JUN 493 NCLEX Blueprint Psychosocial Integrity

A nurse is assessing a pt who reports difficulty dealing with stress. Which questions is appropriate to identify potential stressors? "Do you have a car?" "How do you get along with people at work?" "What do you want to feel like at the time of discharge?" "What are your goals for yourself?"

"How do you get along with people at work?"

A nurse is visiting a pt who is quadriplegic from a spinal cord injury and is adjusting to the home environment. Which pt statements indicate the pt is adapting? "My wife tries to get me to go to the grocery store, but I don't like to go out much." "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." "My greatest pleasure each day is having a few beers every day." "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

A nurse attending a group therapy session is listening to clients discuss coping strategies. Which statements by the clients indicate Adaptive Coping? (SATA). "I exercise three times a day." "I call a friend who makes me smile and laugh." "I think about being on my favorite beach vacation." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty."

"I call a friend who makes me smile and laugh." "I think about being on my favorite beach vacation." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty." WRONG RATIONALES "I exercise three times a day" is incorrect. Physical exercise helps the client manage stress levels. However, excessive exercising may be an indication of an obsessive-compulsive disorder and is not effective.

During a group therapy session, a nurse notes a pt using multiple defense mechanisms. Which pt statements demonstrates maladaptation? "I wrote a short story about a heroic woman when I was really mad at my boss." "I don't care about work anymore since I was not given a promotion." "I mentally separate myself from distractions around me when I paint on canvas." "I still cannot remember the scene of my husband's car accident."

"I don't care about work anymore since I was not given a promotion." (Maladaptation Regression)

A nurse is counseling a group of pts at an outpatient mental health clinic. Which pt statements indicates a problem with role transition? "If my husband had gone to the doctor like I told him to he'd be alive today." "I am so angry with my daughter's attitude. Teenagers think they know everything!" "I want to have an intimate relationship but I end up breaking off relationships as soon as they begin." "I just can't seem to find any energy to take care of my children since my husband divorced me."

"I just can't seem to find any energy to take care of my children since my husband divorced me."

A nurse at a long-term mental health facility is caring for a pt who is verbally upset about the loss of privileges D/T negative behavior. Which statements demonstrates the effective use of assertive communication? "You were made aware of the consequences of negative behavior." "I understand that you are angry; however, I followed the appropriate protocol." "You need to calm down before discussing this matter any further." "Why did you make the choice to behave negatively?"

"I understand that you are angry; however, I followed the appropriate protocol."

A nurse is providing smoking cessation info to a pt. Which pt statements indicate a need for further education? "I will test my ability to quit smoking by going to the bar where I used to smoke." "I will distract myself by working on my woodworking hobby." "I will call someone I know who has quit if I develop the urge to have a cigarette." "I will keep a journal to understand what is the triggering the urge to smoke."

"I will test my ability to quit smoking by going to the bar where I used to smoke."

A nurse is providing care for a pt who appears anxious following a recent tragedy. Which statements reflect an adaptive defense mechanism? "I will work out in the gym every time I get mad about what happened." "I do not have anxiety, and I am not sure why you think I do." "I cannot remember anything that happened, and I am okay." "I am not capable of moving past this time in my life."

"I will work out in the gym every time I get mad about what happened."

A pt who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which response by the nurse is appropriate? "Do I cause more pain than the other nurses?" "Tell me more about that." "Let me get you more pain medication." "You have the right to your judgments."

"Tell me more about that."

A nurse manager is talking with a nurse who was unable to sleep the night before after experiencing an unsuccessful client resuscitation. Which responses by the manager is therapeutic? "Tell me what your concerns are "Maybe you had better schedule an appointment with a psychiatrist." "It's hard at first but you will get used to these things." "Don't worry, we all go through these feelings. They will pass."

"Tell me what your concerns are

A nurse is caring for a pt who is admitted involuntarily for acute mental health treatment. When discussing care with nursing staff, which statements by the nurse is appropriate? "The client is to be given his medications even if he refuses." "The laws regarding restraints are different for clients who are admitted involuntarily." "Clients who are admitted involuntarily can be hospitalized for no more than 30 days." "The client who is involuntarily admitted has the right to informed consent."

"The client who is involuntarily admitted has the right to informed consent."

A nurse is leading a group therapy session for pts who are newly diagnosed with cancer. Which statements by the nurse is therapeutic? "Antidepressants are not your solution, but this therapy group is." "I notice you keep clenching your fists. This needs to stop." "You need to work hard on resolving conflict with those closest to you." "What do you mean when you say you cannot ever return to work?"

"What do you mean when you say you cannot ever return to work?"

A nurse is caring for a pt who has Hypertension and is afraid to take medication. Which nursing statements uses reflection? "You seem upset about your blood pressure." "What time do you take your medication?" "How do you feel when you take the medication?" "Did your symptoms occur before or after you took the medication?"

"You seem upset about your blood pressure."

A home health nurse is creating a plan of care for a pt who has a serious mental illness. Which intervention is appropriate to include to promote self-care with activities of daily living? SATA. Instruct the client on the appropriate way to store medication. Assist the client in identifying modes of public transportation. Teach the client to create a weekly shopping list. Meet with the family to discuss client care goals. Identify the treatment expectations of the client's mental health provider.

1. Instruct the client on the appropriate way to store medication. 2. Assist the client in identifying modes of public transportation. 3. Teach the client to create a weekly shopping list.

A nurse has cared for several pts and reflects on the pts who have experienced anticipatory grieving. Which situations reflect anticipatory grieiving? A client who discovers her pain is from an appendicitis. A client who experiences traumatic amputation of an extremity. A client who is in a coma from a traumatic brain injury. A client who is diagnosed with metastatic liver cancer.

A client who is diagnosed with metastatic liver cancer.

A nurse is caring for a pt who has depression and is assessing his ability to perform ADLs prior to discharge. Which should the nurse include in the assessment? (SATA). Ability to perform oral hygiene Ability to bathe himself Ability to identify how often he should schedule his car for an oil change Ability to balance his bank account Ability to dress himself

Ability to perform oral hygiene Ability to bathe himself Ability to dress himself

A pt tells a nurse that she is considering St. John's Wort instead of lithium carbonate for the treatment of her depression. The nurse should identify this use of herbal remedies as which of the following classifications of medicine practices? Allopathic medicine Traditional medicine Alternative medicine Complementary medicine

Alternative medicine Alternative medicine refers to interventions used instead of traditional, science-based treatments. WRONG RATIONALES Allopathic medicine refers to traditional, science-based medicine, which would include the use of lithium carbonate or other medication for the treatment of depression. Traditional, science-based medicine includes the use of lithium carbonate or other medication for the treatment of depression. Complementary medicine refers to non-traditional interventions used in conjunction with traditional, science-based treatments.

A nurse is caring for a pt who has a depressive disorder. The pt states, "I just can't feel any happiness or joy in my life." Which of the following terms should the nurse use when documenting this finding? ​Anhedonia ​Anergia ​Anosognosia ​Akathisia

Anhedonia

A nurse is conducting a staff education session regarding the manifestations of schizophrenia. Which should the nurse identify as negative symptoms? (SATA). ​Delusions ​Hallucinations ​Anhedonia ​Poor judgment ​Blunt affect

Anhedonia Blunt affect

A nurse is discussing comorbidities associated with eating disorders. Which should the nurse include in the discussion? SATA. ​Anxiety ​Obsessive-compulsive disorder ​Schizophrenia ​Breathing-related sleep disorder ​Depression

Anxiety OCD Depression

A nurse is caring for a pt who is experiencing alcohol withdrawal. Which signs and symptoms should the nurse expect to find during assessment? Muscle aches and chills Fatigue and depression Anxiety and diaphoresis Arrhythmia and respiratory depression

Anxiety and diaphoresis

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first? Ask the toddler what caused the bruises. Notify the provider. Ask the parents what caused the bruises. Notify social services.

Ask the parents what caused the bruises.

A nurse is planning care for a pt who has generalized anxiety disorder. Which of the following interventions is appropriate to promote relaxation? Assist the client in practicing meditation. Recognize the client's spiritual preferences. Encourage the client to identify his positive qualities. Help the client identify his previous accomplishments.

Assist the client in practicing meditation.

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which should she describe as programming the mind to override the stress response? ​Reiki ​Biofeedback ​Acupuncture ​Autogenic training

Autogenic training ​Autogenic training programs the mind to override the stress response, and is thus a helpful strategy for stress management.

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which should she describe as the use of an electronic monitoring device to help pt learn to control physical responses? Reiki Biofeedback Acupuncture Autogenic training

Biofeedback

A nurse in the ED is preparing to care for a pt who has signs of alcohol intoxication. Which should the nurse plan to include in the pt's care? (SATA). ​Contact the laboratory to obtain a blood sample. ​Prepare the client for a CT scan. ​Check the client's pupil reactivity. ​Obtain a urine specimen. ​Perform a developmental screening test.

Contact the laboratory to obtain a blood sample Prepare the client for a CT scan (check for head trauma) Check the client's pupil reactivity (check neuro status) Obtain a urine specimen

A nurse is discussing restraints with a newly licensed nurse. Which should the nurse identify as an acceptable indication for placing a pt in mechanical restraints? Continued self-destructive behavior. Coercion to take prescribed medications. Discipline for throwing chairs at staff. Punishment for verbal abuse of other clients.

Continued self-destructive behavior.

A nurse is providing dietary teaching to an Asian-American pt who is gazing at the floor during the instruction. Which action would demonstrate culturally sensitive nursing care? Stopping the instructions to assess the floor Emphasizing the significance of the information Moving closer to the client for eye contact Continuing with the discussion

Continuing with the discussion

A nurse educator is discussing community mental health with a group of nursing students. Which should the educator identify as a secondary prevention practice site? Day care center Outpatient rehabilitation center Community recreational center Crisis center

Crisis center RATIONALE: A crisis center is an example of secondary public health prevention, which has the goal of early detection and treatment of mental health disorders.

A nurse is caring for a pt who has type 1 diabetes mellitus and is not adhering to guidelines for therapy. Which should the nurse consider as a contributing factor? SATA. Gender Culture Literacy Dexterity Motivation

Culture Literacy Dexterity Motivation

A nurse is performing a psychosocial assessment on an adolescent pt. Which should indicate to the nurse a potential risk for suicide? (SATA). Death of a parent at a young age Recent or impending move Low parental expectations Volunteers at a community center after school Sudden decline in school performance

Death of a parent at a young age Recent or impending move Low parental expectations Sudden decline in school performance

A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which responses should the nurse manager expect? Projection Rationalization Repression Denial

Denial

A young pt with a new diagnosis of Rheumatoid Arthritis states "The pain in my joints is just temporary thing. If I keep eating right & exercising, it will go away." Which Defense Mechanism is this pt demonstrating? ​Denial ​Displacement ​Rationalization ​Reaction formation

Denial

A nurse is discussing suicide with nursing staff. Which should he identify as a risk factor for suicide? (SATA) Diagnosis of schizophrenia Age greater than 55 Ethnic minority Male gender Recent marriage

Diagnosis of schizophrenia Age greater than 55 Male gender

A nurse is caring for a pt who has obsessive-compulsive disorder (OCD). Which are expected findings? (SATA). ​Difficulty relaxing ​Irrational fear of certain objects ​Rule-conscious behavior ​Unaware of compulsions ​Perfectionist behavior

Difficulty relaxing Rule-conscious behavior Perfectionist behavior

A provider tells a pt who has an anterior cruciate ligament that he may not play football for the remainder of the season. The pt yells that the provider doesn't know what he is talking about and kicks a chair. Which defense mechanisms is the pt demonstrating? ​Denial ​Displacement ​Rationalization ​Reaction formation

Displacement

A nurse is having difficulty caring for a pt D/T interpersonal variables affecting the communication process. Which is an interpersonal variable? SATA. ​Education ​Feedback ​Gender ​Perception ​Time

Education Gender Perception RATIONALE Education is correct. The educational background of the client is an interpersonal variable that affects the communication process. Feedback is incorrect. Feedback is the message that the sender returns in the communication process. It is not an interpersonal variable. Gender is correct. Gender is an interpersonal variable that affects the communication process. Perception is correct. Perception provides a uniquely personal view to an individual's experience and is an interpersonal variable that affects communication. Time is incorrect. Time is a critical element of the communication process. It is not an interpersonal variable.

A nurse is preparing to assist with ECT. Which pieces of equipment should the nurse set up in the room prior to treatment? SATA. Electroencephalogram (EEG) monitor Blood pressure monitor Flexible sigmoidoscope Cardiac monitor Portable x-ray machine

Electroencephalogram (EEG) monitor Blood pressure monitor Cardiac monitor

A nurse is teaching a pt about the physical effects of chemotherapy. Following the teaching, the nurse asks the pt to describe one physical effect. The nurse is focusing on which element of the communication process? ​Feedback ​Channel ​Environment ​Message

Feedback WRONG RATIONALES ​Channel​ - A channel is the means of conveying and receiving messages through the use of a sense. ​Environment - ​The environment is the setting for the interaction between the nurse and client. ​Message - ​The message is the content of the communication.

A nurse is planning care for a pt who is in the manic phase of bipolar disorder. Which interventions should the nurse include in the pt's plan of care? Provide a stimulating environment. Have consistent unit routines. Minimize staff interventions. Schedule daily seclusion times.

Have consistent unit routines.

A nurse is caring for a new pt who exhibits signs of major depressive episode. The provider states that she wants to rule out medical conditions which could be linked to the findings. The nurse should expect diagnostic testing for which medical condition? ​Pancreatitis. ​Cholecystitis. ​Tuberculosis. ​Hypothyroidism.

Hypothyroidism

A nurse is assessing an adolescent pt who is newly diagnosed with ADHD. Which manifestations should the nurse expect to find? Avoidance, emotional numbing, and withdrawal Elevated moods, hyperactivity, and insomnia Difficulty concentrating, anxiety, and inattention Inattention, hyperactivity, and impulsivity

Inattention, hyperactivity, and impulsivity

A pt who has bipolar disorder approcahes the nurse and reveeals fresh, self-inflicted, superficial cuts going up and down his right arm. Which should the nurse perform first? implement the pt's behavioral modification plan Document the size & location of the cuts Inspect the cuts for debris Administer a tetanus antitoxin

Inspect the cuts for debris (ADPIE!)

A nurse is providing care to a pt who has schizophrenia. Which behaviors should the nurse anticipate? Periods of elation with unusual talkativeness Preoccupied with folding clothes Invents words that have no meaning Recurrent thoughts of past trauma

Invents words that have no meaning

A nurse is caring for a pt who has a diagnosis of obsessive-compulsive disorder (OCD). Which actions is appropriate for the nurse to take? Interrupt the compulsive behavior. Investigate reasons for the behavior. Encourage avoidance of situations that increase anxiety. Provide a strict environment that inhibits obsessive-compulsive opportunities.

Investigate reasons for the behavior.

A nurse is caring for a pt who has Alzheimer's disease and is confused. Which cognitive therapy may benefit the pt? Turn the television on at all times. Hang abstract pictures on the walls. Keep familiar personal items at the bedside. Encourage bright glaring lighting in the room.

Keep familiar personal items at the bedside.

A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which should the nurse manager identify as being unique to the maladaptive grieving process? Anorexia Sleep disturbances Anergia Low self-esteem

Low self-esteem

A nurse is providing care to a primigravida immediately following a stillbirth delivery. Which should the nurse's initial action be? Assist client with transfer to the gynecology unit. Administer alprazolam (Xanax) 0.5 mg PO Contact the health care facility's clergy Offer mother private time with the newborn.

Offer mother private time with the newborn.

A nurse manager is discussing the differences between normal grief and clinical depression with nursing staff. Which should the nurse manager identify as an indication of Clinical Depression? Open expression of anger Persistent dysphoria Identification of specific cause of sadness Alternating days of feeling sad and hopeful

Persistent dysphoria

A pt develops an adverse medication reaction and states, "The nurse told me not to drink when taking the medication. I am just a social drinker. I didn't realize that having just one drink with my friends would cause such a problem." Which defense mechanisms is the pt demonstrating? Denial Displacement Rationalization ​Reaction formation

Rationalization

A nurse is caring for a pt who is discussing his post-traumatic stress disorder and states "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds, "It must be very frustrating to encounter this kind of attitude." The nurse is using which therapeutic communication techniques? ​Clarifying ​Focusing ​Paraphrasing ​Reflection

Reflection

A nurse is caring for a pt who is 1 day postop following a left radical mastectomy for breast cancer. Which behaviors should alert the nurse to the possibility that the pt is having difficulty adjusting to the loss of her breasts? Refusing to look at the dressing or surgical incision ​Asking for pain medication every 3 hr ​Asking questions about the information on her postoperative care pamphlet ​Performing arm exercises once or twice a day

Refusing to look at the dressing or surgical incision

A nurse is performing care activities for a pt in the zone of touch that requires pt consent. Which activities would the nurse perform in the zone? (SATA). ​Removing the client's dentures ​Checking capillary refill of the client's fingernail ​Palpating for pedal edema ​Taking a radial pulse ​Observing a mole on the client's shoulder

Removing the pt's dentures Palpating for pedal edema Taking a radial pulse RATIONALES Removing the client's dentures is correct. This occurs within the consent zone which includes the mouth, wrists, and feet. Checking capillary refill of the client's fingernail is incorrect. This occurs within the social zone which includes hands, arms, shoulders, and back. Palpating for pedal edema is correct. This occurs within the consent zone which includes the mouth, wrists, and feet. Taking a radial pulse is correct. This occurs within the consent zone which includes the mouth, wrists, and feet. Observing a mole on the client's shoulder is incorrect. This occurs within the social zone which includes hands, arms, shoulders, and back.

A nurse is providing care for a pt who has anorexia nervosa. Which nursing intervention is appropriate? Complement the client for weight gain. Allow the client to eat at any time. Provide privacy when friends visit. Schedule regular weigh-in times.

Schedule regular weigh-in times.

A nurse is caring for a child who has autism. Which are expected behavioral findings? (SATA). ​Short attention span ​Delayed language development ​Spins a toy repetitively ​Ritualistic behavior ​Consistent limit testing

Short attention span Delayed language development Spins a toy repetitively Ritualistic behavior

A nurse is caring for a pt who has a new diagnosis of HIV. He tells you "I don't care what the doctors say, there is no way I have HIV, and I don't need treatment for something I don't have." The nurse identifies that the pt is experiencing which forms of crisis? ​Adventitious ​Internal ​Maturational ​Situational

Situational RATIONALES ​Adventitious - ​An adventitious crisis is one that is not a part of regular life such as a natural disaster or act of terrorism. ​ Internal - ​An internal crisis is one that results from the inability to cope with life changes such as the marriage of a child or age-related changes. ​ Maturational​ - A maturational crisis is one that results from the inability to cope with life changes such as moving away from home to go to college. ​ Situational​ - A diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life such as a serious illness or financial loss.

A nurse is providing a community health education class about Suicide Prevention. Which should the nurse identify as risk factors? SATA. ​Substance abuse ​Age greater than 45 years old ​Female gender ​Currently married ​Schizophrenia

Substance abuse Age greater than 45 yo Schizophrenia

A nurse is caring for a pt who is experiencing maladaptive grief following the unexpected death of his spouse. This pt is at increased risk for which complications? Myocardial infarction Systemic lupus erythematosus Hip fractures Obsessive-compulsive disorder

Systemic lupus erythematosus Maladaptive grief is not known to increase a client's risk for autoimmune disorders such as SLE.

A nurse is planning care to maintain the skin integrity of a pt who has ulcerative colitis and frequent diarrheal stools. Which is the most appropriate for the nurse to include in the plan of care? Soak in a sitz bath for 20 min after each stool. Administer a soap-suds enema to cleanse the colon. Cleanse with antimicrobial scrub and vigorously dry. Wipe perianal area with warm water and apply a barrier cream

Wipe perianal area with warm water and apply a barrier cream

A nurse is discussing Ageism with a newly licensed nurse. Which statements by the newly licensed nurse, indicates understanding? ​"Ageism refers to a higher level of respect that Eastern cultures give to their elders." ​"Ageism refers to the stereotype that older adults are less intelligent than other age groups." ​"Ageism refers to assumptions about an older adult client based on gender and economic status." ​"Ageism refers to the increase in physical care required by older adults."

​"Ageism refers to the stereotype that older adults are less intelligent than other age groups."

A pt who is about to undergo hip arthroplasty tells the nurse that she is afraid of not receiving adequate anesthesia during the procedure. Which is an appropriate response? ​"I will call the anesthesiologist right away." ​"Can you tell me more about this concern?" ​"You have nothing to be concerned about. You have a competent anesthesiologist." ​"You will be monitored constantly, so we'll be right there if any problems arise."

​"Can you tell me more about this concern?"

A nurse is caring for a pt who begins to make sexual advances toward the nurse. Which is an appropriate statement by the nurse? ​"I am going to leave now and I'll return in one hour to spend time with you then." ​"I'm sure that you don't intend to behave this way so I'm going to ignore this behavior." ​"I'm very flattered but I am married and cannot engage in this behavior." ​"I'm curious as to why you are behaving this way. Can you please explain it to me?"

​"I am going to leave now and I'll return in one hour to spend time with you then."

A nurse is teaching client about Alcoholics Anonymous AA. Which of the following client statements indicates an understanding of the program's basic concepts? ​"I am responsible for my alcoholism." ​"I need to identify things that cause me to be an alcoholic." ​"I am powerless about my addiction to alcohol." ​"I need to see a counselor who will be responsible for my recovery."

​"I am powerless about my addiction to alcohol."

A nurse caring for a client who has a mood disorder and is assessing his readiness for discharge. Which client statements indicates readiness for discharge? ​"Right now, I can't bathe myself or dress myself, but I feel good about that." ​"Going home will be fun, but if it isn't fun, I can always have my mother help me." ​"I will take my medicines as I should and know to call the number you gave me if I have bad thoughts." ​"Taking care of myself is important, but it's okay if I don't want to do anything."

​"I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."

A pt whose belongings were lost in a hurricane says, "Whats the use in starting over? It will probably happen again." Which woul dbe an appropriate response by the nurse? ​"I am sure everything will work out." ​"It appears you are feeling hopeless." ​"It is probably not as bad as you think." ​"I would not worry about what can't be changed."

​"It appears you are feeling hopeless."

A nurse is caring for a pt and asks how he is feeling. The pt states, "I'm feeling a bit nervous today." Which is an appropriate response by the nurse? ​"Please explain what you mean by the word nervous." ​"What is making you feel nervous?" ​"Would a backrub ease your nervousness?" ​"You look like you feel nervous."

​"Please explain what you mean by the word nervous."

A 9-year-old boy with a new diagnosis of diabetes mellitus tells the nurse that he is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which is an appropriate nursing response to the mother? ​"Tell me more about how you are feeling about your son's activities." ​"You might want to use tutors to home-school him." ​"I agree. His well-being is the most important." ​"You sound overprotective. Let's talk about this some more."

​"Tell me more about how you are feeling about your son's activities."

A provider diagnoses a pt with cancer and advises chemotherapy. The pt tells the nurse that she wants to try nontraditional treatments first. Which is an appropriate nursing response? ​"Using nontraditional treatments is not a good Idea. I'd rather you avoid that route." ​"A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice." ​"Your doctor is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you." ​"Tell me more about your concerns about taking chemotherapy."

​"Tell me more about your concerns about taking chemotherapy."

A nurse is caring for a pt who has been diagnosed with end-stage liver cancer. Which pt responses is an indication the pt is in the denial phase of the grief process? ​"The doctor has been so good to me. I know he has tried everything he can. It is just my time." ​"I can't believe that doctor graduated from medical school; he doesn't know a thing about treating cancer." ​"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." ​"I can't believe this is happening. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed."

​"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

A pt states, "I just don't know what to do about my husband's drinking. Every time I see him drinking beer, I start to feel extremely anxious." What would be the most therapeutic response by the nurse? ​"Tell me more about what is going on with your son. Is he still causing problems for you?" "At one time you told me you were drinking with your husband. Are you continuing to do that?" ​"The next time your husband starts drinking, what is something you might do to decrease your anxiety?" ​"I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."

​"The next time your husband starts drinking, what is something you might do to decrease your anxiety?"

A nurse is caring for a pt who has a leg amputation. Which pt statements should indicate to the nurse that the pt has a distorted body image? ​"When I look in the mirror, all I see is a person without a leg." ​"I have not always made good choices in life. I deserve to lose my leg." ​"I don't think I will ever be able to play golf again with my friends." ​"No matter how hard I work in physical therapy, I can't seem to make any progress."

​"When I look in the mirror, all I see is a person without a leg."

A nurse is caring for an adolescent pt who has a new diagnosis of schizophrenia. The pt's parents are tearful & express feelings of guilt. Which statements by the nurse is appropriate? ​"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." ​"You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." ​"I'm sure your daughter's diagnosis is very difficult to deal with but everything will be all right once she receives the proper treatment." ​"Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter diagnosis?"

​"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."

A nurse is caring for a group of older adult clients. Which pt findings indicates delirium? ​A client wants to know the current time while there is a clock on the wall. ​A client asks if family members will be arriving after visiting 1 hr earlier. ​A client requests extra blankets when the thermostat in the room indicates 80° F (25.6° C). ​A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.

​A client asks if family members will be arriving after visiting 1 hr earlier.

A nurse is caring for a group of pts on a mental health unit. Which should the nurse recognize as a maladaptive defense mechanism? ​A client slams a drawer after misplacing her wallet. ​A client volunteers in the hospital nursery when unable to get pregnant. ​A client forgets to schedule needed appointments when fearing chemotherapy. ​A client ignores the thought of pain when scheduled for oral surgery.

​A client forgets to schedule needed appointments when fearing chemotherapy.

A nurse is caring for a group of adolescent pts on a mental health unit. Which pts should the nurse identify as the highest risk for a suicidal attempt? A client who has stated there is nothing to live for ​A client who attempted suicide the previous year ​A client who has a history of depression and drug use ​A client who was abused and whose father committed suicide

​A client who attempted suicide the previous year

A nurse is caring for a group of pts who have depression. Which is the most common behavioral finding among these pts? A focus on past failures ​Slowed body movement ​A lack of energy ​Sleep disturbances

​A lack of energy

A Community health nurse is assigned to a pt who has schizophrenia. The pt is to receive an IM med for the control of hallucinations. The pt's prior nurse reports that the pt will let the nurse in her house only if the nurse carries a public health-issued blue bag & wears black pants. the nurse is scheduled to visit this pt tomorrow. which is an appropriate action by the nurse? ​Telephone the client and tell her that the new nurse will be wearing white pants. ​Arrive as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. ​Arrive as scheduled with a police officer. ​Arrive carrying a blue bag and wearing black pants.

​Arrive carrying a blue bag and wearing black pants.

A nurse is caring for a pt who has Schizophrenia and is experiencing a hallucination. Which action by the nurse is appropriate? ​Act to the client as if the hallucination is real. ​Instruct the client to argue with the voices that are a part of the hallucination. ​Ask the client direct questions about the hallucination. ​Tell the client that the hallucination not a part of reality.

​Ask the client direct questions about the hallucination.

A nurse is caring for a pt who has Schizophrenia. The pt asks about medications, their effects, and when the voices will stop that speak to him frequently. The nurse responds by asking the pt why he needs to know this. This is an example of which nontherapeutic communication technique? ​Changing the subject ​Asking for explanation ​Defensive response ​Arguing

​Asking for explanation

A nurse is caring for a pt who has pelvic fractures and will require bed rest & traction for 4-6 weeks. She is a stay at home mother of three teenagers whose father travels extensively for his job. In planning to assist the family, which effects should the nurse consider the priority in planning assistance & referrals for the family? ​Loss of privacy ​Decrease in income ​Changes in family members' roles and tasks ​Loss of autonomy for the children

​Changes in family members' roles and tasks

A nurse is caring for a pt who is postoperative. The nurse should base her pain management interventions primarily on which methods of determining the intensity of the pt's pain? ​Vital sign measurement ​Client's self-report of pain severity ​Visual observation for nonverbals signs of pain ​Nature of invasiveness of the surgical procedure

​Client's self-report of pain severity

A nurse is admitting a pt with a partial hearing impairment. Which is the priority action by the nurse? ​Speak using a normal tone of voice. ​Stand directly in front of the client. ​Rephrase statements as needed. ​Determine if the client uses a hearing aid

​Determine if the client uses a hearing aid

A nurse is caring for a pt who has Paraplegia is monitoring him for signs of depression. Which of the manifestations should alert the nurse that the pt is developing depression? ​Flight of ideas ​Difficulty concentrating ​Palpitations ​Paranoia

​Difficulty concentrating

A nurse is caring for a pt and is in the Orientation Phase of the nurse-client helping relationship. Which communication technique should the nurse use in this phase? ​Elicit information from the client. ​Encourage the client to use self-exploration. ​Review the client's progress toward personal objectives. ​Talk with others who have information about the client .

​Elicit information from the client. RATIONALE ​Obtaining information from the client is an appropriate communication technique in the orientation phase.

A nurse is caring for a pt who expresses anxiety about his impending surgery. Which is the appropriate action by the nurse? ​Explore the client's feelings. ​Discuss the competency of the surgeon. ​Review another individual's similar surgical experience. ​Talk with the client's partner.

​Explore the client's feelings.

A nurse is giving an inservice presentation and cultural and religious dietary practices. The nurse should mention that, of the following religions, pts of which religions may choose pork as a dietary selection? ​Jewish ​Muslim ​Jehovah's Witnesses ​Seventh-Day Adventist

​Jehovah's Witnesses

A nurse drives up to the house of her pt, who has schizophrenia with manic episodes. This is the nurse's fifth visit. On this occasion, the pt is sitting on his front porch with a shotgun in his arms. Which is an appropriate action by the nurse?

​Keep driving in a path that is going away from the client's house.

A nurse is admitting a pt with a suspected cognitive disorder. Which inventories should be included as part of the admission assessment? ​Mental status questionnaire ​CAGE questionnaire ​Abnormal Involuntary Movements Scale (AIMS) ​Hamilton Anxiety Scale

​Mental status questionnaire

​A nurse on an acute MH unit is caring for a pt who has depression. Which is the highest priority nursing intervention? Monitor for risk of self-harm. ​Administer prescribed antidepressants. ​Encourage adequate fluid intake. ​Assist with activities of daily living.

​Monitor for risk of self-harm.

A nurse is caring for a pt who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." What type of communication breakdown does this response represent? ​Providing a passive statement ​Showing disapproval ​Offering false reassurance ​Using a value statement

​Offering false reassurance

A nurse in the ED is caring for a pt who is experiencing acute alcohol withdrawal. All of the following interventions are part of the pt care protocol. Which action should the nurse perform first? ​Implement seizure precautions. ​Insert an IV access site. ​Perform a neurological exam. ​Obtain a blood specimen.

​Perform a neurological exam.

A student nurse is performing postmortem care on a Muslim client. Which action by the student nurse should prompt a nurse to intervene? ​Leaves dentures in mouth ​Prepares to cleanse the body ​Disconnects the cardiac monitor ​Removes soiled linens from room

​Prepares to cleanse the body RATIONALE:​ Following the death of a Muslim, the body is often ritualistically washed and then wrapped with a white cloth and is not to be touched by a non-Muslim person. Also, the use of same-sex caregivers is important in this culture. This action by the student nurse would require intervention. Following the death of non-Muslim clients, the body should be thoroughly cleansed while maintaining safety standards concerning body fluids.

A nurse in the ED is caring for an adolescent following a suicide attempt. In reviewing the pt's history, which is the priority risk factor for suicide completion? ​Active psychiatric disorder ​Previous suicide attempt ​Loss of a parent ​History of substance abuse

​Previous suicide attempt

A nurse on a mental health unit is caring for pts who have the following depressive disorders. The nurse should identify which of the following diagnoses as presenting the greatest risk for suicide? ​Premenstrual dysphoric disorder ​Seasonal affective disorder ​Recurrent brief depression ​Minor depression

​Recurrent brief depression ​ A client who has recurrent brief depression experiences periodic major depressive episodes and is at greatest risk for suicide during these times.

A nurse is leading the team of nurse managers and is planning to make a major announcement. The nurse would use which nonverbal communication techniques to enhance the importance of the announcement? ​Sit in front of the group for the meeting and then stand for the announcement. ​Cross arms over the chest when beginning the announcement. ​Stare at the persons who will be most affected while making the announcement. ​Lean gently over the back of a chair sitting to one side of the room when making the announcement.

​Sit in front of the group for the meeting and then stand for the announcement.

A nurse is caring for a pt who is apparently in denial over the loss of a limb in a MVC. Which of the following nurse interventions is appropriate for this pt at this time? ​Allow the client to continue to deny the situation as part of recovery. ​Provide the client with written information about the phases of loss. ​Slowly intervene to help the client develop awareness. ​Suggest that the client accept his physiologic loss.

​Slowly intervene to help the client develop awareness.

A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which info is included in this discussion? ​The client achieves optimal personal growth ​The nurse forms a personal identity ​The client allows the nurse to satisfy his personal needs ​The nurse's needs take priority over the client's needs

​The client achieves optimal personal growth

A nurse is setting goals for a client who has had AIDS for the last 10 years and is at the end of life. Which are realistic goals? ​The client will verbalize an understanding of the mode of disease transmission. ​The client will experience a weight gain of one to two pounds per week. ​The client will increase attendance at community social activities. ​The client will receive medication to minimize episodes of breakthrough pain

​The client will receive medication to minimize episodes of breakthrough pain.

A nurse is caring for a 48 year old who is grieving. The pt reports that her husband died seven months ago, that she has lost 30 lbs, and that she has difficulty sleeping. which items of data indicate that theft is experiencing Maladaptive Grieving? ​The client is 48 years old. ​The client's husband died seven months ago. ​The client has lost 30 lb. ​The client has difficulty sleeping.

​The client's husband died seven months ago. ​One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after the loss.

The nurse is using the communication principle of presence when establishing a collaborative relationship with a pt. Which intervention behavior should the nurse use? ​Call the client by his first name when providing an introduction. ​Verbalize understanding of how the client feels. ​Offer personal thoughts and beliefs to the client. ​Use attentive listening with the client.

​Use attentive listening with the client.