Fundamentals Success: Communication, Psychological Support, Nutrition
Which statement by a dying client reflects Kubler-Ross's stage of depression in the grief process? 1. "I am upset that I will not be here for my daughter's wedding" 2. "I wrote a letter to be read by my daughter on the day of her wedding" 3. "I just need to get a little stronger so I can go to my daughter's wedding" 4. "I don't care if I die as long as I live long enough to see my daughter's married"
1. "I am upset that I will not be here for my daughter's wedding"
When the nurse analyzes a client's statements, which statement best reflects the dimension of self-esteem? Select all that apply. 1. "I really like the me that I see" 2. "What do I want to achieve?" 3. "How do I appear to others?" 4. "I like things my way" 5. "I'm OK, you're OK"
1. "I really like the me that I see" 5. "I'm OK, you're OK"
A nurse is caring for a very confused client with a diagnosis of dementia of the Alzheimer's type. Which should the nurse say when assisting the client to eat? 1. "Please eat your meat" 2. "It's important that you eat" 3. "What would you like to eat?" 4. "If you don't eat, you can't have dessert"
1. "Please eat your meat"
A client is to have arthroscopic surgery of the knee to repair a torn tendon. The client says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the client? Select all that apply 1. "The type of surgery you are having is minor" 2. "Surgery often can be frightening" 3. "Everything will be all right" 4. "You are not going to die" 5. "You sound scared"
1. "The type of surgery you are having is minor" 3. "Everything will be all right" 4. "You are not going to die"
A client is admitted to the hospital with cirrhosis of the liver caused by long-term alcohol abuse. Which is the best response by the nurse when the client says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem?" 1. "You find it hard to believe that beer can hurt the liver" 2. "How long is it that you have been drinking several beers a day?" 3. "Each beer is equivalent to one shot of liquor, so it's just as damaging to the liver as hard liquor" 4. "Do you believe that beer is not harmful even though research shows that it as just as bad for you as hard liquors?"
1. "You find it hard to believe that beer can hurt the liver"
A nurse is collecting data from a client for an admission nursing history. Which question by the nurse is best to open the discussion? 1. "what brought you to the hospital?" 2. "would it help to discuss your feelings?" 3. "do you want to talk about your concerns?" 4. "would you like to talk about why you are here?"
1. "what brought you to the hospital?"
Which total cholesterol level in a healthy adult female client necessities that the client receives health teaching about a low-cholesterol diet? 1. 210 mg/dL 2. 190 mg/dL 3. 150 mg/dL 4. 120 mg/dL
1. 210 mg/dL
A nurse is caring for a postoperative client. The nurse reviews the client's concurrent health problems, checks the medications prescribed by the primary health-care provider, and performs a focused assessment. Which should the nurse do at 12 p.m? 1. Administer 5 units of regular insulin subcutaneously to the client 2. Notify the primary health-care provider of the client's status 3. Give the oral solution of 15 mg of oxycodone 4. Provide an additional dose of ipratropium
1. Administer 5 units of regular insulin subcutaneously to the client
A nurse administered enteral nutrition via the method depicted in the photograph. Which of the following steps should be implemented when administering enteral nutrition via this method? Select all that apply. 1. Administer water after the feeding 2. Administer the bolus over 60 minutes 3. Ensure that the formula is at room temperature 4. Elevate the head of the bed 15 degrees above horizontal 5. Add formula continuously to the syringe just before it empties
1. Administer water after the feeding 3. Ensure that the formula is at room temperature 5. Add formula continuously to the syringe just before it empties
A nurse is providing for the nutritional needs of several clients. Which problem increased clients' caloric requirements? Select all that apply. 1. Burns 2. Nausea 3. Dysphagia 4. Pneumonia 5. Depression
1. Burns 4. Pneumonia
What is the consequence when the nurse denies a client the use of a defense mechanism? 1. Causes more anxiety 2. Precipitates withdrawal 3. Facilitates effective coping 4. Encourages emotional growth
1. Causes more anxiety
A man with a heart condition continues to perform strenuous sports against medical advice. Which defense mechanism does the nurse identify the patient is using? 1. Denial 2. Repression 3. Introjection 4. Dissociation
1. Denial
A school nurse is preparing a health class about vitamins. Which information about vitamins that is based on a scientific principle should the nurse include? 1. Eating a variety of foods prevents the need for supplements 2. Megadoses of vitamins have proved to be the most effective in preventing illness 3. Taking a prescribed vitamin supplement is the best way to ensure adequate intake 4. Vitamins that are more expensive are purer than those that are less expensive
1. Eating a variety of foods prevents the need for supplements
A client is admitted to the hospital with a history of liver dysfunction associated with hepatitis. With which metabolic problem does the nurse anticipate that this client may have a problem? 1. Emulsifying fats 2. Digesting carbohydrates 3. Manufacturing red blood cells 4. Reabsorbing water in the intestines
1. Emulsifying fats
A client has been blind in one eye for several years because of the complications associated with diabetes mellitus. The client is admitted to the hospital with a detached retina and resulting in loss of sight in the other eye. Which should the nurse do to assist this client with meals? 1. Explain to the client where items are located on the plate according to the hours of a clock 2. Encourage eating one food at a time according to the preference of the client 3. Order finger foods that are permitted to the client's diet 4. Feed the client prescribed meals
1. Explain to the client where items are located on the plate according to the hours of a clock
A nurse uses reflective technique when communicating with an anxious client. On which does the nurse focus when using reflective technique in this situation? 1. Feelings 2. Content themes 3. Clarification of information 4. Summarization of the topics discussed
1. Feelings
A client without any identified current health problems is having a yearly physical examination. The laboratory results indicate the presence of ketosis. Which rationale explains the presence of ketosis in the otherwise healthy adult? 1. Inadequate intake of carbohydrates 2. Increased intake of protein 3. Excessive intake of starch 4. Decreased intake of fiber
1. Inadequate intake of carbohydrates
A nurse is obtaining a health history from a client. Which of the following reflects healthy behavior? Select all that apply. 1. Increasing fruits and vegetables to 50% of food intake 2. Substituting fish for meat 3. Wanting to lose 20 pounds 4. Consuming 4 eggs a week 5. Eating foods low in fat
1. Increasing fruits and vegetables to 50% of food intake 2. Substituting fish for meat 4. Consuming 4 eggs a week 5. Eating foods low in fat
Which defense mechanism is being used when a client who has just been diagnosed with terminal cancer calmly says to the nurse, "I'll have to get on the internet to assess my options?" 1. Intellectualization 2. Introjection 3. Depression 4. Denial
1. Intellectualization
A young adult woman tells the nurse that she has been taking St. Johns wort for several weeks for depression. Which should the nurse teach the client that is important to know about taking St. John's wort? Select all that apply. 1. It should not be taken without an evaluation by a primary health-care provider 2. Use a different method of birth control if taking an oral contraceptive 3. Discontinue it if there is no change in symptoms within 3 months 4. Stop talking it 2 weeks before surgery with general anesthesia 5. Apply sunscreen to skin exposed to the sun
1. It should not be taken without an evaluation by a primary health-care provider 2. Use a different method of birth control if taking an oral contraceptive 4. Stop talking it 2 weeks before surgery with general anesthesia 5. Apply sunscreen to skin exposed to the sun
Which should a nurse never do when documenting information on a client's electronic medical record? Select all that apply 1. Leave the client's medical record open on the computer screen when entering the client's room to administer a medication 2. Share information verbally about a client with another nurse who is also caring for the client 3. Document nursing care administered to a client immediately after it is completed 4. Give personal access code to another member of the health-care team 5. Document exact quotes of a client's subjective information
1. Leave the client's medical record open on the computer screen when entering the client's room to administer a medication 4. Give personal access code to another member of the health-care team
A client has a high serum cholesterol level. Which of the following should the nurse teach the client to avoid? Select all that apply. 1. Liver 2. Shrimp 3. Skin milk 4. Turkey burger 5. Sliced bologna
1. Liver 2. Shrimp
Which nursing action demonstrates support of human dignity in the practice of nursing? Select all that apply. 1. Maintaining confidentiality of information about clients 2. Supporting the rights of others to refuse treatment 3. Obtaining sufficient data to make inferences 4. Calling clients by their preferred name 5. Staying at the scene of an accident
1. Maintaining confidentiality of information about clients 4. Calling clients by their preferred name
A client is scheduled for surgery, and the nurse is teaching the client about the importance of vitamin C in wound healing. Which source of vitamin C should the nurse include in the teaching plan? Select all that apply. 1. Potatoes 2. Papayas 3. Yogurt 4. Beans 5. Milk
1. Potatoes 2. Papayas
A woman with diabetes does not follow her prescribed diet and states, "Everyone with diabetes cheats on their diet." Which defense mechanism does the nurse identify this client is using? 1. Rationalization 2. Sublimation 3. Undoing 4. Denial
1. Rationalization
A client expresses a sense of hopelessness. Which concern identified by the nurse is the priority? 1. Risk for self-harm 2. Inability to cope 3. Powerlessness 4. Fatigue
1. Risk for self harm
An older adult states that he is experiencing all the signs and symptoms of an enlarged prostate and is interested in taking the herbal supplement saw palmetto. Which is important for the nurse to teach the client about treatment with saw palmetto? Select all that apply. 1. Saw palmetto should be avoided until after an evaluation by a urologist 2. Taking saw palmetto generally is considered safe as a dietary supplement 3. Saw palmetto interferes with the measurement of the prostate-specific antigen 4. Some clients report an improvement in erectile dysfunction after taking saw palmetto 5. The most recent research by reputable institutions indicates that saw palmetto is more effective than a placebo in reducing the symptoms of an enlarged prostate
1. Saw palmetto should be avoided until after an evaluation by a urologist 2. Taking saw palmetto generally is considered safe as a dietary supplement 4. Some clients report an improvement in erectile dysfunction after taking saw palmetto
A primary health-care provider prescribes a low-residue diet for a client with inflammatory bowel disease. Which of the following should the nurse teach the client include in the diet? Select all that apply. 1. Scrambled eggs 2. Cooked oatmeal 3. Orange juice 4. Green beans 5. Rye bread
1. Scrambled eggs
A primary health care provider informs a client that the diagnosis is inoperable cancer and the prognosis is poor. After the primary health care provider leaves the room, the client begins to cry. Which should the nurse do? 1. Touch the client's hand to provide support 2. Leave the room to give the client privacy to cry 3. Telephone the patient's family to inform them of the diagnosis 4. Ask the client questions to encourage an expression of feelings
1. Touch the client's hand to provide support
A risk manager is conducting a retrospective audit of a client's clinical record to identify the use of unacceptable abbreviations. Which abbreviation did the risk manager identity that is on The Joint Commission's official Do Not Use List? Select all that apply. 1. U 2. ml 3. mg 4. MS 5. QOD 6. 0800 hour
1. U 4. MS 5. QOD
Which ability of the nurse is important to achieve effective therapeutic communication? Select all that apply. 1. Using interviewing skills 2. Remaining nonjudgemental 3. Sending only verbal messages 4. Being assertive when collecting data 5. Displaying sympathy when communicating
1. Using interviewing skills 2. Remaining nonjudgemental
Which vitamin that does not require fat in the diet to be absorbed should a nurse teach a client about? 1. Vitamin C 2. Vitamin A 3. Vitamin E 4. Vitamin D
1. Vitamin C
Which interviewing skill is used when the nurse says, "You mentioned before that you are having a problem with your colostomy?" 1. focusing 2. clarifying 3. paraphrasing 4. acknowledging
1. focusing
A client is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed. Where in the client's medical record can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the primary health-care provider? 1. Progress notes 2. Admission sheet 3. History and physical 4. Social service record
1. progress notes
A primary health-care provider prescribes folic acid 0.8 mg PO once daily for a client with anemia. Unit-dose tablets of 0.4 mg/tablet are available. How many tablets should the nurse administer?
2 tablets (0.8/0.4 = 2)
A nurse is caring for a client who is being admitted for a cardiac catheterization. The client tells the nurse, "I am so stressed out." Which question should the nurse ask when assessing the effectiveness of the client's coping ability? 1. "How do you feel when you are stressed?" 2. "How have you coped with similar stressors before?" 3. "Did you receive treatment for any stress-related problems in the past?" 4. "What has been the most stressful event that you have ever had before?"
2. "How have you coped with similar stressors before?"
Which client statement supports the nurse's conclusion that the client with a newly diagnosed tumor of the lung may be experiencing denial? Select all that apply. 1. "It's really hard for me to ask other people for help" 2. "I really think that it is just a cold" 3. "I don't care what you do to me" 4. "It's not so bad; I'll get over it" 5. "I feel like I'm losing it"
2. "I really think that it is just a cold" 4. "It's not so bad; I'll get over it"
A bathrobe is draped over a chair near a client in the hospital who is confused. The client tells the nurse, "tell that scary man to get out of my chair". Which is the best response by the nurse? 1. "People in an unfamiliar environment sometimes think that they see things that are not really there" 2. "I understand you are afraid, but there is no one there. Your bathrobe on the chair may look like a person" 3. "The medication is making you confused. There is nobody sitting in that chair" 4. "Tell me more about the scary man that you see sitting in the chair"
2. "I understand you are afraid, but there is no one there. Your bathrobe on the chair may look like a person"
An agitated 80 year old patient states, "I'm having trouble with my bowels." Which response by the nurse incorporates the interviewing skill of reflection? Select all that apply. 1. "Tell me what you mean by having trouble." 2. "It sounds like your bowels are causing you problems" 3. "You sound upset that your bowels are causing difficulties." 4. "It's common to have problems with bowels at your age." 5. "When did you first notice having trouble with your bowels?"
2. "It sounds like your bowels are causing you problems"
A nurse is teaching a client about the positive effects of exercise to reduce anxiety. Which client comment about how exercise reduces anxiety indicates that the client understands the nurse's teaching? 1. "It interferes with the ability to concentrate" 2. "It stimulates the production of endorphins" 3. "It reduces the metabolism of epinephrine" 4. "It decreases the acidity of blood"
2. "It stimulates the production of endorphins"
A client with a newly created colostomy wants to learn how to irrigate the colostomy. The nurse provides this teaching by developing a therapeutic nurse-client relationship and implementing teaching strategies. Identify the statement that is included in the working stage of this therapeutic relationship. Select all that apply. 1. "How do you feel about doing this procedure?" 2. "Would you like to try to insert the cone yourself today?" 3. "You did a great job managing the instillation of fluid today" 4. "I am here to help you learn how to irrigate your colostomy" 5. "I'll arrange for a home-care nurse to visit you in your home when you are discharged"
2. "Would you like to try to insert the cone yourself today?" 3. "You did a great job managing the instillation of fluid today"
A client who is withdrawn says, "When I have the opportunity, I am going to commit suicide." Which is the best response by the nurse? 1. "You have a lovely family. They need you" 2. "You must feel overwhelmed to want to kill yourself" 3. "Let's explore the reasons you have for wanting to live" 4. "Suicide does not solve problems. Tell me what is wrong"
2. "You must feel overwhelmed to want to kill yourself"
A client who has had postoperative complications appears upset and agitated yet withdrawn. Which is the most appropriate statement by the nurse? 1. "You seem distressed. Tell me why you are upset" 2. "You've been having a pretty rough time recovering since surgery" 3. "It's not uncommon to have complications after the kind of surgery that you had" 4. "I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery"
2. "You've been having a pretty rough time recovering since surgery"
A nurse is screening clients who are in various age groups for clinical manifestation of eating disorders. In which age group should the nurse expect more problems to become evident? 1. Toddlerhood 2. Adolescence 3. Senescence 4. Infancy
2. Adolescence
A nurse plans to foster a therapeutic relationship with a client. Which is important for the nurse to do? 1. Sympathize with the client when the client communicates sad feelings 2. Demonstrate respect when discussing emotionally charged subjects 3. Use humor to defuse emotionally charged topics of discussion 4. Work on establishing a friendship with the client
2. Demonstrate respect when discussing emotionally charged subjects
A primary health-care provider identifies that a client may have a fluoride deficiency. Which physical characteristic identified by the nurse supports this conclusion? 1. Stomatitis 2. Dental caries 3. Bleeding gums 4. Mottling of the teeth
2. Dental caries
Which is the nurse doing when using the interviewing technique of active listening? 1. Identifying the client's concerns and exploring them with "why" questions 2. Determining the content and feeling of the client's message 3. Employing silence to encourage the client to talk 4. Using verbal skills to obtain information
2. Determining the content and feeling of the client's message
A nurse is caring for clients with a variety of nutrition-related problems. Which problem should the nurse anticipate eventually may require a client to have a feeding tube inserted? 1. Malabsorption syndrome 2. Difficulty swallowing 3. Stomatitis 4. Vomiting
2. Difficulty swallowing
A nurse is developing a therapeutic relationship with a client with emotional needs. Which nursing intervention is essential during the working stage of the relationship? 1. Establish a formal or informal contract that addresses the client's problems 2. Implement nursing actions that are designed to achieve expected client outcomes 3. Develop rapport and trust so the client feels protected and an initial plan can be identified 4. Clearly identify the role of the nurse and establish the parameters of the professional relationship
2. Implement nursing actions that are designed to achieve expected client outcomes
A client is diagnosed with iron-deficiency anemia. Which major cause of iron deficiency will influence a focused assessment by the nurse? 1. Metabolic problems 2. Inadequate diets 3. Malabsorption 4. Hemorrhage
2. Inadequate diets
A nurse is evaluating the effectiveness of a nutritional program for a client with anemia. For which clinical finding should the nurse monitor the client because it is a short-term indicator of an improved nutritional status? 1. Weight gain of two pounds daily 2. Increasing transferrin level 3. Decreasing serum albumin 4. Appropriate skin turgor
2. Increasing transferrin level
A nurse is reviewing the laboratory findings of a client to asses the client's nutritional status. Which laboratory result from among the following tests is an indicator of inadequate protein intake? 1. High hemoglobin 2. Low serum albumin 3. Low specific gravity 4. High blood urea nitrogen
2. Low serum albumin
A nurse teaches a postoperative client about foods high in protein that will promote wound healing. Which food selection by the client indicates that the teaching was effective? Select all that apply. 1. Milk 2. Meat 3. Fruit 4. Bread 5. Vegetables
2. Meat
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the client has no teeth and is having difficulty eating. Which diet should the nurse encourage the primary health-care provider to prescribe for this client? 1. Liquid supplements 2. Mechanical soft 3. Pureed 4. Soft
2. Mechanical soft
A client is told that surgery is necessary. The client begins to experience elevations in pulse, respirations, and blood pressure. Which stage of anxiety is indicated by these nursing assessments? 1. Mild 2. Moderate 3. Severe 4. Panic
2. Moderate
Which statement describes the following proverb? 'What you do speaks so loudly I cannot hear what you say'? 1. Hearing ability is an important factor in communicating 2. Nonverbal messages are often more meaningful than words 3. Listening to what people say requires attention to what is being said 4. When people talk too loudly, it is hard to understand what is being said
2. Nonverbal messages are often more meaningful than words
To provide appropriate nursing care, which concept about anxiety is important to consider? 1. Panic attacks related to anxiety, which generally have a slow onset, can be prevented if identified early 2. One can conceptualize anxiety as being similar to the health-illness continuum 3. People who lead healthy lifestyles rarely experience danger 4. Anxiety is an abnormal reaction to realistic danger
2. One can conceptualize anxiety as being similar to the health-illness continuum
Which stage of an interview establishes the relationship between the nurse and the client? 1. Preinteraction stage 2. Orientation stage 3. Examining stage 4. Working stage
2. Orientation stage
A client is diagnosed with vitamin A deficiency. The client loves pie for dessert. Which type of pie should the nurse encourage the client to ingest? 1. Blueberry 2. Pumpkin 3. Cherry 4. Pecan
2. Pumpkin
A client appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." Which interviewing approach did the nurse use? 1. Examining 2. Reflecting 3. Clarifying 4. Orienting
2. Reflecting
A client with a terminal illness tells the nurse, "I have lived a long life. I am ready to go." Which is the nurse's best response? 1. Offer the client a back rub 2. Sit quietly by the patient's bedside 3. Tell the family about the client's statement 4. Discuss with the client how dying is part of the life cycle
2. Sit quietly by the patient's bedside
A preoperative client is anxious about pending elective surgery. Which nursing intervention will help the client reduce the anxiety. Select all that apply. 1. Involve significant others 2. Use distraction techniques 3. Explore identified concerns 4. Foster expression of feelings 5. Use progressive desensitization strategies
2. Use distraction techniques 3. Explore identified concerns 4. Foster expression of feelings
A nurse is admitting a client to the unit who was transferred from the emergency department. Which should the nurse do to facilitate communication? 1. Ensure that the client has an effective way to communicate with the health-care team members 2. Use interviewing techniques to control the direction of the client's communication 3. Minimize energy spent by the client on negative feelings and concerns 4. Refocus to the positive aspects of the client's situation and prognosis
2. Use interviewing techniques to control the direction of the client's communication
A young adult who had a leg amputated because of trauma says, "No one will ever choose to love a person with one leg". Which is the best response by the nurse? 1. "You are a good-looking person, and you will have no trouble meeting someone who cares" 2. "You may feel that way now, but you will feel differently as time passes" 3. "Do you feel that no one will marry you because you have one leg?" 4. "How do you see your situation at this point?"
3. "Do you feel that no one will marry you because you have one leg?"
A client with chest pain is being admitted to the emergency department. When asked about next of kin, the client states, "Don't bother calling my daughter, she is always too busy." Which is the best response by the nurse? 1. "Your daughter might be upset if you don't call" 2. What does your daughter do that makes her so busy?" 3. "Is there someone else besides your daughter that I can call?" 4. "I think that your daughter would want to know that you are sick"
3. "Is there someone else besides your daughter that I can call?"
A client says, "I am really nervous about having a spinal tap tomorrow." Which is the best response by the nurse? 1. "I'll ask the doctor for a little medication to help you relax" 2. "Clients who have had a spinal tap say it is not that uncomfortable" 3. "It's all right to be nervous, and I don't remember anyone who wasn't" 4. "Your physician is excellent and is very careful when spinal taps are done"
3. "It's all right to be nervous, and I don't remember anyone who wasn't"
A client states, "I am surprised that I couldn't even eat half my breakfast." Which statement by the nurse uses the interviewing skill of reflection? Select all that apply 1. "Let's talk about your inability to eat" 2. "What part of your breakfast were you able to eat?" 3. "You appear startled that you did not finish your tray of food" 4. "How long have you been unable to eat most of your breakfast?" 5. "You seem surprised that you were unable to eat all of your breakfast"
3. "You appear startled that you did not finish your tray of food" 5. "You seem surprised that you were unable to eat all of your breakfast"
A nurse is using military time when entering information into a client's clinical record. For example, the clock below indicated that the time is 0708 a.m. Which number in military time should the nurse enter to document a wound irrigation that was implemented at 9 p.m.? 1. 0900 2. 1900 3. 2100 4. 2300
3. 2100
A client has multiple fractures from a skiing accident. To best facilitate bone growth, the nurse should encourage the client to eat more foods high in calcium. Which food selected by the client indicates an understanding of those that are high in calcium? Select all that apply. 1. Orange juice 2. Peanut butter 3. Cottage cheese 4. Baked flounder 4. Low-fat yogurt 5. Cooked spinach
3. Cottage cheese 4. Low-fat yogurt 5. Cooked spinach
A nurse is counseling a client with the diagnosis of osteoporosis. In addition to calcium, which vitamin supplement should the nurse anticipate that the primary health-care provider will prescribe for this client? 1. B 2. K 3. D 4. E
3. D
A nurse is assessing a client who is admitted to the hospital with withdrawal from alcohol. Which effect of alcohol on the body will influence the client's plan of care? 1. Interferes with the absorption of glucose 2. Accelerates the absorption of medications 3. Decreases the absorption of many important nutrients 4. Lengthens passage time of stool through the intestinal tract
3. Decreases the absorption of many important nutrients
Which word reflects the ability of a nurse to perceive a client's emotions accurately? 1. Autonomy 2. Sympathy 3. Empathy 4. Trust
3. Empathy
A client says to a nurse, "I'm the same age as my father when he died. Am I going to die of my cancer?" Which is the appropriate inference about what the client is experiencing? 1. Grieving associated with the potential for death 2. Powerlessness associated with feelings of being out of control 3. Fear associated with the perceived threat to biological integrity 4. Impaired coping associated with inadequate psychological resources
3. Fear associated with the perceived threat to biological integrity
A nurse is caring for a client who is confused and disoriented. Which type of food containing chicken is the most appropriate for this client? 1. Soup 2. Salad 3. Fingers 4. Casserole
3. Fingers
Which is being communicated when the nurse leans forward during a patient interview? 1. Aggression 2. Anxiety 3. Interest 4. Privacy
3. Interest
A client is anorexic because of stomatitis related to chemotherapy. Which should the nurse be most concerned about when planning care for this client? 1. Aspiration 2. Dehydration 3. Malnutrition 4. Constipation
3. Malnutrition
A nurse is caring for a client who is expending energy that is greater than the client's caloric intake. For which human response should the nurse monitor the client? 1. Fever 2. Anorexia 3. Malnutrition 4. Hypertension
3. Malnutrition
A client has a decreased hemoglobin level because of a low intake of dietary iron. Which food that is an excellent source of iron should the nurse include when teaching the clients? Select all that apply. 1. Eggs 2. Fruit 3. Meat 4. Bread 5. Spinach
3. Meat 5. Spinach
A nurse identifies that a vegetarian understands the importance of eating kidney beans when the client indicates that they are essential because they contain which nutrient? 1. Carbohydrates 2. Minerals 3. Protein 4. Fat
3. Protein
A client is scheduled for an elective abortion. Which is the best way for the nurse to reinforce this client's self-esteem needs? 1. Supporting the use of defense mechanisms 2. Encouraging social interaction with others 3. Providing a nonjudgemental environment 4. Employing a positive mental attitude
3. Providing a nonjudgemental environment
Which is the most common independent nursing intervention to help a debilitated older adult maintain body weight while in the hospital? 1. Making mealtime a social activity 2. Taking a thorough nutritional history 3. Providing assistance with the intake of meals 4. Encouraging dietary supplements between meals
3. Providing assistance with the intake of meals
A dying client is withdrawn and depressed. Which nursing action is therapeutic? Select all that apply. 1. Assisting the client to focus on positive thoughts daily 2. Explaining that the client should focus on future goals 3. Remaining available in case the client wants to talk 4. Involving the client in conversations during the day 5. Offering the client advice when appropriate
3. Remaining available in case the client wants to talk
A nurse concludes that a woman is remembering only the good times after the death of her husband. Which defense mechanism is the women using? 1. Compensation 2. Minimization 3. Repression 4. Regression
3. Repression
A confused client becomes extremely upset. Which is the best action by the nurse? 1. Speak louder with a lower-pitched voice 2. Use touch to communicate caring and concern 3. Talk to the client in a way that is simple and direct 4. Administer medication to minimize the client's anxiety
3. Talk to the client in a way that is simple and direct
A nurse is attempting to develop a helping relationship with a client who was recently diagnosed with cancer. Which factor is unique to this helping relationship? Select all that apply. 1. The client should always assume the dominant role 2. The nurse and the client equally share information 3. The interaction is specific to the client 4. The interaction is guided by a purpose 5. The needs of both participants are met
3. The interaction is specific to the client 4. The interaction is guided by a purpose
A client strongly states the desire to go to the hospital coffee shop for lunch regardless of the hospital policy. Which does the nurse conclude that this behavior most likely reflects? 1. Anger with the policies of the hospital 2. Dissatisfaction with hospital meals 3. The need to regain a little control 4. A desire for a change of scenery
3. The need to regain a little control
A nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use? 1. probing 2. clarification 3. direct questions 4. paraphrasing statements
3. direct questions
A nurse is changing a client's dressing over an abdominal wound. Which level of space around the client is entered during the dressing change? 1. public 2. social 3. intimate 4. personal
3. intimate
Which is the purpose of the use of humor by a nurse when interacting with a client? 1. diminish feelings of anger 2. refocus the client's attention 3. maintain a balanced perspective 4. delay dealing with the inevitable
3. maintain a balanced perspective
A client is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's best response? 1. "it's natural to worry about your job" 2. "your job must be very important to you 3. "calm down so that I can understand what you are saying" 4. "I'm not quite sure I heard what you were saying about your work"
4. "I'm not quite sure I heard what you were saying about your work"
A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse? 1. "Everyone will remember her because she was so cute. She was one of our favorites" 2. "As hard as this is, it is probably for the best because she was in a lot of pain" 3. "She put up the good fight, but now she is out of pain and in heaven" 4. "It must be hard to deal with such a precious loss"
4. "It must be hard to deal with such a precious loss"
A client is exhibiting anxious behavior and states, "I just found out that I have cancer everywhere, and I don't have very long to live. My life is over." Which is the best response by the nurse? 1. "It might be good if your family were here right now. Shall I call them?" 2. "What might be the best way to approach this terrible news?" 3. "That is so sad. You must feel like crying" 4. "It sounds like you feel hopeless"
4. "It sounds like you feel hopeless"
A client states, "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." Which is the best response by the nurse? 1. "I'm sure your wife will be willing to make this sacrifice in exchange for your well-being" 2. "The surgeons are getting great results with nerve-sparing surgery today" 3. "Your wife may not put as much emphasis on sex as you think" 4. "Let's talk about how you feel about this surgery"
4. "Let's talk about how you feel about this surgery"
A woman comes to the emergency department with multiple traumas from a suspected assault by a boyfriend. The client indicates an unwillingness to talk about what happened. Which is the best statement by the nurse? 1. "Did your boyfriend do this to you?" 2. "You really got beat up pretty bad this time" 3. "Would you like to talk about how this happened to you?" 4. "Sometimes people are reluctant to share information about their situation"
4. "Sometimes people are reluctant to share information about their situation"
A client says, "I have something important to tell you, but you have to promise me that you will not tell anyone." Which is the best response by the nurse? 1. "I will share everything you tell me with the health team, because we are here to help you" 2. "Something is clearly upsetting you for you to place such a restriction on our interaction" 3. "Whatever you tell me is between us, because your personal information is confidential" 4. "You will have to trust that I will maintain your confidentiality as long as it will not cause harm to you or others"
4. "You will have to trust that I will maintain your confidentiality as long as it will not cause harm to you or others"
A male client is diagnosed with hypertension. The nurse reviews the primary health-care providers prescriptions, obtains the client's vital signs, and interviews the client and the client's wife. Which should the nurse do? 1. Obtain the client's vital signs in one hour 2. Explain to the wife that garlic will not help lower her husband's blood pressure 3. Explore with the couple the idea that prayer will not lower a person's blood pressure 4. Accept the couple's decision about consuming a clove of garlic and the juice of a lemon daily
4. Accept the couple's decision about consuming a clove of garlic and the juice of a lemon daily
A nurse identifies that a client is mildly anxious. Which assessment of the client supports this conclusion? 1. Preoccupied 2. Forgetful 3. Fearful 4. Alert
4. Alert
Which situation identified by the nurse reflects the defense mechanism of displacement? 1. A woman is very nice to her mother-in-law, whom she secretly dislikes 2. A man says that he is not so bad, so don't believe what they say about him 3. An adolescent puts a poor grade on a test out of her mind when at her after-school job 4. An older man gets angry with friends after family members attempt to talk with him about his illness
4. An older man gets angry with friends after family members attempt to talk with him about his illness
A nurse is caring for a client receiving bolus enteral feedings several times daily. Which nursing intervention is most important to help prevent diarrhea? 1. Flush the tube after every feeding 2. Check the residual before each feeding 3. Elevate the head of the bed for 30 degrees continually 4. Discard the refrigerator opened cans of formula after 24 hours
4. Discard the refrigerator opened cans of formula after 24 hours
A nurse is teaching a client about the importance of balancing protein, carbohydrates, and fats in the diet. The nurse identifies that the teaching was successful. Which of the following did the client indicate is provided by carbohydrates? 1. Electrolytes 2. Vitamins 3. Minerals 4. Energy
4. Energy
A occupational nurse is facilitating a group discussion on weight reduction. Which should the nurse explain is the most common contributing factor to obesity? 1. Sedentary lifestyle 2. Low metabolic rate 3. Hormonal imbalance 4. Excessive caloric intake
4. Excessive caloric intake
An older adult tends to bruise easily, and the primary health-care provider recommends that the client eats foods high in vitamin K. In addition to the teaching the client about food sources of vitamin K, the nurse should include nutrients that must be ingested for vitamin K to be absorbed. Which foods that increase the absorption of vitamin K should be included in the teaching plan? 1. Carbohydrates 2. Starches 3. Proteins 4. Fats
4. Fats
A woman who is advised to follow a low-fat diet frequently eats in Chinese restaurants. Which of the following foods should the nurse teach the woman is lowest in fat? 1. Egg rolls 2. Spareribs 3. Crispy noodles 4. Hot and sour soup
4. Hot and sour soup
Which is unrelated to the balance of calcium in the body? 1. Osteoporosis 2. Vitamin D 3. Tetany 4. Iron
4. Iron
When assessing a client for anxiety, which characteristic about anxiety should the nurse consider? 1. It is triggered by a known stressor 2. It occurs simultaneously with fear 3. It is a response that is avoidable 4. It is a universal experience
4. It is a universal experience
An obese client of a nursing home who is receiving a 1,500-calorie weight reduction diet has not lost weight in the past 2 weeks. Which should the nurse do first? 1. Inform the primary health-care provider of the client's lack of progress 2. Instruct the client to limit intake to 1,000 calories per day 3. Schedule a multidisciplinary team conference 4. Keep a log of the oral intake for 3 days
4. Keep a log of the oral intake for 3 days
A client states, "Do you think I could have cancer?" The nurse responds, "What did the doctor tell you?" Which interviewing approach did the nurse use? 1. Paraphrasing 2. Confrontation 3. Reflective technique 4. Open-ended question
4. Open-ended question
A client states, "I think that I am dying." The nurse responds, "You believe that you are dying?" Which interviewing approach did the nurse use? 1. Focusing 2. Reflecting 3. Validating 4. Paraphrasing
4. Paraphrasing
As a nurse is caring for a client who is scheduled for IV chemotherapy for cancer. Which defense mechanism is being used when the client says to the daughter, "Be brave"? 1. Rationalization 2. Minimization 3. Substitution 4. Projection
4. Projection
A primary health-care provider prescribes a clear liquid diet for a client. Which of the following should the nurse teach the client to avoid when following this diet? Select all that apply. 1. Strawberry gelatin 2. Decaffeinated tea 3. Strong coffee 4. Pureed soup 5. Ice cream
4. Pureed soup 5. Ice cream
A nurse teaches a client about the prescribed low-fat diet. Which food selected by the client indicates that the teaching was understood? Select all that apply. 1. Eggs 2. Liver 3. Cheese 4. Turkey 5. Scallops 6. Flounder
4. Turkey 5. Scallops 6. Flounder
Which statement about communication should the nurse consider to be accurate? 1. verbal communication is essential for human relationships 2. hands are the most expressive part of the body 3. behavior clearly reflects feelings 4. communication is inevitable
4. communication is inevitable
A nurse is caring for a client who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with the client? 1. touch the client's left arm before initiating a conversation 2. ensure that the door to the client's room is on the client's left side 3. close the window curtains and dim the lights before speaking with the client 4. knock on the door and request permission to enter before approaching the client
4. knock on the door and request permission to enter before approaching the client
A nurse is caring for a client who has problems comprehending the spoken word. Which should the nurse do to support the client? Select all that apply. 1. Use simple words and sentences 2. Speak directly in front of the client 3. Encourage the client to request that unclear words be repeated 4. Paraphrase statements when they are not understood by the client 5. Employ facial expressions and gestures to enhance communication
All of the above
A nurse is providing emotional support to a client who is upset. Which action depicted in this photograph is a therapeutic communication technique? Select all that apply. 1. Making eye contact 2. Holding the client's hand 3. Leaning toward the client 4. Sitting at the client's eye level 5. Maintaining personal distance from the client
All of the above
Which nursing action should the nurse implement when speaking with an older adult whose hearing is impaired? Select all that apply. 1. Limit background noise 2. Enunciate words without exaggeration 3. Use gestures to augment communication 4. Stand directly in front of the client when speaking 5. Talk in a normal rate and volume when speaking with the client
All of the above