervention

feed, bathe, and dress the client as needed until the client can perform these activities independently

when the patient is told that his insurance will no longer pay for his physical therapy, the nurse is aware that this obstruction to his goal may result in which concept

frustration

the patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. how should the nurse document this behavior

hallucination

a nurse cares for a client diagnosed with schizoaffective disorder. the nurse assesses for what sign or symptom typical of this disorder

hallucination -depressed mood - manic episode

if the patient tells the nurse, im not an alcoholic. i can stop whenever i want to" what should be the nurses most therapeutic response

hasnt alcohol use interfered with your employment

a home health nurse has a patient who is taking lithium. what should be included in the teaching plan

have her drug blood level checked every month

during a nursing interview, a client says "my daughter was murdered in her New York apartment, and her estranged husbnad called to tell me. i cant stop myself from wondering if he killed her, but the police have ruled him out as a suspect "which statement reflects a therapeutic nursing response"

have you shared your concerns with the police

the nurse is performing an initial assessment on an alcoholic patient. which of the following by the nurse would best ensure honest answers

having a nonjudgemental attitude

the nurse educates a client on smoking cessation. the client demonstrates understanding by which statement

hypnosis may help me successfully quit smoking - i may experience depression when trying to quit smoking

a patient is concerned about confidentiality and asks the nurse not to tell anyone whit is said. what is the best response by the nurse

i am required to report any intent to hurt yourself or others

during the detoxification period, what does the nurse aim to achieve when designing intervention

keep the patient safe from aspiration and seizure

when a patient is admitted with an overdose of an opioid narcotic, the nurse should anticipate an order for which drug to reverse the effects of the narcotic

narcan

a patient is frequently late for appointments because he goes back to his room numerous times to assure himself that none of his belongings have been stolen. what does this behavior represent

obsessive-compulsive

what is the term for a long term and intense form of psychotherapy developed by sigmund freud that allows a patients unconscious thoughts to be brought to the surface

psychoanalysis

when the patient who overeats insists that weight gain is related to retained fluids, the nurse recognizes the patient is using which defense mechanism

rationalization

the nurse cares for a school-age child diagnosed with separation anxiety. what symptom of this condition will the nurse identify for the childs parents

school avoidance - excessive worry -reports of head or stomach aches

the patient complains of recurrent, multiple physical ailments for which there is no organic cause. how should the nurse assess this

somatic symptom disorder

the nurse is caring for a patient with a diagnosis of catatonic schizophrenia. what behavior is consistent with this diagnosis

stands on one foot for 15 minutes

a patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. what other feelings may the patient have that should be recognized

suicidal ideation

what is the greatest problem with lysergic acid diethylamide lsd) use

the drug causes flashbacks

the licensed practical nurse is overseeing a new graduate nurse care for a client with somatic symptom disorder. which action by the new graduate nurse would require a need for further teaching

the new graduate nurse repeatedly takes vital signs after client complaints of palpitations have been investigated and are determined to be benign

what action consistently done by a patient should indicate to a nurse that the patient has a poor self-concept?

apologizes to other repeatedly