HESI quiz week 10

A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse?

"Are you going to kill yourself?" A direct assessment is necessary to determine whether the client is contemplating suicide.

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. Which statement best describes how clients with obsessive-compulsive behavior view this disorder?

"I know there's no reason to do these things, but I can't help myself." Intellectually the person knows that the compulsive acts are senseless but is unable to stop doing them because they control anxiety.

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

A hemolytic transfusion reaction results from a recipient's antibodies that are incompatible with transfused red blood cells; it is called a type II hypersensitivity. The clinical findings are a result of red blood cell hemolysis, agglutination, and capillary plugging.

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.

Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia.

During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?

Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to act appropriately.

A nurse is intervening with a client who is having a crisis. What is the nurse's concern after the initial crisis issues have been addressed?

Assessment of the client's current status and ability to perform activities of daily living is the priority because it will influence the choice of an appropriate therapeutic regimen.

An older man is widowed suddenly when his wife is killed in an automobile accident. What should the nurse in the emergency department do first to best help the client at this time?

Assuring the man that everything possible was done for his wife helps allay guilt, eases anxiety, and assists with coping.

A nurse plans to evaluate a newly admitted depressed client's potential for suicide. What is the best approach to obtaining this information?

Directness is the best approach at the first interview, because this sets the focus and concern and lets the nurse know what the client is feeling now.

A nurse manager determines that one of the nurses in the intensive care unit may be experiencing burnout. What can the nurse manager do to help this nurse begin to confront the problem?

Identifying work stressors in the environment and coping strategies used and evaluating their effectiveness are the first steps. A transfer to another nursing care unit may help, but prevention begins with knowing one's self and the effectiveness of one's coping strategies.

A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using?

In transference a client assigns to someone the feelings and attitudes originally associated with an important significant other.

A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? Select all that apply.

Lying in bed when one is unable to sleep increases frustration and anxiety and further impedes sleep; other activities, such as reading or watching television, should not be conducted in bed. Exercise during the day expends energy and promotes sleep at night; exercise too close to bedtime is stimulating and may interfere with sleep. Counting backward requires minimal concentration but is enough to interfere with thoughts that distract a person from falling asleep.

A client at 8 weeks' gestation tells the nurse that since becoming pregnant, she has not felt like making love with her husband. She is concerned that her husband does not understand. What is the most appropriate response by the nurse?

Often the pregnant woman experiences a decrease in sexual desire during the first trimester, probably as a result of nausea and vomiting; if couples are informed about this, they are less likely to become distressed.

A client with a history of gambling is experiencing legal difficulties for embezzling money and has been required to obtain counseling. During an intake interview the client says, "I never would have done this if I'd been paid what I am worth." What factor will create the greatest difficulty in helping this client develop insight?

Projection of reasons for difficulties onto others. The development of insight is impeded by the client's unwillingness or inability to face his own contribution to a problem.

A client going through an emotional disturbance often gets violent and tries to commit suicide. Which care system is best for the client?

Psychiatric Facility Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities.

A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, "I don't know what I'll do when I can't see you anymore." The nurse determines that the client is doing what?

Reacting to the planned discharge. The stress of termination may precipitate fears of abandonment, and the client may regress. The client is expressing fear, not thanks.

A healthcare provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the healthcare provider leaves, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychologic process best explains this client's reaction?

Repudiation A refusal to recognize anticipated loss in an attempt to protect oneself against the overpowering stress of illness is called repudiation.

A female client's stream of consciousness is occupied exclusively with thoughts of her mother's death. The nurse plans to help the client through this stage of grieving, which is known as what?

Resolving the loss. Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features, emerges. The shock-and-disbelief stage is usually dominated by a refusal to accept or comprehend the fact that a loved one has died. The reality of the death and its meaning as a loss, plus anger, dominate this stage. The various rituals of the funeral help to initiate the recovery or restitution stage.

A depressed, withdrawn client exhibits sadness through nonverbal behavior. What should the nurse plan to help the client to do?

Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing of these feelings usually decreases depression.

A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?

The anniversary of a death frequently reemphasizes the feeling of loss and abandonment and serves to heighten current feelings of depression and hopelessness.

A client with cancer is told by a healthcare provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing?

The client has difficulty accepting the inevitability of death and attempts to deny the reality of it.

A nurse recalls that the environment is important when caring for a client with the diagnosis of bipolar II disorder with hypomanic episodes. What should the nurse do when caring for clients with this disorder?

The excited, overactive client needs a calm environment; external stimulation causes further excitation. The nurse should provide a quiet atmosphere by placing the client in a private room.

In an outpatient mental health clinic a nurse is working with a client who is beginning to address more effective ways to handle stressful situations. The best nursing action to include in the plan of care is to have the client do what?

The identification of unhealthy habits or specific problems will allow the client to determine which additional coping skills need to be developed and practiced.

A nurse is counselling a parent about the changes a toddler may exhibit after the death of a family member. What should the nurse include in the counselling? Select all that apply.

The nurse should tell the parent that after the death of a family member, toddlers will express the sense of absence they feel through changes in eating and in sleeping patterns, fussiness, or bowel and bladder disturbances.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse?

The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings.

A female client is diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. While being admitted to ambulatory surgery by the nurse, the client has tears in her eyes and her chin is quivering. In a shaky voice the client says, "I can't believe this is happening." Which response by the nurse is best?

The response "This must be a very scary time for you" identifies the client's feelings and provides an opportunity for further discussion.

A client who is diagnosed with sexual dysfunction makes a comment to the nurse, "Well, I guess my sex life is over." Which is the most appropriate response by the nurse?

The response "You are concerned about your sex life?" explores the meaning of the statement and allows further expression of concern.

A client experiencing thyrotoxic crisis tells the nurse, "I know I'm going to die. I'm very sick." Which is the best response by the nurse?

The response "You must feel very sick and frightened" reflects the client's feelings and encourages a further exploration of concerns.

The grieving spouse of a client who has just died says to the nurse, "We should have spent more time together. I always felt that my work came first." What should the nurse conclude that the spouse is experiencing?

The spouse is expressing the typical feelings of guilt associated with the death of a loved one; often there is initial guilt over what might have been.

The parents of a 2½-year-old child whose older sibling recently died tell a nurse in the pediatric well-child clinic that their child has started to hit them and refuses to go to bed at night. What is the best explanation the nurse can give for this behavior?

This is an appropriate reaction to anxiety within the household. Changes in daily routines in the home and anxiety expressed by family members lead to anxiety in children. The toddler has not yet developed a reality-based concept of death