Leadership 2 Questions

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states a) "I do not believe I have this disease." b) "I just want to see my son have a family of his own." c) "Why did this have to happen to me?" d) "I don't care about anything. I have no energy."

"Why did this have to happen to me?" Correct Explanation: The client is expressing anger when displaying a "why me" attitude. The other statements are reflective of other stages of grief.

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states a) "I don't care about anything. I have no energy." b) "I do not believe I have this disease." c) "Why did this have to happen to me?" d) "I just want to see my son have a family of his own."

"Why did this have to happen to me?" Correct Explanation: The client is expressing anger when displaying a "why me" attitude. The other statements are reflective of other stages of grief.

When describing the term "grief" to a group of students, which of the following would the instructor include? a) A part of the life cycle in the form of change, growth, and transition b) A feeling of connectedness with one's self and others c) The response experienced by anyone who has suffered a loss d) Feelings of apprehension or worry in response to a situation

The response experienced by anyone who has suffered a loss Correct Explanation: Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation

Which of the following stages of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead? a) Protest b) Shock c) Depression d) Doubt

Shock Correct Explanation: In the shock and disbelief stage, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies the emotional impact.

Nursing students are reviewing the various weapons of mass destruction, specifically biologic agents. The students demonstrate understanding of the information when they identify which of the following as the most likely weaponized agent? a) Anthrax b) Plague c) Tularemia d) Botulism

Anthrax Correct Explanation: Although tularemia, botulism, and plague are biologic agents that can be used as weapons of mass destruction, anthrax is recognized as the most likely weaponized biologic agent.

A client admitted to a mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which of the following? a) Battery b) Malpractice c) Negligence d) Slander

Battery Correct Explanation: Battery is intentional and wrongful physical contact with a person that entails an injury or offensive touching. Performing treatment without permission or receiving informed consent from the client might constitute both assault and battery. Judgments of battery suits have been based on the application of restraints to confused clients. The other options do not meet the definition described in the question

Which ethical principle refers to the obligation to do good? a) Beneficence b) Nonmaleficence c) Veracity d) Fidelity

Beneficence Correct Explanation: Beneficence is the duty to do good and the active promotion of benevolent acts. Fidelity refers to the duty to be faithful to one's commitments. Veracity is the obligation to tell the truth. Nonmaleficence is the duty not to inflict, as well as to prevent and remove, harm; it is more binding than beneficence

Situations that are considered risk factors for complicated grief are A inadequate support and old age. B childbirth, marriage, and divorce. C death of a spouse or child, death by suicide, and sudden and unexpected death. D inadequate perception of the grieving crisis.

C

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining a this client? a) Reviewing facility policy regarding how long the client may be restrained b) Preparing an as-needed dose of the client's psychotropic medication c) Checking that the restraints have been applied correctly d) Asking if the client needs to use the bathroom or is thirsty

Checking that the restraints have been applied correctly Correct Explanation: A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained

A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful? a) Encourage the client to see, touch, and hold the dead neonate. b) Let the child's father decide what information the client receives. c) Provide information about possible causes of the stillbirth only if the client requests it. d) Be selective in providing the information that the client seeks.

Encourage the client to see, touch, and hold the dead neonate. Correct Explanation: When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for the client to bond with the dead neonate and allow the neonate to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the neonate's father decide which information the client receives is inappropriate

A female client is brought to the emergency room with matted hair, bruising, and malnutrition. The nurse suspects physical abuse and neglect. The nurse states, ?this happens to many women.? Which type of ethical approach is the nurse exhibiting? a) Moralizing b) Values clarification c) Paternalism d) Feminist

Feminist Correct Explanation: A feminist approach is one where the focus is on specific female problems and concerns, and the statement "this happens to many women" is an example of this. The other choices are not correct as they are not reflective of this ethical approach

Which of the following terms is used to describe the personal feelings that accompany an anticipated or actual loss? a) Spirituality b) Grief c) Mourning d) Bereavement

Grief Correct Explanation: Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life

Which of the following solid organs is most frequently injured in a penetrating trauma? a) Lungs b) Liver c) Pancreas d) Brain

Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.

The nurse is caring for a patient who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the patient's death is imminent? a) Shallow breathing b) Mottling of the lower limbs c) Increased swallowing d) Slow steady pulse

Mottling of the lower limbs Correct Explanation: The time of death is generally preceded by a period of gradual diminishment of bodily functions in which increasing intervals between respirations, weakened and irregular pulse, and skin color changes or mottling may be observed. The patient will not be able to swallow secretions, so suctioning, frequent and gentle mouthcare, and possibly the administration of a transdermal anticholinergic drug may be required.

The hospice nurse is teaching a client's family the physical signs of approaching death. The nurse knows that learning has occurred when the family says they will know that death is imminent when they see which of the following? (Select all that apply.) a) Fast respiratory rate b) Cyanosis of dependent areas c) Bowel constipation d) Increased body temperature e) Restlessness

Restlessness • Bowel constipation • Cyanosis of dependent areas Explanation: Clinical signs of impending or approaching death include bowel incontinence or constipation, decreasing body temperature, irregular or Cheyne-Stokes respirations, slow or irregular heart rate, restlessness and/or agitation; and cooling, mottling, and cyanosis of the extremities and dependent areas

A nurse is caring for a 5-year-old boy with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that he is ready to go to heaven and see his grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should she do? a) Tell the physician that the family would like to discontinue treatment. b) Talk with the parents about the dying process and make them aware of what their child has confided. c) Tell the child that she will talk with his parents and change their minds. d) Listen to the child but recognize that he's too young to make his own decisions.

Talk with the parents about the dying process and make them aware of what their child has confided. Correct Explanation: Chronically ill children commonly recognize their fate, whereas their parents continue to believe they'll become well again. The nurse should talk with the parents about the child's concerns. It's possible that the parents don't know what their child is feeling. Chronically ill children tend to have a good understanding of death, and should have input into decisions about their care. The nurse shouldn't tell the child that she can change the parents' minds; she might not be able to keep that promise. It would be unethical for the nurse to call the physician and misrepresent the parents' wishes

When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? a) The nurse tells the client she cannot leave the hospital because she is seriously ill. b) While bathing a client behind pulled curtains, two nurses are discussing a different client. c) The staff nurse threatens to restrain the client if she did not take her medication. d) The elderly client refuses the intramuscular injection, but the staff nurse administered it.

The elderly client refuses the intramuscular injection, but the staff nurse administered it. Correct Explanation: If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening a client is assault. Discussing another client within earshot of others is an invasion of privacy. Keeping a client against her wishes, regardless of her health status, is false imprisonment.

The nurse recognizes that the community affects the ability of individuals to meet basic human needs. Which example is not a characteristic of a healthy community? a) Volunteer opportunities for older adults increased the past two years. b) The quality of drinking water exceeds the state requirements. c) A new youth center provides after school programs for teens. d) The number of assaults increased 2% over the last year.

The number of assaults increased 2% over the last year. Correct Explanation: Violent crimes negatively impact the health of a community. A healthy community provides a safe and healthy environment for its residents (quality drinking water), offers services to meet the needs of the residents (youth center, volunteer opportunities), and offers access to healthcare services

Paul Cavanagh, a 63-year-old retired teacher, had oral cancer and had extensive surgery to excise the malignancy. Although his surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to Mr. Cavanagh and his family? a) Having a courageous attitude b) Time to mourn, accept, and adjust to the loss c) Not giving in to anger d) Knowing that everything will work out just fine

Time to mourn, accept, and adjust to the loss Correct Explanation: The first time family members or clients see the effects of surgery, the experience usually is traumatic. The nurse needs to promote effective coping and therapeutic grieving at this time. Responses may range from crying or extreme sadness and avoiding contact with others to refusing to talk about the surgery or changes in appearance. Allowing the client time to mourn, accept, and adjust to losses is essential.

The nurse is providing care to a group of terminally ill clients. The client who exhibits signs of impending death is the client who has a) a blood pressure of 100/64 mm Hg, regular pulse of 64 beats/minute. b) eyes closed, temperature 98.4 degrees Farenheit. c) warm, pale skin and frequent urination. d) distended abdomen, Cheyne-Stokes respirations.

distended abdomen, Cheyne-Stokes respirations. Correct Explanation: Signs of impending death include abdominal distention and Cheyne-Stokes respirations. Other signs are decreasing blood pressure, slow or irregular pulse, restlessness, decreasing temperature, cooling and cyanosis of the extremities, and urinary incontinence. The other clients exhibit normal vital signs or do not exhibit these signs.

The client has been diagnosed with a disease that requires a risky treatment for survival. The client is indecisive about treatment and states, "I don't know what to do." The nurse determines the most appropriate outcome is that the client will a) report feelings of peace about decision regarding treatment. b) have the healthcare provider make the treatment decision. c) identify and use appropriate coping strategies. d) express feelings, needs, and concerns about treatment.

report feelings of peace about decision regarding treatment. Explanation: The situation is about the client's inability to make the decision regarding treatment. The option that most addresses this is the client reporting feelings of peace about treatment decision. It is inappropriate for the healthcare provider to make treatment decisions

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Report this finding to the nurse who is taking care of the client. b) Report this finding to the physician. c) Document the bruising and continue to assess the area over the next 72 hours. d) Report this finding to the Adult Protective Services (APS).

Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.

A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse? a) "Could I call the physician for you?" b) "This is a normal response to the loss of a loved one." c) "I would like to sit with you for a while and talk about your child and family." d) "Would you like me to call your spouse?"

"I would like to sit with you for a while and talk about your child and family." Correct Explanation: This choice is the focused therapeutic response that would generate client-focused discussion. Calling someone else is not client focused and nursing intervention based. Stating that this is a normal response is nontherapeutic, and calling the physician is incorrect because the it is within the nurse's scope of practice to resolve this issue.

Which nursing statement is most effective when the nurse is trying to defuse a client's impending violent behavior? a) "This is a good time for you to play cards with me." b) "Do you feel you need to be alone in your room?" c) "The crisis team and I will escort you to the seclusion room." d) "Let's talk about what happened to make you this angry."

"Let's talk about what happened to make you this angry." Explanation: In many instances, the nurse can defuse impending violence by helping the client identify and express his feelings of anger and anxiety. This approach may help the client verbalize his feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because this type of seclusion reduces environmental stimulation and provides a feeling of security

During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which response would the nurse find inconsistent with the profile of a battered partner? a) "I am responsible for keeping my family together." b) "I am not sure I could get a job that pays even minimum wage." c) "The abuse adds spice to our relationship." d) "I love my husband and will help him."

"The abuse adds spice to our relationship." Correct Explanation: Saying that abuse "adds spice" suggests the woman actually enjoys the violent relationship and is inconsistent with the profile of victim of battery. Women are conditioned to be responsible for the family's well-being. This is often a motivation for a battered woman to stay in an abusive relationship. The victim believes that she can save the relationship and that her partner will change. Feelings of guilt surrounding issues such as these often influence an abused woman's decisions about staying with her partner. A woman's lack of job skills and financial resources may cause her to stay. Many women are injured or killed when they try to leave a violent relationship.

An adolescent admitted for panic attacks tells the nurse that an uncle has been making sexual advances. The client begs the nurse to not say anything because of what the uncle may do. What should be the nurse's initial response? a) "The law requires me to make a report so you can be protected." b) "Have you told anyone else what is happening?" c) "He can't hurt you here, and we'll make sure you're safe." d) "You have a right not to report this, so I will not either."

"The law requires me to make a report so you can be protected." Correct Explanation: Although the nurse needs to maintain a therapeutic relationship, disclosure of potential sexual abuse supersedes confidentiality issues. It's appropriate for the nurse to reassure the adolescent that she'll be safe, but the nurse must first explain her responsibilities in relation to this disclosure. Asking the adolescent if she has disclosed this situation to anyone else is important, but the immediate priority is to report the abuse to the proper authorities within the time specified by law. The adolescent does not have the right to not report this abuse.

A client diagnosed with thyroid cancer signed a living will that states he doesn't want ventilatory support if his condition deteriorates. As his condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best? a) "Maybe you should talk with your family." b) "Do you understand that you'll be placed on a ventilator?" c) "What exactly do you mean by wanting 'everything' done for you?" d) "I'll ask your physician to revoke your do-not-resuscitate order."

"What exactly do you mean by wanting 'everything' done for you?" Explanation: Asking the client what he means is the best response. The nurse should clarify the client's request and get as much information as she can before notifying the physician of the client's wishes. Asking the physician to revoke the client's do-not-resuscitate (DNR) order makes an assumption about the client's wishes without obtaining clarification of his statement. The client might want aggressive treatment without reversing the DNR order. Asking the client if he understands that he'll be placed on a ventilator places him on the defensive. Telling the client to talk with his family is an inappropriate response; the client has the right to change his treatment plan without input from his family

Which of the following situations is most likely to warrant an autopsy? a) A patient's death involves an allegation of a medical error. b) A palliative patient dies unwitnessed during the night. c) A patient's death is attributed to an infectious disease. d) A patient dies after unsuccessful cardiopulmonary resuscitation.

A patient's death involves an allegation of a medical error. Correct Explanation: Allegations of incompetence or malpractice create a need for an autopsy. An unwitnessed death, an unsuccessful code, or a death by infectious disease may require an autopsy due to other situation-specific factors, but these situations themselves do not necessarily require an autopsy

Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse? a) A person who is obsessed with cleanliness and showers many times a day. b) A person who is angry, hostile, and alienated from their family. c) A person who says, "I have found a solution for this mess." d) A person who is unable to make decisions and is helpless and tearful.

A person who says, "I have found a solution for this mess." Correct Explanation: The statement by the person who says "I have found a solution for this mess" contains suicidal ideation, and that person is more of a safety risk than the angry, alienated client or the obsessed or helpless one. The other clients may need intervention as well, but the potentially suicidal client has the greatest need for nursing intervention

After teaching a group of cancer survivors about loss and grief, the nurse determines that the teaching was successful when the group identifies loss as which of the following? a) The response experienced by anyone who has suffered distress b) A part of the life cycle in the form of change, growth, and transition c) Feelings of apprehension or worry in response to a situation d) A feeling of connectedness with one's self and others

A part of the life cycle in the form of change, growth, and transition Correct Explanation: Loss is part of the life cycle and occurs in the form of change, growth, and transition. Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation.

When assessing a client, which statement indicates that the client is experiencing the anger stage of death and dying? a) ?I am a good person. Why did this happen to me?? b) ?Now I can go in peace knowing everyone will be fine.? c) ?If I can just make it to Christmas, I?ll be satisfied. d) ?Maybe they made a mistake in my diagnosis.?

?I am a good person. Why did this happen to me?? Correct Explanation: Although each person reacts to the knowledge of impending death or to loss in his or her own way, there are similarities in the psychosocial responses to the situation. In the anger stage, the client expresses rage and hostility and adopts a ?why me?? attitude. The other options are examples of statements appropriate to the other stages of death and dying.

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? a) ?The client will have to go to an inpatient hospice unit in order to receive palliative care.? b) ?In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops.? c) ?The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms.? d) ?Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis.?

?The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms.? Correct Explanation: Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.

A female client comes to an urgent care clinic and says, "I've just been raped." What should the nurse do? A Allow the client to express whatever she wants. B Ask the client if staff can call a friend or family member for her. C Offer the client coffee, tea, or whatever she likes to drink. D Get the examination completed quickly to decrease trauma to the client. E Provide the client privacy—let her go to a room to make phone calls. F Stay with the client until someone else arrives to be with her.

A, B, F

A nurse is caring for a client who began taking the antidepressant paroxetine (Paxil) 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, ?My mind is made up, I can do this.? What is the best action by the nurse to incorporate this information into the plan of care? a) Add the nursing diagnosis: Risk for self-harm. b) Document the depression has resolved. c) Tell another nurse about this client statement. d) Encourage the client to join a therapy group

Add the nursing diagnosis: Risk for self-harm. Correct Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and effective

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning? a) Offer emotional support to the family b) Have the client?s family remain at the bedside c) Administer sedation and analgesia d) Provide explanation of the process

Administer sedation and analgesia Explanation: Terminal weaning is the gradual withdrawal of mechanical ventilation from a client with a terminal illness. Providing sedation and analgesia are the best way to reduce the client?s discomfort during the process. The nurse participates in the process by educating the client and family about the burdens and benefits of continued ventilation and what to expect when terminal weaning is initiated. Supporting the family and having the family remain at the bedside are important roles of the nurse during terminal weaning, but do not directly affect discomfort as much as sedation and analgesia

A nurse is part of a team involved with informing a client and his wife about the spread of his cancer. When communicating with the client and wife, which of the following would be most appropriate? a) Arranging to meet with the client and wife in the waiting room of the facility b) Using technical terminology when describing the condition c) Providing them with extensive details of the findings and proposed treatment d) Allowing time for the client and wife to absorb and respond to the information

Allowing time for the client and wife to absorb and respond to the information Correct Explanation: When communicating with the client and his wife about the spread of cancer, the team members should allow the couple time to absorb and respond to the information presented. The setting should be quiet with minimal distractions. Information should be presented using the language of the client and wife in terms that they can understand. Technical language should be avoided. Information should be presented in small chunks, to allow the client and his wife to absorb it and cope with it.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? a) Denial b) Anger c) Bargaining d) Acceptance

Anger Explanation: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close

Upon interviewing the client, the nurse finds that the client is providing care for her mother who is terminally ill. The client is depressed and already mourning the loss. Which nursing diagnosis would be most appropriate for the client? a) Dysfunctional grieving b) Prolonged grieving c) Anticipatory grieving d) Normal grieving

Anticipatory grieving Correct Explanation: Anticipatory grieving is the most appropriate nursing diagnosis for this client. It comprises the intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of loss. Normal grieving, dysfunctional grieving, and prolonged grieving are inappropriate diagnoses because they can only happen after the actual loss

A client and family are dealing with the client's recent terminal diagnosis. A nurse identifies a nursing diagnosis of hopelessness. Which of the following would be most helpful in supporting hope for this family? Select all that apply. a) Helping to obtain support from the community b) Encouraging the client to participate in care to foster control c) Avoiding the sharing of information and feelings d) Arranging for appropriate psychosocial counseling e) Assisting in establishing long-term goals

Arranging for appropriate psychosocial counseling • Encouraging the client to participate in care to foster control • Helping to obtain support from the community Explanation: To enable, support, and foster hope in terminally ill clients and their families, nurses should encourage and support the client's control over circumstances, choices, and environment whenever possible, make referrals for psychosocial and spiritual counseling, and assist with developing suports in the home and community when none exist. Goals set should be realistic, rather than long-term. Information and feelings should be shared. The information provided also should be accurate

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action? a) Ask the client if she is afraid that her husband will be angry. b) Inform the surgeon that the nurse will not sign the informed consent form. c) Ask the surgeon to wait until the client has had a chance to talk to her husband. d) Remind the client that she is responsible for her own health care decisions.

Ask the surgeon to wait until the client has had a chance to talk to her husband. Correct Explanation: It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to her husband. Telling the client that she is responsible for her health care decisions does not respect the client's desire to consult her husband. The client has not indicated that there she is fearful of her husband. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

The nurse overhears an older client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? a) Report the suspicions to to the authorities. b) Ask to examine the client alone in order to speak to her privately. c) Nothing, as it is none of the nurse's concern. d) Document the observed behaviors in the client's chart

Ask to examine the client alone in order to speak to her privately. Correct Explanation: In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols

A nurse volunteers to serve on the hospital ethics committee. Which of the following indicates that the nurse knows what the purpose of an ethics committee is? a) Assist in decision-making based on the client's best interests b) Convince the family to choose a specific decision c) Decide the care for a client who is unable to voice their opinion d) Present options about the type of care

Assist in decision-making based on the client's best interests Explanation: An ethics committee will meet when a client is unable to make an end-of-life decision and the family cannot come to a consensus. The committee members are there to advocate for the best interest of the client. The committee would not convince, decide, or present options about the type of care. This is not the role of an ethics committee

A nurse who provides the information and support that patients and their families need to make the decision that is right for them is practicing what principle of bioethics? a) Fidelity b) Nonmaleficence c) Autonomy d) Justice

Autonomy Correct Explanation: Autonomy, also known as self-determination, is respecting the rights of clients or their surrogates to make health care decisions. The nurse would provide the information and support the client and family need to make the decision that is right for them, including collaborating with other members of the health care team to advocate for the client. Nonmaleficence is avoiding causing harm. Justice is giving each individual their due and acting fairly. Fidelity is the keeping of promises.

A patient diagnosed with terminal cancer is making plans to take flying lessons because that has always been the patient's personal goal and it will allow her to visit her elderly parents. What stage of death and dying according to Kbler-Ross is best illustrated in this description? a) Depression b) Acceptance c) Anger d) Bargaining

Bargaining Explanation: This example demonstrates characteristics of bargaining, such as a desire to fulfill wishes, make a will, visit relatives, and put affairs in order. This stage is unlike the acceptance stage during which the patient feels tranquil and is prepared to die with all arrangements in order. During the anger stage, the patient expresses rage and hostility. In the depression stage, the patient goes through a period of grief before death

When preparing to present a community program about women who are victims of physical abuse, which should the nurse stress about the incidence of battering? a) Death from battering is rare. b) Lower socioeconomic groups are primarily affected. c) Physical abuse typically begins early in a relationship well before a women gets pregnant. d) Battering is a major cause of injury to women.

Battering is a major cause of injury to women. Explanation: Battering is a major cause of injury to women. Although battering occurs in all socioeconomic groups, it may appear to be more common in members of lower socioeconomic groups because they are more likely to use emergency department services. Many women experience battery for the first time when they become are pregnant. Death from battering is not rare

A graduate nurse enters a patient's room and finds the patient unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the patient has mentioned he does not wish to be resuscitated, but there is no DNR order on the patient's chart. What is the nurse's best action? a) Consult with the charge nurse or nurse manager before calling the code. b) Call a code and begin resuscitating the patient. c) Initiate a slow-code until the physician arrives. d) Respect the patient's wishes and avoid calling a code.

Call a code and begin resuscitating the patient. Explanation: The standard of care obligates professionals to attempt resuscitation if a patient stops breathing or his or her heart stops and there is no DNR order to the contrary. It is important for nurses to clarify a patient's code status if the nurse has reason to believe a patient would not want to be resuscitated. Slow-codes are never good practice, and the nurse could be charged with negligence in the event of a slow-code and resultant patient death.

A 15-year-old client needs life-saving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? a) No action is necessary in this case because consent is not needed. b) Send the client to surgery without the consent. c) Have the family sign the consent form as soon as they arrive. d) Call the family for a consent over the telephone, and have another nurse listen as a witness.

Call the family for a consent over the telephone, and have another nurse listen as a witness. Explanation: When the client cannot sign the operative consent and it is a true life-saving emergency, consent may be obtained over the telephone from the client's next-of-kin or guardian. The surgeon must obtain the telephone consent, but if it is a true life-saving emergency the surgeon often is already in surgery, so the nurse makes the telephone call and another nurse witnesses the call. Some institutions have a special consent form for emergency surgery. Consent can be waived in situations in which no family is available; however, if the family can be reached by telephone before surgery, verbal consent is legally required

A nursing instructor is discussing death and dying with a group of students as part of a clinical conference. Which of the following would the instructor identify as the current cause of most deaths? a) Cancer b) Mental health problems c) Trauma d) Chronic illness

Chronic illness Correct Explanation: In recent years, the experience of dying has changed as advances have been made in the care of chronically and terminally ill patients. Technologic innovations and modern therapeutic treatments have prolonged the lifespan, and many deaths are now the result of chronic illnesses that result in progressive physiologic deterioration and subsequent multisystem failure.

A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? a) Collaborate with the physician to make a referral to social services. b) Contact hospital security to escort the husband from the hospital. c) Tell the husband that he must leave because he is intimidating the client. d) Question the woman in front of her husband.

Collaborate with the physician to make a referral to social services. Correct Explanation: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her spouse does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security

The son of a dying patient is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? a) Perform a detailed spiritual assessment of the patient. b) Organize a meeting between the chaplain, the son, and the patient to achieve a resolution. c) Document the patient's request and wait to see if she reiterates her request. d) Contact the chaplain to arrange a visit with the patient.

Contact the chaplain to arrange a visit with the patient. Correct Explanation: The nurse's primary duty is to honor the patient's request for a meeting with a spiritual adviser.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? a) Restrain the client with vest restraints. b) Apply wrist restraints instead of vest restraints. c) Ask a family member to come in to supervise the client. d) Contact the physician and obtain necessary orders.

Contact the physician and obtain necessary orders. Correct Explanation: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? a) Call the supervisor and report the officer's decision to keep the cuffs on. b) Ask the physician for an order to remove the handcuffs. c) Continue to assess the client, allowing the officer to assume responsibility for the restraint. d) Refuse to provide care while the client is handcuffed to the stretcher.

Continue to assess the client, allowing the officer to assume responsibility for the restraint. Correct Explanation: In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action? a) Coordinate with the case manager to make a safe discharge plan. b) Arrange for a counseling session for the parents of the client. c) Give the mother telephone numbers of women's shelters. d) Advise the mother that she should report her concerns to the police.

Coordinate with the case manager to make a safe discharge plan. Correct Explanation: The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client

Upon admission, the nurse should give the highest priority to addressing which need of a client who is displaying symptoms of dysfunctional grief? a) Pain management b) Self-care activities c) Coping strategies d) Spiritual distress

Coping strategies Correct Explanation: Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed

Upon admission, the nurse should give the highest priority to addressing which need of a client who is displaying symptoms of dysfunctional grief? a) Self-care activities b) Pain management c) Spiritual distress d) Coping strategies

Coping strategies Explanation: Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed

The nurse-manager of a local hospice care agency is responsible for orienting newly hired nurses. Which of the following correctly reflects hospice care? a) The Medicaid hospice benefit, enacted by Congress in 1982, is the predominant source of payment for hospice care. b) After the hospice client's death, the nurse will assist the family with the bereavement process up to one year. c) The hospice nurse cares for the client and the family from admission to service until death. d) The focus of hospice nursing is on prolonging life and promoting dignity.

Correct response: After the hospice client's death, the nurse will assist the family with the bereavement process up to one year. Explanation: Hospice nurses are involved with patients and families from the time of admission until up to one year after the death of the client. The focus of hospice nursing is on client dignity and easing suffering, not on prolonging life. It is the Medicare, not the Medicaid hospice benefit that was enacted in 1982

When planning care for a 55-year-old male client with newly diagnosed terminal pancreatic cancer, which nursing diagnosis would be most appropriate? a) Ineffective coping b) Failure to thrive c) Death anxiety d) Impaired comfort

Death anxiety Explanation: The data the nurse collects about how a client or the client?s caregivers are responding to an actual or impending loss or to impending death may support several different nursing diagnoses. Death anxiety is common when the diagnosis is new and is related to inability to predict how the last stage of illness will play out. Coping mechanisms are important in the dying process and will need to be assessed to determine their adequacy. Failure to thrive is not appropriate for this client and his medical diagnosis. Impaired comfort may be appropriate but is not as important as death anxiety at this time due to the newness of the client?s diagnosis

The nurse is assessing a client recently diagnosed with terminal lung cancer who states, ?This can't be happening to me. Maybe the doctor made a mistake.? Which stage of death and dying is the client exhibiting? a) Denial b) Bargaining c) Anger d) Depression

Denial Correct Explanation: In the denial stage, the client denies the reality of death and may repress what is discussed. The client may think the doctor made a mistake in the diagnosis or that his or her records were mixed up with another client?s records. In the anger stage, the client demonstrates rage and hostility. In the bargaining stage, the client tries to barter for more time. In the depression stage, the client demonstrates a period of grief before death characterized by crying and not speaking much.

Which of the following is an appropriate nursing intervention for a client who plans to use a hearing aid? a) Advise the client to purchase from a company salesman. b) Advise the client to purchase a hearing aid that is unnoticeable. c) Advise the client to purchase the hearing aid from a mail order catalogue. d) Describe the various types of hearing aids that are available to the client.

Describe the various types of hearing aids that are available to the client. Correct Explanation: The nurse should describe the various types of hearing aids that are available, some of which fit almost unnoticeably in the ear. If the client fears that wearing a hearing aid is a stigma, the nurse describes the various types of hearing aids that are available

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, teaching them about the signs of approaching death. Which of the following would the nurse include in this teaching plan? a) Decreased pain b) Difficulty swallowing c) Increased urinary output d) Increased sensory stimulation

Difficulty swallowing Correct Explanation: A sign that death is approaching is the client's difficulty in swallowing. People who are dying do not experience decreased pain. They may not be in a position to report pain; therefore, the caregiver should observe the client closely. Urinary output decreases when a person is approaching death due to system failure and limited intake. The client approaching death has decreased sensory stimulation.

While providing care to a client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on the arms and trunk. When the nurse asks about these bruises, the client responds, "I tripped." What actions would the nurse take? Select all that apply. a) Call the client's partner to discuss the situation. b) Report abuse of the client to the local authorities. c) Assist the client in developing a safety plan for times of increased violence. d) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. e) Tell the client that she needs to leave the abusive situation as soon as possible. f) Provide the client with telephone numbers of local shelters and safe houses.

Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. • Assist the client in developing a safety plan for times of increased violence. • Provide the client with telephone numbers of local shelters and safe houses. Explanation: The nurse would objectively document the assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All individuals, men or women, suspected of being abuse victims would be counseled on a safety plan, which consists of recognizing escalating violence within the family, formulating a plan to exit quickly, and knowing the telephone numbers of local shelters and safe houses. The nurse would not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Contacting the client's spouse without consent violates confidentiality. The nurse would respond to the client in a nonthreatening manner that promotes trust, rather than ordering the client to break off the relationship

Which of the following would be inconsistent with a normal grief reaction? a) Denial b) Anger c) Elation d) Fear

Elation Correct Explanation: Denial, sadness, anger, fear, and anxiety are normal grief reactions in people with life-threatening illness and those close to them. Elation would not be a normal grief reaction.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Inform the family that everything is being done to assist with the client's survival. b) Contact a spiritual advisor to provide comfort to the family. c) Open up discussion among the family members about nursing home placement. d) Encourage the family to touch and talk to the client.

Encourage the family to touch and talk to the client. Correct Explanation: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

A client is scheduled to have an elective surgical procedure performed and cannot decide if he wants to do it or not. He asks the nurse to help him make the decision because he does not feel that he knows enough about the procedure. Which of the following is the best way for this nurse to advocate for this client? a) Facilitate the client's decision by allowing him to verbalize his feelings and by providing information to help him assess his options. b) Call the surgeon and have him explain the procedure again. c) Refuse to help the client and state that he must make the decision on his own. d) Refer the client to the social worker so that she can call in the people who need to help him make his decision.

Facilitate the client's decision by allowing him to verbalize his feelings and by providing information to help him assess his options. Explanation: Nurses as advocates must realize that they do not make decisions for their clients, but they can facilitate decision making by allowing the client to verbalize his feelings and by providing information to help him assess his options. This is not an appropriate time to call in the surgeon or the social worker, and refusing to help the client is not the best example of patient advocacy performed by a nurse

A nurse is providing care for a client with cancer. The client's wife indicates that she does not want her husband to be told he is terminal. This is a breach of which of the following ethical principles? a) Nonmaleficence b) Beneficence c) Fidelity d) Autonomy

Fidelity Explanation: The principle of fidelity involves being faithful to the client who has the right to the truth. The other choices do not reflect this principle.

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent? a) Let the client know that her behavior is not acceptable. b) Use sedation to keep the client calm. c) Get help to handle the situation safely. d) Provide a physical outlet for the client's energies.

Get help to handle the situation safely. Explanation: The recommended first course of action is to prevent accidents and injuries when a client becomes violent. In this situation, it would be best to call for help to handle the situation safely. Providing a physical outlet for the client's energies is an appropriate course of action but only after the situation is safely under control. Letting the client know that her behavior is not acceptable is an important useful intervention but is not likely to be useful in an unstable, escalating situation. Using sedation to control behavior is not the nurse's first course of action. The first course of action is to summon help.

The nurse has noted that a dying patient is often teary at various times during the day. The nurse recognizes that crying may indicate the patient is currently experiencing which stage of grief? a) Rejection b) Fear c) Denial d) Guilt

Guilt Explanation: Fear may prompt some individuals to cry, but crying is more likely to accompany a deep sense of guilt. Denial and rejection are less likely to prompt an individual to cry frequently

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. a) Fall from a roof b) Knife-stab wound c) Motor-vehicle crash d) Being struck with a baseball bat e) Gunshot wound

Gunshot wound • Knife-stab wound Correct Explanation: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

The nurse is caring for a victim of a sexual assault. The patient is fearful and experiencing flashbacks. The nurse recognizes that the patient is experiencing which of the following phases of the psychological reaction to rape? a) Reorganization phase b) Denial phase c) Heightened anxiety phase d) Acute disorganization phase

Heightened anxiety phase Explanation: During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

A nurse is assessing a dying patient for realism of expectations and perception of condition. Which interview questions address this concern? (Select all that apply.) a) How do you see the next few weeks playing out? b) What have you been told about your condition? c) Do you know how to contact your doctor and get answers to your questions? d) How well do you think those around you are coping? e) Have you had any previous experience with this condition before? f) What do you think may be happening in the midst of all of this?

Have you had any previous experience with this condition before? • How do you see the next few weeks playing out? • What do you think may be happening in the midst of all of this? Explanation: A focused assessment regarding realism of expectations and perception of condition include the following questions: Have you had any previous experiences with this condition or with the death of someone you love? What are your expectations in this case? How do you see the next few weeks (days) playing out? What are your fears, hopes, concerns, worries? What good do you think might be happening in the midst of all this? The objective is to discover whether the patient and family have unrealistic expectations or misperceptions about the diagnosis, prognosis, and care options that will interfere with their decision making and coping. Asking the patient if he knows how to contact his doctor, what he has been told about his condition, and how well others around him are coping don't address these objectives.

A child with leukemia had been in remission for several years, but death is now imminent. The nurse is assisting the parents as they prepare for the child's death. Which approach will be most helpful? a) Help parents understand that grief is stronger when preceded by hope. b) Understand the parent's trust in the health care system will be undermined by the death of their child. c) Recognize that the parents have been prepared for this death since the time of diagnosis. d) Reflect to the parents that the death of a child is more difficult than that of an adult.

Help parents understand that grief is stronger when preceded by hope. Correct Explanation: Parents often experience greater grief when they have experienced the hope provided by the remission of their child's disease. The nurse allows the parents to express this grief. Reactions to death of a family member are not based on the age of the dying family member. No matter how well prepared the parents may be for the death of their child, it will not make coping with death easier. Family members may displace anger and frustration on the health care system and health care providers (HCPs), but death does not necessarily undermine trust

A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, "My boyfriend has been beating me up once in a while since I became pregnant, but I cannot bring myself to leave him because I do not have a job and I do not know how I would take care of my other children." What is the priority by the nurse at this time? a) Tell the client that she should not allow anyone to hit her or her children. b) Contact a social worker for assistance and family counseling. c) Provide the client with brochures on the statistics about violence against women. d) Help the client make concrete plans for the safety of herself and her children.

Help the client make concrete plans for the safety of herself and her children. Correct Explanation: In this situation, the client has indicated that she is not willing to leave the abusive boyfriend because of potential economic concerns and other children in the household. The nurse should explain the cycle of abuse (e.g., tension-building phase, battering incident, and honeymoon phase). The priority intervention is to assist the client to make concrete plans for the safety of herself and her children. The client should identify the safest, quickest routes out of the house and be able to identify where she will go once the cycle of violence escalates. Contacting a social worker at this time is not appropriate because the client is not ready to leave the abusive situation. The nurse can tell the client that these services are available, but it is up to the client to determine whether a referral is necessary. Telling the client that she should not allow anyone to hit her or her children does not assist the client to make plans for her safety and the children's safety should the violence escalate. The client may have a flat affect or feel extreme humiliation from the abuse. The client may also be feeling that the abuse is her fault. When the client is ready to leave the abusive situation and receive continuous counseling, efforts can be made to increase her self-esteem and prevent additional violence. The client should be made aware of the available services in the community for women who are involved in abusive relationships. The location and phone numbers for available shelters should be provided to the client. Giving her a brochure related to the statistics about violence against women is not helpful and, if found by the abuser, may lead to further violence.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? a) Her parents show shame and suspicion about her part in the rape. b) Her life becomes focused on helping other rape victims like herself. c) She seeks support from formerly ignored relatives and friends. d) She becomes upset when talking about the rape to anyone.

Her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims

The wife of a man who is dying tells the nurse: "Harold was so good to me. He was like a saint with his patience. I will miss him terribly" Which stage of grief is this woman experiencing, according to Engel? a) Outcome b) Idealization c) Awareness d) Restitution

Idealization Correct Explanation: Idealization is the exaggeration of the good qualities that the person or object had, followed by acceptance of the loss and a lessened need to focus on it. Restitution involves the rituals surrounding loss—with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying. Outcome, the final resolution of the grief process, includes dealing with loss as a common life occurrence.

The wife of a man who is dying tells the nurse: "Harold was so good to me. He was like a saint with his patience. I will miss him terribly" Which stage of grief is this woman experiencing, according to Engel? a) Outcome b) Idealization c) Awareness d) Restitution

Idealization Explanation: Idealization is the exaggeration of the good qualities that the person or object had, followed by acceptance of the loss and a lessened need to focus on it. Restitution involves the rituals surrounding loss—with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying. Outcome, the final resolution of the grief process, includes dealing with loss as a common life occurrence

The oncology nurse is learning to care for dying clients. Which of the following ideals should guide the nurse in facilitating a good death for these clients? (Select all that apply.) a) Independence and dignity are central issues for many dying clients. b) A good death is one that allows a person to die on his or her family's terms. c) The care of the dying client should be guided by the values and preferences of the nurse. d) The characteristics of a good death vary for each client. e) Care for dying clients should focus on pharmacologic relief of pain.

Independence and dignity are central issues for many dying clients. • The characteristics of a good death vary for each client. Explanation: A good death is one that allows a person to die on his or her own terms. Independence and dignity are central issues for many dying patients. The characteristics of a good death vary for each client. The care of a dying client should be guided by the values and preferences of the individual. Care for dying clients should focus on the relief of symptoms, not limited to pain, and should use both pharmacologic and nonpharmacologic means

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 pounds since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is a) Ineffective Denial related to poor grief resolution. b) Decisional Conflict related to inability to progress following spouse's death. c) Ineffective Coping related to failure of previously used coping mechanisms. d) Death Anxiety related to death of spouse.

Ineffective Coping related to failure of previously used coping mechanisms. Correct Explanation: The nursing diagnosis best supported by the data is Ineffective Coping. Defining characteristics include poor coping skills with activities of daily living as evidenced by unkempt appearance, eating poorly and losing weight, and client statement. Death Anxiety refers to an impending death or thoughts of death. Ineffective Denial refers to denying the reality of the situation. Decisional Conflict refers to inability to make decisions

A nurse informs a woman that there is nothing more that can be done medically for her premature infant who is expected to die. The mother suppresses her grief and tells the nurse she is experiencing heart palpitations. What type of grief might the mother be experiencing? a) Dysfunctional grief b) Inhibited grief c) Anticipatory grief d) Unresolved grief

Inhibited grief Explanation: With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited

A client who recently had a bilateral mastectomy is working on developing a positive body image. Which intervention by the nurse is most appropriate? a) Providing all the wound care if the client does not want look at the surgical area b) Teaching the client how she will feel regarding the removal of the breasts c) Encouraging the client to move forward and understanding that grief is not necessary d) Intervening when a client's spouse makes the client cry

Intervening when a client's spouse makes the client cry Correct Explanation: Assessing the response of the spouse to an altered body image and intervening if it negatively influences the client is part of the nursing role. The nurse cannot teach how a client will feel about the mastectomy as this is an individual response. Grief is part of the process when there is an significant alteration in body image. The client should be encouraged to participate in care as this helps with accepting the changes

The nurse is caring for a 5-year-old child who has a history of multiple admissions for fractures and cuts. The mother explains that the child fractured the femur by falling, but does not give any further details. The child indicates that the mother's boyfriend was present when the injury occurred, and the child's recollection of the event conflicts with the mother's explanation. What is the nurse's immediate responsibility? a) Restrict family who are visiting the child. b) Keep the child safe and assess for abuse. c) Call the police department and report abuse. d) Collect forensic specimens for laboratory analysis.

Keep the child safe and assess for abuse. Correct Explanation: The assessment for risk is the priority nursing action. This would include verbalizing your concerns to the most immediate supervisor and involving hospital social workers and the medical team. These initial steps need to be implemented, and then the appropriate authorities must be alerted.

The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include? a) Lesbians are more likely to get preventive services for cancer. b) Lesbians and bisexual females are more likely to be underweight or anorexic. c) LGBT youth are 2 to 3 times more likely to attempt suicide. d) LGBT populations have lower rates of tobacco, alcohol, and other drug use.

LGBT youth are 2 to 3 times more likely to attempt suicide. Correct Explanation: Healthy People 2020 found that LGBT youth are 2 to 3 times more likely to attempt suicide. Lesbians and bisexual females are more likely to be overweight or obese. LGBT populations have higher rates of tobacco, alcohol, and other drug use than other populations. Lesbians are more likely to get preventive services for cancer

Which of the following actions most clearly demonstrates a nurse's commitment to social justice? a) Ensuring that a hospital client's diet is culturally acceptable. b) Documenting nursing care in a timely, honest, and through manner. c) Lobbying for an expansion of Medicare eligibility and benefits. d) Answering a client's questions about her care clearly and accurately.

Lobbying for an expansion of Medicare eligibility and benefits. Correct Explanation: Social justice is a professional value that encompasses efforts to promote universal access to healthcare, such as the expansion of publicly funded programs like Medicare. Culturally competent care is a reflection of human dignity while answering clients' questions and documenting accurately are expressions of the value of integrity

The experience of parting with an object, person, belief, or relationship that one values is a) Loss b) Grief c) Death d) Bereavement

Loss Correct Explanation: Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the person's life

A nurse shows client advocacy by doing which of the following examples? a) Sending a client home with verbal discharge instructions b) Offering a hospice consultation to a client who is terminally ill c) Refusing to allow a spouse to stay by the bedside d) Insisting that a medication be taken

Offering a hospice consultation to a client who is terminally ill Correct Explanation: The definition of advocacy is to ensure that the best interests are being met. A hospice consult is an appropriate example. The other choices do not reflect advocacy for the client.

A nurse is caring for a neonate born addicted to opiates in the special care nursery. The neonate is exhibiting signs of withdrawal. When planning care, which nursing interventions would the nurse expect be included? Select all that apply. a) Increase environmental stimuli b) Encourage parental handling c) Feed every one to two hours d) Maintain intravenous fluids e) Administer Morphine f) Swaddle and/or provide a pacifier

Maintain intravenous fluids • Administer Morphine • Swaddle and/or provide a pacifier • Feed every one to two hours Explanation: Neonatal narcotic withdrawal syndrome includes symptoms of irritability, a high pitched cry, tremors, poor feeding with vomiting and diarrhea, and nasal stuffiness. Nursing interventions include to swaddle and/or offer a pacifier to soothe the neonate, decreasing handling and environmental stimuli, and maintain intravenous fluids with regular feeding. The nurse would also administer Morphine to ease the withdrawal symptoms and potential seizure activity.

During a course on terrorism, a group of emergency room nurses learn about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of what type of terrorism? a) Chemical terrorism b) Bioterrorism c) Mass trauma terrorism d) Nuclear terrorism

Mass trauma terrorism Correct Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death

A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome." This is an example of which type of loss? a) Anticipatory loss b) Physical loss c) Situational loss d) Maturational loss

Maturational loss Explanation: Maturational loss is experienced as a result of natural developmental processes, such as sending children off to kindergarten or away to college. A situational loss occurs as a result of an unpredictable event. Physical loss is a loss such as a body part. Anticipatory loss involves a display of loss and grief behaviors for a loss that has yet to take place.

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors? a) Mourning b) Spirituality c) Grief d) Bereavement

Mourning Explanation: Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Grief refers to the personal feelings that accompany an anticipated or actual loss. Bereavement refers to the period of time during which mourning takes place. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. (less)

What are examples of psychosocial stressors? (Select all that apply.) a) News reports on television about a war b) Fearing a terrorist attack c) Being caught in a blizzard d) Being involved in an accident e) Being diagnosed with HIV f) Acquiring a nosocomial infection

News reports on television about a war • Fearing a terrorist attack • Being involved in an accident Explanation: Psychosocial stressors include both real and perceived threats. News reports about war, fear of a terrorist attack, and being involved in a car accident represent psychosocial stressors. Physiologic stressors have both a specific effect and a general effect. Primary physiologic stressors include chemical agents (drugs, poisons), physical agents (heat, cold, trauma; such as being caught in a blizzard), infectious agents (viruses, bacteria; such as acquiring a nosocomial infection or diagnosed with HIV), nutritional imbalances, hypoxia, and genetic or immune disorders.

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? a) Trying to sit up on the stretcher b) Trying to move away from the nurse c) Not crying when moved d) Not answering the nurse's questions

Not crying when moved Explanation: Not crying when moved most strongly suggests child abuse because a victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills

A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? a) Notify the local Child Protective Services. b) Advise the child that the inappropriate behavior must stop. c) Continue to observe the behavior of the child. d) Discuss the child's behavior with the parents.

Notify the local Child Protective Services. Explanation: If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation

nurse on the crisis team in the emergency department is caring for a client who is angry and is experiencing delusional episodes. The client says to the nurse, "I'm going to kill my wife and chop her up to get rid of her." What is the nurse's priority action in this situation? a) Note it on the mental status form only. b) Ignore the remarks as delusional symptoms. c) Notify the wife that she may be in danger. d) Include "risk for injury" on the care plan.

Notify the wife that she may be in danger. Correct Explanation: The client is making statements that may be acted on. The nurse is obliged to notify the wife that she might be in danger. If the nurse believes the statements reflect a new symptom, such as delusions, the attending psychiatrist should be contacted for further direction. The other options are incorrect because they do not protect the client's wife, whom he has clearly indicated he has a plan to harm

While performing an assessment of a 75-year-old female in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately? a) Follow the facility's policy and procedures for reporting elder abuse. b) Notify the physician. c) Obtain more information from the client about the nurse's findings. d) Notify the nursing supervisor.

Obtain more information from the client about the nurse's findings. Explanation: The nurse should try to obtain more information from the client to complete the assessment. Without supporting information, she shouldn't assume the bruises indicate abuse, and she shouldn't notify her nursing supervisor until she has obtained additional facts. She should, however, inform the physician so he can examine the client. She should follow the facility's policy and procedure for reporting abuse. The nurse should make a report if, after the assessment, she has a strong suspicion that abuse is the cause

Which of the following is the most common and most fatal primary malignant bone tumor? a) Rhabdomyoma b) Osteochondroma c) Enchondroma d) Osteogenic sarcoma (osteosarcoma)

Osteogenic sarcoma (osteosarcoma) Correct Explanation: Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Benign primary neoplasms of the musculoskeletal system include osteochondroma, enchondroma, and rhabdomyoma

Which of the following is a true statement regarding hospice care? a) It encourages the prolongation of life through artificial means b) Patients have a life expectancy of 6 months or less c) It is cure-focused d) Patients have an acute illness

Patients have a life expectancy of 6 months or less Correct Explanation: A criterion of hospice care is that the patient has a life expectancy of 6 months or less, due to a terminal illness. It is not cure-focused and it does not seek to encourage prolongation of life through artificial means

When providing end-of-life care for patients, what will the nurse most often need to prioritize? a) Hydration and hygiene b) Pain control and emotional support c) Neurological assessment and protection of skin integrity d) Oxygen supplementation and assistance with end-of-life planning

Pain control and emotional support Correct Explanation: End-of-life care requires comprehensive blended nursing skills and is unique to each patient's circumstances. Common priorities, however, include the need to provide vigilant pain control and emotional support.

The nurse is assessing a victim who is reported to have been exposed to sulfur mustard. The nurse's assessment should include evaluation for which of the following? a) Pulmonary edema b) Cardiac arrest and death c) Diarrhea d) Partial-thickness burns

Partial-thickness burns Correct Explanation: Sulfur mustard causes superficial to partial-thickness burns with vesicles that coalesce. Phosgene causes pulmonary edema. Sarin causes increased GI motility and diarrhea. Cyanide causes cardiac arrest and death

Nurses are involved in many types of evaluation. All of the following are activities that are related to evaluation, but which of the following is the priority concern for nurses? a) Measuring patient outcome achievement b) Patients and their care c) Helping targeted groups of patients to achieve their specific outcomes d) Measuring the competence of individual nurses

Patients and their care Correct Explanation: The priority concern for nurses should always be related to care of patients. The other choices are all activities related to evaluation but are not the priority.

The parents of a 3-month-old infant have been told that their infant has died of sudden infant death syndrome. Which intervention is most important to include in the plan of care to assist the parents with their grieving process? a) Provide an opportunity for them to see the infant. b) Give them a package containing the infant's clothing. c) Reassure them that the infant's death was not their fault. d) Ask them if they would like to call their religious advisor.

Provide an opportunity for them to see the infant. Correct Explanation: The parents should be given the opportunity to say their final farewells to their infant. This last contact helps them focus on the reality of the infant's death.

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client? a) Fear b) Rape-trauma syndrome c) Anxiety d) Hopelessness

Rape-trauma syndrome Explanation: The nursing diagnosis Rape-trauma syndrome refers to the acute and long-term phases experienced by the victim of sexual assault. Specific nursing interventions can be planned on the basis of this diagnosis. A rape victim may also experience fear, anxiety, and hopelessness; however, these aren't the most accurate nursing diagnoses for this client.

A nurse caring for a client with a terminal illness understands which of the following to be true? a) Recovery is dependent on selected treatment b) Recovery will be slow c) Recovery is not expected d) Recovery will be longer than 3 months

Recovery is not expected Correct Explanation: A terminal illness is a condition from which recovery is not expected. Clients with terminal illness do not recover from the illness; they may be treated symptomatically and provided care and comfort

The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful? a) Provide her with the local suicide hotline number. b) Refer her to a group for survivors of suicide. c) Encourage her to receive counseling from a chaplain. d) Suggest she receive individual therapy by the nurse.

Refer her to a group for survivors of suicide. Correct Explanation: The survivor of suicide, in this situation, would be referred to a group for survivors of suicide to help her with her feelings and to work through the grief reaction. This group provides support and understanding of what the individual is experiencing by members who are experiencing similar reactions, including anger and guilt. Depression and unresolved grief can occur when the survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline number would be appropriate if the survivor herself were thinking about suicide

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Report this finding to the nurse who is taking care of the client. b) Document the bruising and continue to assess the area over the next 72 hours. c) Report this finding to the Adult Protective Services (APS). d) Report this finding to the physician.

Report this finding to the Adult Protective Services (APS). Correct Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS

An adult is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling sounds. The client's spouse asks the nurse, "Can you do something to help with the breathing?" Which is the nurse's best response in this situation? a) Explain to the spouse that it is standard practice not to suction clients when treatments have been discontinued. b) Suction the client so that the client's spouse knows all interventions were performed. c) Direct the unlicensed assistive personnel (UAP) to assess the client's vital signs and provide oral care. d) Reposition the client, elevate the head of the bed, and provide a cool compress.

Reposition the client, elevate the head of the bed, and provide a cool compress. Correct Explanation: Repositioning the client, elevating the head of the bed, and providing a cool compress are comfort interventions consistent with the concept of palliative care of the dying. Directing the UAP to assess vital signs focuses on the dying process, not the client. Suctioning may not benefit the client and is considered invasive and uncomfortable. Telling the spouse an intervention is not needed discounts the spouse's judgment and concerns

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? a) Restrain the client, as he is harmful to the other clients. b) Do not restrain the client, as it is equivalent to false imprisonment. c) Inform the physician and complete a comprehensive assessment. d) Do not restrain the client, as it is equivalent to battery.

Restrain the client, as he is harmful to the other clients. Explanation: The nurse should restrain the client because he is potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.

A nurse is planning care for a client with a diagnosis of schizophrenia who has been admitted to the psychiatric unit. Which nursing diagnosis should receive the highest priority? a) Impaired verbal communication b) Compromised family coping c) Risk for other-directed violence d) Imbalanced nutrition: Less than body requirements

Risk for other-directed violence Correct Explanation: Such characteristics as suspiciousness, anxiety, and hallucinations put the client with schizophrenia at risk for violence toward himself or others. Imbalanced nutrition: Less than body requirements, Compromised family coping, and Impaired verbal communication are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him has been established

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Provide details of the factors attendant to the sudden death b) Inform the family that the patient has passed on c) Show acceptance of the body by touching it, giving the family permission to touch d) Obtain orders for sedation for family members

Show acceptance of the body by touching it, giving the family permission to touch Correct Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as passed on. The nurse should avoid giving sedation to family members, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).

The children of a male patient with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to do which of the following? a) Dictate how the patient wants his estate handled after his death and by whom. b) Make legal provisions for active euthanasia. c) Specify the treatment measures that the patient wants and does not want. d) Give permission for organ donation.

Specify the treatment measures that the patient wants and does not want. Correct Explanation: Living wills provide instructions about the kinds of healthcare that should be used or rejected under specific circumstances. The management of an individual's estate is specified in a will, not a living will, and it is not legal for a living will to make provisions for active euthanasia. A living will may or may not include reference to organ donation, but normally this is addressed in a separate, specific consent card or document

The children of a male patient with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to do which of the following? a) Specify the treatment measures that the patient wants and does not want. b) Give permission for organ donation. c) Make legal provisions for active euthanasia. d) Dictate how the patient wants his estate handled after his death and by whom.

Specify the treatment measures that the patient wants and does not want. Correct Explanation: Living wills provide instructions about the kinds of healthcare that should be used or rejected under specific circumstances. The management of an individual's estate is specified in a will, not a living will, and it is not legal for a living will to make provisions for active euthanasia. A living will may or may not include reference to organ donation, but normally this is addressed in a separate, specific consent card or document

A nurse works with patients in a crisis intervention center. What ability would be most important for this nurse to develop? a) Strong communication and counseling skills b) Ability to relate to coworkers on a professional level c) Well-developed technical skills d) Low tolerance for frustration

Strong communication and counseling skills Correct Explanation: Strong communication and counseling skills are the most important skills or abilities that the nurse would need to develop to work with clients in a crisis intervention center. The ability to relate to coworkers on a professional level is important but not the priority answer. Well-developed technical skills and low tolerance for frustration would be important, but not the priority skill to have for the position.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? a) Obtaining consent for examination b) Performing the pelvic examination c) Collecting semen d) Supporting the client's emotional status

Supporting the client's emotional status Correct Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present

A nurse is aware that the principle of autonomy is being applied in which of the following situations? a) The client has decided to stop chemotherapy treatments. b) An order for an antibiotic is being written in the chart. c) The family is discussing care with the physician. d) A hospice consult is ordered by the nurse.

The client has decided to stop chemotherapy treatments. Correct Explanation: The principle of autonomy respects the client's right to make his or her own decisions. The other choices do not reflect this as the client is not making the decisions.

When describing the term "grief" to a group of students, which of the following would the instructor include? a) Feelings of apprehension or worry in response to a situation b) The response experienced by anyone who has suffered a loss c) A part of the life cycle in the form of change, growth, and transition d) A feeling of connectedness with one's self and others

The response experienced by anyone who has suffered a loss Correct Explanation: Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation

A 20-year-old single parent brings her 3-year-old son into the emergency department because he "fell." The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, "Sometimes I guess I am pretty rough with him. I am alone, and I just do not know how to manage him." The nurse should ask the mother if she would find it helpful to have a referral to: a) a support group for abusive parents. b) a parenting education program. c) a support group for single parents. d) a women's support group.

a parenting education program. Explanation: The mother's statements reveal that she is having problems with parenting. Therefore, a referral to a parenting education program is the most appropriate measure at this time.

A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. To assess for the likelihood of further violence and abuse, the nurse should determine that the husband: a) has moderate impulse control. b) has learned violence as an acceptable behavior. c) feels secure in his relationship with his wife. d) trusts his wife and supports her independence.

has learned violence as an acceptable behavior. Correct Explanation: Family violence is usually a learned behavior. This couple is at risk for further violence. Poor, not moderate, impulse control indicates a risk for more violence. Violent people generally are jealous and possessive and feel insecure in their relationships

A client with terminal cancer tells the nurse that she is not afraid to die and she is thinking about how to plan her funeral. The most appropriate referral the nurse could suggest would be to the: a) home health care service. b) social worker. c) pastoral care department. d) psychologist.

pastoral care department. Explanation: Spiritual support and planning for a funeral are offered by spiritual leaders from a pastoral care department. Home health care services may be an appropriate referral for discharg

A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time? a) referral to an outpatient therapist b) a prescription for fluoxetine 20 mg every morning c) a prescription for olanzapine 10 mg daily d) a joint session with the client and his ex-wife

referral to an outpatient therapist Correct Explanation: Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated

When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be especially cautious about which client behavior? a) visual hallucinations b) bizarre behavior c) violent behavior d) loud screaming

violent behavior Explanation: The nurse must be especially cautious when providing care to a client who has taken phencyclidine (PCP) because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.

In which situation can a client's confidentiality be breached legally? a) when a client's employer requests the client's diagnosis to initiate medical claims b) to answer a request from a client's spouse about the client's medication c) in a student nurse's clinical paper about a client d) when a client near discharge is threatening to harm an ex-partner

when a client near discharge is threatening to harm an ex-partner Correct Explanation: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.

A young adult client with severe depression and suicide ideation has been started on the selective seratonin reuptake inhibitor (SSRI) sertraline. Which client statement would indicate the client needs further teaching about seratraline? a) "Being on sertraline will significantly decrease the chances that I might hurt myself." b) "I can take this medicine with food." c) "Sexual side effects are pretty common with sertraline." d) "It may take several weeks for depression to get better "

"Being on sertraline will significantly decrease the chances that I might hurt myself." Correct Explanation: SSRIs reduce the risk of suicide in the long run, but they are associated with an increased risk of suicide during the initial phase of treatment, especially in young adults. Thus, clients need to be monitored closely for unusual behavior or worsening depression. SSRIs may be taken with food to reduce nausea. SSRIs take anywhere from 2 to 8 weeks to improve mood. Sexual side effects are common with SSRIs, so clients should be encouraged to discuss these with their health care provider should they occur.

A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, "My 6-year-old is starting to act just like his father. I just do not know how to handle this." Which response by the nurse is most appropriate? a) "You will have to limit your son's contact with his father." b) "Most boys outgrow these behaviors." c) "Setting limits on his behavior is all you need to do now." d) "Counseling for your son would be helpful."

"Counseling for your son would be helpful." Explanation: Children who witness domestic violence commonly grow up to be victims or abusers. Counseling helps interrupt the pattern of violence in families. Limiting contact between the father and child does not address the child's behavior, and outgrowing violent behaviors is not likely without other interventions. Setting limits on violent behaviors alone does not address the child's feelings and needs

The psychologist is teaching students about the factors that affect a person's reaction to grief. Which of the following statements by the students about developmental considerations is most accurate? a) "Death of a parent can delay a child's development." b) "Terminally ill children normally do not ask questions about death." c) "Sense of loss for a child is just as great as it is for an adult." d) "Children do not need to go through the same grief reactions as adults." e) "Children understand death on the same level as adults."

"Death of a parent can delay a child's development." • "Sense of loss for a child is just as great as it is for an adult." Correct Explanation: Children do not understand death on the same level as adults, but their sense of loss is just as great. Death of a parent or another significant person can delay a child's development. Both terminally ill children and their siblings are likely to talk and ask questions about death. Children need to go through the same grief reactions as adults

After the nurse has taught the parents of a 5-year-old boy who has leukemia how to talk with their child about death and dying, which statement would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death? a) "He is too young to understand what is happening to him." b) "He will understand how much his siblings will miss him." c) "He might think he has caused his death because he has misbehaved." d) "He will accept his death as caused by his disease."

"He might think he has caused his death because he has misbehaved." Correct Explanation: A 5-year-old child is in the preoperational stage of cognitive development and commonly thinks about behavior as magical; thus, the child may think that his behavior can cause death. Generally, children under 3 years of age are unable to differentiate death from temporary separation and are unable to understand what is happening, but by age 5 to 7 children understand that death means a body can no longer function. Logical thinking, evidenced by accepting death due to his disease, would occur during Piaget's stage of concrete operations, which occurs between ages 6 and 12 years. Although a 5-year-old child will be able to understand that he will be missed, he lacks the cognitive development to understand the extent of how much his siblings will miss him.

The cardiac nurse, who has been caring for a hospitalized terminally ill client for 3 days, finds that the client has expired. The nurse manager knows that the nurse can legally care for these clients when the nurse states which of the following? a) "Hospitals are mandated to notify transplant programs of potential donors." b) "The physician will give consent for the autopsy." c) "I need to notify the coroner of all deaths." d) "Organs are only retrieved from totally brain-dead clients."

"Hospitals are mandated to notify transplant programs of potential donors." Correct Explanation: The scarcity of organs has resulted in legislation mandating hospitals to notify transplantation programs of potential donors. Consent for autopsy is legally required, usually from the closest surviving family member. It is usually the physician's responsibility to obtain permission for an autopsy. If death is caused by accident, suicide, homicide, or illegal therapeutic practice or if it occurs within 24 hours of admission to the hospital, the coroner must be notified. Organs can be obtained from brain-dead clients and non-heart-beating cadavers

The cardiac nurse, who has been caring for a hospitalized terminally ill client for 3 days, finds that the client has expired. The nurse manager knows that the nurse can legally care for these clients when the nurse states which of the following? a) "The physician will give consent for the autopsy." b) "Organs are only retrieved from totally brain-dead clients." c) "Hospitals are mandated to notify transplant programs of potential donors." d) "I need to notify the coroner of all deaths."

"Hospitals are mandated to notify transplant programs of potential donors." Explanation: The scarcity of organs has resulted in legislation mandating hospitals to notify transplantation programs of potential donors. Consent for autopsy is legally required, usually from the closest surviving family member. It is usually the physician's responsibility to obtain permission for an autopsy. If death is caused by accident, suicide, homicide, or illegal therapeutic practice or if it occurs within 24 hours of admission to the hospital, the coroner must be notified. Organs can be obtained from brain-dead clients and non-heart-beating cadavers

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence? a) "Is your partner excited about your pregnancy?" b) "Does your partner own a gun?" c) "Does your partner have an arrest record?" d) "How safe do you feel in your home?"

"How safe do you feel in your home?" Correct Explanation: The act of screening for intimate partner violence is a key intervention to help open doors for at risk women to discuss ways to improve their safety and well-being. Asking clients how safe they feel in their home open is an open-ended, nonjudgmental way to elicit perceptions of safety. Asking if a partner is excited about a pregnancy is not a good screening question because many couples are not excited to learn of an unplanned pregnancy. However couples with healthy relationships eventually adjust. Having an arrest record and gun ownership do not automatically equate to having a history of violence.

On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate? a) "It is important that you do not try to get pregnant too soon." b) "Are you having a great deal of uterine pain?" c) "I am truly sorry you lost your baby." d) "Commonly spontaneous abortion means a defective embryo."

"I am truly sorry you lost your baby." Correct Explanation: The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I am truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a "yes-no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should not get pregnant again too soon is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond? a) "Let me check with your physician and get you something that will help you relax." b) "Pregnancy should be avoided until all of your testing is normal." c) "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." d) "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better."

"I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." Explanation: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.

In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement? a) "I did not fight him, but I guess I did the right thing because I am alive." b) "Suicide would be an easy escape from all this pain, but I could not do it to myself." c) "I wish they gave the death penalty to all rapists and other sexual predators." d) "I get so angry at times that I have to have a couple of drinks before I sleep."

"I get so angry at times that I have to have a couple of drinks before I sleep." Explanation: Use of alcohol reflects unhealthy coping mechanisms. The client's report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape. The client's acknowledging this indicates that she is aware that she made the right choice. Although suicidal thoughts are common, the statement that suicide is an easy escape but the client would be unable to do it indicates low risk. Fantasies of revenge, such as giving the death penalty to all rapists, are natural reactions and are a problem only if the client intends to carry them out directly

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the bargaining stage of grief is the one who states: a) "I don't care about anything. I have no energy." b) "Why did this have to happen to me?" c) "I do not believe I have this disease." d) "I just want to see my son have a family of his own."

"I just want to see my son have a family of his own." Correct Explanation: The client is expressing the bargaining stage of grief when the client tries to barter for more time, as in the statement, "I just want to see my son have a family of his own." The other statements are reflective of other stages of grief

A client states that her "life has gone down the tubes" since her divorce 6 months ago. Then, after she lost her job and apartment, she took an overdose of barbiturates so she "could go to sleep and never wake up." Which statement by the nurse should be made first? a) "Helplessness is common after losing a job. Are you having trouble making decisions?" b) "It seems as if your self-esteem has been affected by all your losses." c) "You sound hopeless about the future since your divorce." d) "I know you took an overdose of barbiturates. Are you thinking of suicide now?"

"I know you took an overdose of barbiturates. Are you thinking of suicide now?" Correct Explanation: The highest priority is assessing for suicide risk. When the client is safe, then the self-esteem, helplessness, and hopelessness issues can be addressed.

A client with antisocial personality disorder tells the nurse, "I punched the guy out because he deserved it, and then the cops arrested me." Which response would be most helpful to the client? a) "I would not do that again if I were you." b) "If you punch people out, you will get into trouble." c) "It is wrong to punch others." d) "Do not ever do that again; you are an adult."

"If you punch people out, you will get into trouble." Correct Explanation: Saying, "If you punch people out, you will get into trouble," helps the client by pointing out the negative consequences of his behavior. Clients with antisocial personality disorder are aggressive, impulsive, and reckless; engage in illegal activities; and lack guilt or remorse. The nurse teaches the client that there are consequences to his irresponsible behavior and that the way to stay out of trouble is to change his behavior. Saying, "It is wrong to punch others," is not helpful since the client does not feel guilt or remorse. Saying, "I would not do that again if I were you" or "Do not ever do that again," is authoritative and scolds the client without helping him.

After the physician has discussed euthanasia with a terminal client and his family, the nurse assesses their understanding of the topic. Which of the following statements by the family indicates that learning has occurred? a) "Allowing him to stop eating is a form of active euthanasia." b) "Passive euthanasia is taking specific steps to cause a client's death." c) "The doctor will give him a lethal dose of barbiturates." d) "It is alright to stop dialysis."

"It is alright to stop dialysis." Correct Explanation: Active euthanasia is taking specific steps to cause a client's death (lethal dose of barbiturates) and has been deemed both immoral and illegal in most states. Passive euthanasia is defined as withdrawing medical treatment (dialysis) with the intention of causing the client's death and is morally and legally justified. Allowing the client to stop eating would be a form of passive euthanasia

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs? a) "It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." b) "I know her well and am familiar with her issues. I think the best chance for success for her would be if she was adopted into my family." c) "She just needs someone who will love her and give her the things she has missed out on in life. An adoptive family needs to be found for her as soon as possible." d) "I am not sure she can get past all the loss and rejection she has experienced. I do not think adoption will ever be a viable option for her."

"It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Correct Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment.

A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I do not know why she did not keep the doors locked like I told her. I cannot believe she has had sex with another man now." The nurse should respond by saying: a) "Your wife needs your support right now, not your criticism." b) "It was not consensual sex. Let us see if your wife was physically injured." c) "Let us talk about how you feel. Maybe it would help to talk to other men who have been through this." d) "Maybe the doors were locked, but the man broke in anyway."

"Let us talk about how you feel. Maybe it would help to talk to other men who have been through this." Correct Explanation: The nurse should respond to the husband's needs and concerns and should offer support. Protecting or defending the wife against his criticism ignores the husband's needs.

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following? a) "Would you like us to complete HIV testing?" b) "Let's talk about this; do you want me to call a support person?" c) "Do you want the phone number for the National Sexual Assault Hotline?" d) "Do you want to discuss antipregnancy measures?"

"Let's talk about this; do you want me to call a support person?" Correct Explanation: The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial

The nursing student is learning how to care for clients whose death is expected within a limited period of time. Which of the following statements makes the faculty member believe the student has mastered this topic? a) "Health care personnel should not discuss the client's condition with the client's grieving family members." b) "Clients and their families should be told their diagnosis and prognosis without regard to cultural influences." c) "Competent clients do not have the right to refuse life-sustaining treatment." d) "Many clients know they have a terminal illness by picking up on nonverbal communication."

"Many clients know they have a terminal illness by picking up on nonverbal communication." Explanation: A terminal illness is an illness in which death is expected within a limited period of time. The nurse, and other health care professionals, are involved in discussions with these clients and their families. Many clients realize without being told that they have a terminal illness, picking up this knowledge from nonverbal communication by their families and health care professionals. Competent clients have the right to consent and/or refuse any and all medical treatment—even life-sustaining treatment. Cultural influences may dictate how much information is desired and which family members are to be informed. Health care personnel should be available to discuss the client's condition with family members and should offer support and care as the family begins the grieving process.

When the nurse asks a child suspected of being physically abused how his shoulder was hurt, he replies, "It was my fault. I was bad." What would be the nurse's best response? a) "You will have to behave better so this will not happen again." b) "Tell me what you did that made your father hurt you." c) "We will make you better, and we will not let your father do this to you again." d) "Perhaps it was not your fault. Can we talk about what happened?"

"Perhaps it was not your fault. Can we talk about what happened?" Explanation: Encouraging the abused child to talk about or play out events surrounding the "accident" can help the child and also provide assessment data. An abused child may feel self-blame. Even if the parent is accused of abuse, the child may still accept responsibility for the act. Asking the child to tell what he did to cause the abuse is inappropriate because it implies that the child is at fault and the problem. Telling the child that the nurse will not let the father hurt the child again is a promise that the nurse cannot keep. The nurse should never make promises that cannot be kept. The child is not at fault, and the child's behavior did not cause the abuse.

A 19-year-old client has undergone an examination and had evidence collected after being raped. Her father is overheard yelling at his daughter, "You are going to tell me who did this to you. What is his name?" Which is the nurse's best response? a) "If you do not stop yelling, I will have to call Security." b) "Stop yelling. You are being inappropriate." c) "Please be quiet. You are not helping your daughter this way." d) "Please come with me, sir. I need some important information."

"Please come with me, sir. I need some important information." Correct Explanation: With this level of anger in a crisis, the father needs simple but firm directions to leave the room, calm down, and then to talk. Doing so relieves the daughter of any pressure from her father. Telling the father to stop yelling or be quiet provides no concrete directions to the father and may embarrass him in front of his daughter. Telling the father that if he does not stop yelling, the nurse will call Security is a threat, possibly leading to an escalation of the situation

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? a) "It is a simple escape mechanism to go back and live again in happier times." b) "Be patient. It takes time to adjust to such a massive loss." c) "Reviewing your losses is a way to help you work through your grief and loss." d) "Talking about the past is a form of denial. We have to help you focus on today."

"Reviewing your losses is a way to help you work through your grief and loss." Correct Explanation: Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? a) "Talking about the past is a form of denial. We have to help you focus on today." b) "It is a simple escape mechanism to go back and live again in happier times." c) "Reviewing your losses is a way to help you work through your grief and loss." d) "Be patient. It takes time to adjust to such a massive loss."

"Reviewing your losses is a way to help you work through your grief and loss." Correct Explanation: Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling? a) "My daughter sent me here. She is mad because I do not have the energy to take care of my grandkids." b) "My son got worried because I made this silly comment about wanting to be with my husband in heaven." c) "My primary care provider just put me on an antidepressant, and I will be fine in a week or so." d) "Since I have gotten over the death of my husband, I have had more energy and been more active than before he died."

"Since I have gotten over the death of my husband, I have had more energy and been more active than before he died." Correct Explanation: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling

A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint? a) "I'm so clumsy." b) "I'm afraid I'll lose my job because I'm going to miss so much work." c) "Sometimes my husband gets so angry with me." d) "I'm going to need help at home after I'm discharged."

"Sometimes my husband gets so angry with me." Correct Explanation: Legally, the nurse must further investigate the client's statement concerning her husband's anger. This statement suggests that the client's injury might be caused by domestic abuse. The other statements are common and don't require further investigation, from a legal standpoint, by the nurse.

The new hospice nurse is reviewing the concepts of loss and grief with her preceptor. Which of the following statements leads the preceptor to believe that the nurse has an understanding of grief and loss? a) "People only experience grief when someone dies." b) "Elderly clients who are lamenting their loss of youth is demonstrating actual loss." c) "The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." d) "Clients can experience a sense of loss when their child leaves for college. This is a type of situational loss."

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." Explanation: Normal expressions of grief may be physical, emotional, social (feeling detached from others and isolating oneself from social contact), and spiritual. Grief is an internal emotional reaction to loss and occurs with loss caused by separation (e.g., divorce) or by death. Clients lamenting their loss of youth are demonstrating a type of perceived loss, which is intangible to others. Situational losses are experienced as a result of unpredictable events; a child going to college would be a maturational loss for the parent

An adolescent admitted for panic attacks tells the nurse that an uncle has been making sexual advances. The client begs the nurse to not say anything because of what the uncle may do. What should be the nurse's initial response? a) "You have a right not to report this, so I will not either." b) "The law requires me to make a report so you can be protected." c) "He can't hurt you here, and we'll make sure you're safe." d) "Have you told anyone else what is happening?"

"The law requires me to make a report so you can be protected." Correct Explanation: Although the nurse needs to maintain a therapeutic relationship, disclosure of potential sexual abuse supersedes confidentiality issues. It's appropriate for the nurse to reassure the adolescent that she'll be safe, but the nurse must first explain her responsibilities in relation to this disclosure. Asking the adolescent if she has disclosed this situation to anyone else is important, but the immediate priority is to report the abuse to the proper authorities within the time specified by law. The adolescent does not have the right to not report this abuse.

A client with advanced cancer makes the following comment to the nurse: "Why are you bathing me? I am going to die no matter what." What is the most appropriate response of the nurse? a) "A bath will make you feel better." b) "Do you want to skip the bath today?" c) "I can give you some medicine to make you feel better." d) "Would you like to talk about what you are feeling?"

"Would you like to talk about what you are feeling?" Explanation: By asking the client talk may open the door for further discussion and sharing of feelings, fears, etc. Statements A and B are matter-of-fact comments and disconnect, resulting in a shutdown to further communication. Statement D is a quick fix and demonstrates a nontherapeutic response

The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What is the use of living? My time is running out." What is the nurse's best response? a) "Life is precious and worth living." b) "Do not give up. There could be a cure for AIDS tomorrow." c) "Let us talk about making some good use of that time." d) "You are in a lot of pain. What are you feeling?"

"You are in a lot of pain. What are you feeling?" Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client. Telling the client to make good use of his remaining time diverts attention from the content of the client's statements and blocks expression of feelings. "Do not give up" is a type of pep talk that ignores the client's feelings. Saying that life is precious and worth living ignores the client's needs and inhibits his expression of feelings.

A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client's anger? a) "I know it's frustrating to wait. I'm sorry this happened." b) "I really care about you, and I'll never let this happen again." c) "You had to wait. Can we talk about how this is making you feel right now?" d) "If it had been your emergency, I would have made the other client wait."

"You had to wait. Can we talk about how this is making you feel right now?" Correct Explanation: This response may defuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Telling the client that if the situation was an emergency involving him other clients would have to wait wouldn't address the client's anger. Apologizing is incorrect because a client with a borderline personality disorder blames others for things that happen; apologizing reinforces his misconception that someone is at fault. The nurse can't promise that a delay will never occur again because such matters are beyond her control.

Critical factors for successful integration of loss during the grieving process are A the client's adequate perception, adequate support, and adequate coping. B the nurse's trustworthiness and healthy attitudes about grief. C accurate assessment and intervention by the nurse or helping person. D the client's predictable and steady movement from one stage of the process to the next.

A

Which type of child abuse can be most difficult to treat effectively? A Emotional B Neglect C Physical D Sexual

A

Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid? A If she tried to leave, she would be at increased risk for violence. B If she would do a better job of meeting his needs, the violence would stop. C No one else would put up with her dependent clinging behavior. D She often does things that provoke the violent episodes.

A

You are the nurse caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. You know that these clients would be classed as being victims of which of the following? a) A natural disaster b) A chemical disaster c) A biologic disaster d) A radiologic disaster

A biologic disaster Correct Explanation: Anthrax is a biologic agent that could be the cause of a biologic disaster, one in which pathogens or their toxins cause harm to many humans and other living species. Anthrax is not a natural, radiologic, or chemical agent of disaster.

While teaching about advance care planning, which fact is important for the nurse to share with a client who has been diagnosed with a terminal illness? a) The Patient Self-Determination Act of 1990 requires hospital clients to have an advance directive. b) Living wills provide specific instructions related to the client's personal property upon death. c) A durable power of attorney for health care appoints an agent the person trusts to make decisions. d) Advance directives must be completed 30 days prior to hospitalization in order to be valid.

A durable power of attorney for health care appoints an agent the person trusts to make decisions. Explanation: Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care if certain circumstances arise. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. In the United States, the Patient Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives. Advance directives do not have to be completed prior to hospitalization in order to be valid

Which of the following assessment findings would best support a nursing diagnosis of Dysfunctional Grieving? a) A man is unable to return to work after his sister's death 18 months ago. b) A woman has been experiencing chronic insomnia since her mother's death earlier this year. c) A man blames himself for not doing more to make his wife's recent death more comfortable. d) A woman cries frequently and loudly in the weeks following her child's death in an accident.

A man is unable to return to work after his sister's death 18 months ago. Correct Explanation: An inability to return to normal activities 18 months after a sibling's death is suggestive (though not definitive) of Dysfunctional Grieving. Crying and having difficulties sleeping are not unusual and will often accompany healthy grieving. A feeling of "not doing enough" is common during grief and would only be considered dysfunctional if this became a long-term and all-encompassing belief

A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care? a) Explain to the client that denial of the situation is unhealthy. b) Accept the client's denial of the situation. c) Correct the client's misconsceptions about the illness and treatment goals. d) Seek help from other health care team members to address the client's denial.

Accept the client's denial of the situation. Explanation: When working with terminally ill clients, nurses need to understand that denial is often a useful coping mechanism that enables the client to gain temporary emotional distance from a situation that is too painful to think about. Therefore, nurses must accept clients regardless of the degree to which they are in denial about their illness and work with other health care providers to present the same message. Consulting with other team members would be helpful to ensure that all members present the same information to the client. Denial is a coping mechanism and only becomes unhealthy if the client or family refuses to acknowledge a diagnosis or refuse to hear about treatment options. Correcting the client's misconceptions would disrupt the client's coping mechanism of denial and possibly lead to greater upset

A woman has responded to her recent diagnosis of lung cancer by making extensive plans for overseas travel with her children, despite the fact that her oncologist has informed her of her extremely poor prognosis. The patient is adamant that she does not want to discuss her cancer and the nurse consequently recognizes that the patient is likely in the denial stage of grief. How can the nurse best facilitate the patient's healthy grieving? a) Enlist the assistance of another nurse to help the patient face the reality of her situation. b) Address the patient's diagnosis and prognosis at a later time or date. c) Restate the patient's situation in more specific and detailed terms. d) Supplement conversations with the patient by using written material about her diagnosis.

Address the patient's diagnosis and prognosis at a later time or date. Explanation: In the absence of the patient's readiness to become more aware of her situation, the nurse should respect the patient's current position and revisit the matter when the patient is more ready. It is disrespectful, and likely counterproductive, to have others reiterate the message, to provide written material, or to increase the amount of detail if the patient is not ready to engage at this time.

A mother states that she is very angry with the health care provider (HCP) who diagnosed her child with leukemia. Which statement helps the nurse understand this mother's reaction? a) Anger is a natural result of a sense of loss and helplessness. b) Parents of sick children are usually unable to control their anger. c) The mother cannot overcome her anger in an acceptable manner. d) Anger is rarely demonstrated by parents when coping with a sick child.

Anger is a natural result of a sense of loss and helplessness. Correct Explanation: Anger is a natural result of feelings of loss and helplessness in normal, healthy people. It is a natural response to coping with a sick child. Nurses should recognize anger in clients and families. Parents are usually able to control their anger in a socially acceptable manner. Nurses can assist clients and families to overcome helplessness and anger in an acceptable manner.

The nurse overhears an older client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? a) Report the suspicions to to the authorities. b) Ask to examine the client alone in order to speak to her privately. c) Document the observed behaviors in the client's chart. d) Nothing, as it is none of the nurse's concern.

Ask to examine the client alone in order to speak to her privately. Correct Explanation: In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

A male client with a diagnosis of lung cancer is seen in the clinic for follow-up care. Which nursing interventions are essential to include in this client's plan of care to address his grief? (Select all that apply.) a) Assist the client to form a support system b) Promote good nutrition and sleep habits c) Urge the client to continue his usual routine d) Help the client establish coping strategies e) Encourage participation in religious rituals

Assist the client to form a support system • Help the client establish coping strategies • Promote good nutrition and sleep habits • Encourage participation in religious rituals Explanation: Nursing interventions used to help clients move through grief include helping the client mobilize a support system. The nurse can also help the client establish coping behaviors used in the past. Other interventions to include when helping clients move through grief are good nutrition and sleep habits. The nurse should encourage the client to participate in religious rituals important to the client. The nurse should not urge the client to continue his usual routine because it may not include healthy behaviors. For example, the nurse should not encourage use of alcohol, drugs, and caffeine during the grief process

To adequately assist a client and family from a different culture with the death and dying process, the nurse should: a) Experience death in his own life b) Progress through the stages of grief c) Have felt distress and anger d) Be aware of the client's cultural beliefs

Be aware of the client's cultural beliefs Correct Explanation: Nurses should be aware of the specific cultural and religious beliefs of the clients they are serving and help their clients deal with loss in a manner that is congruent with their cultural and religious beliefs and practices

Of the following terms, which is used to refer to the period of time during which mourning a loss takes place? a) Mourning b) Grief c) Bereavement d) Hospice

Bereavement Explanation: Bereavement is the period of time during which mourning a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group and cultural expressions of grief and associated behaviors. Hospice is a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill patients and their families.

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After her lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence her husband represents. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the nurse who witnesses this scene? a) Telling the client's husband that he must leave at once b) Calling a security guard and another staff member for assistance c) Remaining with the client and staying calm d) Determining why the husband feels so angry

Calling a security guard and another staff member for assistance Explanation: The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective in his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply. a) Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. b) Child molesters resort to molestation because they have bad childhoods, so understanding that can help them decrease their molesting. c) Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. d) Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret. e) Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention.

Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. • Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. • Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. • Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret. Explanation: Child molesters prey on teens or children that they have some authority over. Though some child molesters have had difficult childhoods in which they may have been molested, having them recognize that is not enough to keep them from offending again. Once trust is established, molesters push for a more sexual relationship, which they justify by pointing out what they have done to help the child. Child molesters prey on lonely children or those who spend a lot of time at home alone due to a working parent. They initially show interest and assist the child and family by measures such as providing rides, money, and homework help. If the child tries to stop the sexual interaction or appears ready to tell someone, molesters will use threats to maintain the secret.

A nurse is preparing an in-service education program to a group of nurses who are members of a disaster response team specializing in biologic weapons. Which of the following would the nurse include as the agent of choice when dealing with a mass casualty incident involving anthrax? a) Ciprofloxacin b) Erythromycin c) Gentamicin d) Penicillin

Ciprofloxacin Explanation: In mass casualty incidents involving anthrax, treatment with ciprofloxacin or doxycycline is recommended. Overall recommended agents for treating anthrax include penicillin, erythromycin, gentamicin, and doxcycline

Though smoking is prohibited on hospital property, a client with anti-social personality disorder smokes in the client lounge and refuses to follow other unit and hospital rules. The client gets others to do his/her laundry and other personal chores and refuses to work with nurses he/she doesn't like. The plan of care for this client should focus on which of the following? a) Consistently enforcing unit rules and facility policy b) Eliminating negative behaviors with behavior modification c) Engaging in power struggles until the client changes behaviors d) Isolating the client from easily manipulated clients

Consistently enforcing unit rules and facility policy Correct Explanation: Firmness and consistency regarding rules are the hallmarks of a plan of care for a client with personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.

A 9-year-old child presents to a school nurse with complaints of arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? a) Contact the authorities immediately. b) Arrange for a meeting with the nurse, psychologist, school administrators, and the child's parents. c) Contact an ambulance to transport the child to the emergency department. d) Arrange for the child to speak with the school psychologist as soon as possible.

Contact the authorities immediately. Correct Explanation: When a nurse suspects abuse, she must contact the authorities immediately. Although speaking with the school psychologist may be helpful, the nurse shouldn't delay contacting the authorities. A family meeting might provide additional information, but the nurse must allow the authorities to investigate suspected abuse before confronting the child's parents. Because the child isn't in imminent distress, there's no need for an ambulance

When the home care nurse visits a 78-year-old female patient who is recently widowed and finds that the home is cluttered with trash and the patient appears sad and disheveled, the nurse should assess the patient for symptoms of a) Fatigue b) Presbyopia c) Drug overdose d) Depression

Depression Correct Explanation: Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative.

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply. a) Despair b) Acceptance c) Peacefulness d) Anger e) Ambivalence

Despair • Ambivalence • Anger Correct Explanation: Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may quesion the meaning of suffering or life and express a sense of emptiness

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply. a) Despair b) Peacefulness c) Acceptance d) Ambivalence e) Anger

Despair • Ambivalence • Anger Correct Explanation: Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may quesion the meaning of suffering or life and express a sense of emptiness

A widow has just returned home from the funeral of her husband. She feels alone in her home. Her family has left to go back to their home in another area of the country. What stage of Engel's model does this represent? a) Restitution b) Shock and disbelief c) Resolving the grief d) Developing awareness

Developing awareness Correct Explanation: Developing awareness occurs as the reality and meaning of the loss penetrate the person's consciousness.

A client with a diagnosis of antisocial personality disorder has a potential for violence and aggressive behavior. Which short-term client outcome is most appropriate for the nurse to include in the plan of care? a) Discuss feelings of anger with staff. b) Ask the nurse for medication when upset. c) Use indirect behaviors to express anger. d) Use humor when expressing anger.

Discuss feelings of anger with staff. Correct Explanation: The nurse assists the client with identifying and putting feelings into words during one-to-one interactions. This helps the client express her feelings in a nonthreatening setting and avoid directing anger toward other clients. A client with an antisocial personality disorder needs to understand how others feel and react to her behaviors and why they react the way they do. The client also needs to understand the consequences of her behaviors. Using humor or indirect behaviors to express anger is a passive-aggressive method that will not help the client learn how to express her anger appropriately. Asking the nurse for medication when upset is a way to avoid dealing with feelings and is not helpful. However, medication may be necessary if talking and engaging in a physical activity have not been effective in lowering anxiety or if the client is about to lose control of her behavior

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond? a) Ask the client to discuss the decision with family members. b) Notify the physician of the client?s refusal. c) Discuss with the client the reasons for declining surgery. d) Review with the client the risks and benefits of surgery.

Discuss with the client the reasons for declining surgery. Explanation: The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete

A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!" Which nursing interventions would be appropriate? Select all that apply. a) Help the client express anger safely. b) Ask the client if he would like to attend a support group. c) Monitor the client's level of anger and potential aggression. d) Assist the client in processing his feelings about the sexual abuse. e) Discuss the client's attitude about going to jail after discharge.

Help the client express anger safely. • Assist the client in processing his feelings about the sexual abuse. • Ask the client if he would like to attend a support group. • Monitor the client's level of anger and potential aggression. Correct Explanation: Safety of others is a priority, and the nurse must monitor the client's anger and potential for aggression. The nurse should also find safe ways for the client to express the client's anger and any other feelings about the abuse. A referral to a support group is appropriate because anger management groups are one way to assist the client in learning to manage anger. Nothing about jail is mentioned in the question. Discussion of jail does not help the client address the client's issues with anger and the abuse causing the anger.

Which nursing action is most appropriate when trying to defuse a client's impending violent behavior? a) Placing the client in seclusion b) Leaving the client alone until he can talk about his feelings c) Helping the client identify and express feelings of anxiety and anger d) Diverting attention by involving the client in a quiet activity

Helping the client identify and express feelings of anxiety and anger Correct Explanation: In many instances, a nurse can defuse impending violence by helping a client identify and express feelings of anger and anxiety. Such statements as "What happened to make you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. The danger of an agitated and potentially violent client acting out is too great for him to be left alone or unsupervised. The client should be placed in seclusion only if other interventions fail or the client requests it. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and gives them a feeling of security.

The wife of a man who is dying tells the nurse: "Harold was so good to me. He was like a saint with his patience. I will miss him terribly" Which stage of grief is this woman experiencing, according to Engel? a) Restitution b) Idealization c) Outcome d) Awareness

Idealization Explanation: Idealization is the exaggeration of the good qualities that the person or object had, followed by acceptance of the loss and a lessened need to focus on it. Restitution involves the rituals surrounding loss—with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying. Outcome, the final resolution of the grief process, includes dealing with loss as a common life occurrence

Your client, the mother of three young children, has been diagnosed with stage III breast cancer and is distraught. Which of the following statements best communicates a spirit of hopefulness to your client? a) I believe that you will fight hard to beat this and see your babies grow up. b) Let's take this one day at a time; remember you have your daughter's dance recital next month. c) You should seek a second medical opinion about your diagnosis. d) I know another client with the same diagnosis who's been in remission for 10 years.

Let's take this one day at a time; remember you have your daughter's dance recital next month. Correct Explanation: Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. This statement is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Althoughthe client may choose another medical opinion, she needs to come to that decision without the nurse's advice. This response conveys false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism

A nurse is providing care to a client who has just been diagnosed with a terminal illness. Which of the following would be most appropriate for the nurse to do? a) Attempt to help the client make decisions about care. b) Listen nonjudgmentally while allowing time for client reflection. c) Engage the client in conversation to provide distraction. d) Explain to the client that the nurse understands how he or she must feel.

Listen nonjudgmentally while allowing time for client reflection. Correct Explanation: A client needs time to adjust to and cope with the information that he or she has just learned. The nurse's most appropriate action is to listen effectively, without making any judgments or attempting to solve the client's problems. Engaging the client in conversation and telling the client the nurse understands do not address the client's needs at this time. The client needs time to make sense of the information before he or she makes and decisions

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? a) Kidneys b) Stomach c) Large intestine d) Liver

Liver Explanation: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

The nurse is discussing end-of-life decisions with a patient who has terminal cancer. Which statements describe the patient's options? (Select all that apply.) a) Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. b) The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. c) Nurses are legally responsible for arranging for a durable power of attorney for all terminal patients. d) Legally, all attempts must be made by the health care team to resuscitate a terminal patient. e) The status of advance directives varies from state to state. f) In a living will, a patient appoints an agent that he or she trusts to make decisions if he or she becomes incapacitated.

Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. • The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. • The status of advance directives varies from state to state. Explanation: Advance directives, including living wills, helps the patient to make decisions concerning their end-of-life care. Appointing an agent for care involves identifying a durable power of attorney for healthcare, which is the responsibility of the patient, family, or significant others. If a patient has advance directives, resuscitation is not warranted.

The emergency department (ED) nurse accepts an unconscious client brought in by ambulance. The client's family presents a durable power of attorney for health care for the client. Which of the following actions should the nurse take? a) Communicate to other ED staff that there should be no attempts to resuscitate the client b) Obtain contact information for the person designated to make decisions for the client c) Initiate active euthanasia d) Initiate a slow code in the case of cardiopulmonary or respiratory arrest

Obtain contact information for the person designated to make decisions for the client Correct Explanation: Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care should certain circumstances develop. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. In this case of an unconscious client, the nurse would want to obtain contact information for the person designated by the client as decision maker. The durable power of attorney does not give direction regarding medical care (the other options).

A nurse is making a follow-up phone call to a client who reported being raped. The client answers the phone and states, "I don't know what you are talking about. I have never been raped." What action should the nurse take? a) Apologize and end the phone call. b) Report the statements to the police department. c) Provide a detailed account of what the client stated when reporting the event. d) Offer support, recognizing that the client may be using repression as a defense mechanism.

Offer support, recognizing that the client may be using repression as a defense mechanism. Correct Explanation: The defense mechanism of repression allows the individual to remove the situation that causes anxiety from his or her consciousness. Give the client support information such as a phone number to a rape intervention hotline or local support chapter. Ending the phone call and reporting the statements to the police without investigating the possible use of repression would be inappropriate. Providing a detailed account of the event per the client's statements may cause increased stress or anxiety, which would be better handled in a face-to-face situation.

Even though several teaching sessions have been documented in the client's health record, the mother asks the nurse again what caused her child's phenylketonuria (PKU). Which statement would best reflect the nurse's interpretation of why the mother keeps asking for information that she has already received? a) Parents of a chronically ill child commonly require a long time to work through the grieving process for their child's disease. b) Parents commonly deal with their guilt about possibly causing their child's disease by asking challenging questions. c) Parents commonly test health workers' knowledge about the causes of and treatments for their child's disease. d) Because the child's condition is chronic, parents commonly want very detailed explanations about the causes of and treatments for their child's disease.

Parents of a chronically ill child commonly require a long time to work through the grieving process for their child's disease. Correct Explanation: PKU is considered a chronic illness. Parents typically grieve about the loss of health in their child afflicted with a chronic disease. Many times, they repeat questions, as though trying to deny what is really happening. This type of behavior represents an attempt to integrate the experience and their feelings with their self-image as they pass through the grieving process. Asking for detailed explanations, testing the competence of health workers, and expressing impatience with health workers may explain the parents' behavior, but viewing the behavior as a part of the grieving process is the most plausible explanation.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? a) Providing care to the injured b) Protecting himself or herself c) Securing the area d) Gaining control of the situation

Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured

What is the most important goal of care for the dying client who is receiving comfort care? a) Providing a comfortable, dignified death b) Identifying appropriate coping mechanisms c) Using a feeding tube to provide nutrition d) Ensuring family members are present at the bedside

Providing a comfortable, dignified death Correct Explanation: Clients or their surrogates may request a comfort-measures-only order, which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. Using a feeding tube and identifying appropriate coping mechanisms are not characteristics of comfort care. The presence of family members at the bedside is important for any dying client and is not specific to comfort care

What is the primary role of the nurse in the care of clients that experience domestic violence? a) Providing prompt recognition of the potential or actual threat to safety b) Identifying health education and counseling measures for the family c) Serving as a witness in court d) Calling the police

Providing prompt recognition of the potential or actual threat to safety Correct Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

A client who is a victim of domestic violence tells the nurse she is contemplating leaving the relationship. Which assessment should be a priority for the nurse? a) Use of drugs or alcohol to cope with victimization b) Readiness to leave the perpetrator and knowledge of helpful resources c) Reasons for remaining in the abusive relationship d) History of previous victimization

Readiness to leave the perpetrator and knowledge of helpful resources Correct Explanation: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses may then provide the victims with information and options to enable them to leave when they're ready. The reasons victims remain in violent relationships are complex and can be explored at a later time. Victims may use drugs or alcohol to cope with victimization, but this isn't the priority assessment at this time. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships

The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful? a) Refer her to a group for survivors of suicide. b) Encourage her to receive counseling from a chaplain. c) Suggest she receive individual therapy by the nurse. d) Provide her with the local suicide hotline number.

Refer her to a group for survivors of suicide. Correct Explanation: The survivor of suicide, in this situation, would be referred to a group for survivors of suicide to help her with her feelings and to work through the grief reaction. This group provides support and understanding of what the individual is experiencing by members who are experiencing similar reactions, including anger and guilt. Depression and unresolved grief can occur when the survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline number would be appropriate if the survivor herself were thinking about suicide

A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care? a) Referral for bereavement counseling b) Decreased need for pain medications c) Decreased need for antidepressant medication d) Decreased need for nutritional supplementation

Referral for bereavement counseling Correct Explanation: Referral to a bereavement counselor may help the client and his family make decisions about unfinished business. This client should continue to receive pain medications, antidepressants, and nutritional therapy at home and in the hospice setting. It isn't appropriate to decrease these comfort measures

After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which statement offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death? a) It is more difficult for relatives to accept the death of an older child than that of a toddler. b) Relatives are especially grieved when a child does well at first but then declines rapidly. c) Knowing that the prognosis is poor helps prepare relatives for the death of children. d) Trust in health care personnel is most often destroyed by a death that is considered untimely.

Relatives are especially grieved when a child does well at first but then declines rapidly. Explanation: It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child's death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more difficult for parents to accept the death of an older child than that of a younger child

A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of his head, and multiple 1-cm round scabs and blisters on his upper back. The parents state that their child sustained the injuries by falling out of his high chair. What is the best action for the nurse to take? a) Refer the child and the family to social services for follow up. b) Document the suspected child abuse in the child's medical record. c) Report the suspected child abuse to Child Protective Services. d) Ask the physician to question the parents about the suspected child abuse.

Report the suspected child abuse to Child Protective Services. Correct Explanation: The physical function of the family is to provide a safe environment necessary for growth and development. The child's injuries (fractured femur with head injury and 1-cm round scabs and blisters on the upper back) suggest physical abuse by slamming the child into a wall while holding on to his leg, along with cigarette burns. All suspected cases of abuse must be reported to the appropriate agency or authority. Failure to report suspected child abuse is considered nursing negligence. Documenting "suspected abuse" in the client's record is inappropriate. Only the objective physical findings and observations should be documented. Referring the family for follow-up care to social services does not satisfy the legal obligation to report the suspected crime of child abuse to the proper authorities. Asking the physician to question the parents about the suspected abuse can jeopardize the child's safety by alienating the parents and creating distrust between the parents and the healthcare providers.

During the admission assessment of a 40-year-old female patient with a suspected mandibular fracture, the patient discloses to the nurse that her injury came as a result of her husband hitting her. Which of the following actions should the nurse prioritize when responding to this disclosure? a) Reporting the abuse to the appropriate authorities b) Informing the patient of her right to keep this information private c) Performing an assessment to confirm the patient's statement d) Ensuring the patient's statement is confirmed by another nurse

Reporting the abuse to the appropriate authorities Correct Explanation: Nurses have a legal and ethical obligation to report cases of abuse. It would be inappropriate and likely unethical to require a third party witness to the statement or to withhold action pending assessment results. The nurse's obligation to report abuse legally supersedes the patient's right to privacy

A nurse is assessing a client and attempting to differentiate if the client is experiencing grief or depression. Which of the following would the nurse identify as indicative of grief? a) Feelings of worthlessness b) Sleep problems c) Self-blame d) Weight changes

Self-blame Explanation: Blaming one's self or others is characteristic of grief. Sleep problems occur with depression and grief. Weight gain or loss and feelings of worthlessness are associated with depression

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury? a) Urinalysis b) White blood cell count c) Hemoglobin and hematocrit d) Serum amylase

Serum amylase Correct Explanation: Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding

A father asks the nurse who is caring for his 13-year-old daughter why his daughter might be doing poorly on school work lately and why she is distancing herself from friends and family. As the nurse, you consider which of these possibilities to be the priority risk? a) She has lost interest in academics because she has a boyfriend now. b) She may be developing nutritional deficiencies from poor dietary habits. c) She may be beginning her menses. d) She may be the victim of cyber-bullying.

She may be the victim of cyber-bullying. Correct Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health complaints, isolating oneself from peers/friends, and increased anxiety and/or depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time

Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse? a) BMI 24; "My family never gives me my favorite foods." b) Diabetic with fasting blood sugar 92; "It is difficult to afford food with all of these medication costs." c) Obvious deformity to right arm; "I tripped on the rug and fell on my arm." d) Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore."

Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." Explanation: Neglect is the most common form of elder abuse. The inability of an older adult to obtain basic care is considered neglect. If a patient is not being turned or repositioned to prevent skin breakdown, then neglect is happening. A BMI of 24 is within the normal range and the inability of the patient to have his or her favorite foods would not be abuse. The patient with diabetes blood sugar is within normal ranges and the patient is only expressing concerns over the cost of medications; social services may need to be notified to provide help through community resources. The story provided by the older adult with the deformed arm is consistent with the injury

The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder? a) Clients may eat anything that is facility prepared. b) A security guard is present at the door. c) Suicide precautions are instituted. d) Clients may come and go as they desire.

Suicide precautions are instituted. Correct Explanation: Clients with anxiety disorders including panic disorder are at risk for suicide because they can be impulsive. Unit standards include maintaining suicide precautions. Nutritional problems do not typically accompany panic disorder and family can bring in client requests. Clients, depending on their status, typically remain on the unit; however, while there is facility security, there is no guard at the unit door.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? a) Performing the pelvic examination b) Obtaining consent for examination c) Supporting the client's emotional status d) Collecting semen

Supporting the client's emotional status Correct Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present

The family of a patient with a severe traumatic brain injury is considering the withdrawal of his mechanical ventilation. What is the nurse's primary role in the preparation for terminal weaning? a) Assisting with chest physiotherapy before and after ventilation ceases b) Teaching the family what to reasonably expect after ventilation is discontinued c) Preparing the bedside for postmortem care d) Assisting with pulmonary resuscitation if the patient is unable to breathe independently

Teaching the family what to reasonably expect after ventilation is discontinued Correct Explanation: The nurse's role surrounding terminal weaning is to educate and assist as needed in the decisional process. It would be premature and possibly upsetting to prepare the bedside in anticipation of postmortem care. Chest physiotherapy and resuscitation would not typically be attempted in cases of terminal weaning

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? a) The physician, so he can provide education about HELLP syndrome b) The chaplain, because his educational background includes strategies for handling grief c) The human resource director, so she can arrange vacation time for the staff d) The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff

The chaplain, because his educational background includes strategies for handling grief Correct Explanation: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate

The oncology nurse is learning to care for dying clients. Which of the following ideals should guide the nurse in facilitating a good death for these clients? (Select all that apply.) a) Care for dying clients should focus on pharmacologic relief of pain. b) The characteristics of a good death vary for each client. c) A good death is one that allows a person to die on his or her family's terms. d) Independence and dignity are central issues for many dying clients. e) The care of the dying client should be guided by the values and preferences of the nurse.

The characteristics of a good death vary for each client. • Independence and dignity are central issues for many dying clients. Correct Explanation: A good death is one that allows a person to die on his or her own terms. Independence and dignity are central issues for many dying patients. The characteristics of a good death vary for each client. The care of a dying client should be guided by the values and preferences of the individual. Care for dying clients should focus on the relief of symptoms, not limited to pain, and should use both pharmacologic and nonpharmacologic means

When talking with 10-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. a) Logical explanations are not appropriate. b) The children will know that death is inevitable and irreversible. c) Telling children that death is the same as going to sleep as a way of relieving fear is appropriate. d) The children will be curious about the physical aspects of death. e) Teaching about death and dying should not start before age 11 years. f) Attitudes of the adults in their lives will influence the children.

The children will be curious about the physical aspects of death. • The children will know that death is inevitable and irreversible. • Attitudes of the adults in their lives will influence the children. Explanation: By age 10 years, most children know that death is universal, inevitable, and irreversible. School-age children are curious about the physical aspects of death and may wonder what happens to the body. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. The adults in their environment influence their attitudes toward death. Adults should be encouraged to include children in the family rituals and should be prepared to answer questions that might seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

A nurse is providing end-of-life care to a client at a health care facility. The client is anticipating death. The nurse understands that the client is in the acceptance stage of dying. Which of the following indicates that the client is in the acceptance stage of dying? a) The client gets into arguments with the health care personnel. b) The client hopes to live long enough to see his daughter settled in life. c) The client wants to get a second opinion on the diagnostic reports. d) The client has settled all financial matters for his surviving family members.

The client has settled all financial matters for his surviving family members. Correct Explanation: The client is in the acceptance stage of dying, because the client has settled all financial matters for his surviving family members. The client who hopes to live long enough to see his daughter settled in life is in the bargaining stage of dying, trying to bargain for more time. A client in the second stage of dying, which is anger, gets into arguments with the health care personnel; it is an emotional response to feeling victimized. A client who wants to get a second opinion on the diagnostic reports is in the denial stage of dying.

A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach? a) The client is imminently suicidal. b) The client's medication dosage is too high. c) The client is improving. d) The client is overstimulated.

The client is imminently suicidal. Correct Explanation: When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from ambivalent thoughts about suicide and that the client has an immediate plan for killing himself

A nursing diagnosis of "Complicated grieving" has been identified for a client whose spouse died one year ago. What assessment data would be appropriate evidence to justify this diagnosis? (Select all that apply.) a) The client no longer indulges in his usual activities. b) The client attempted suicide one month ago. c) The client keeps a picture of his wife at the bedside. d) The client states, "I have no interest in doing anything." e) The client states, "I miss my wife every day."

The client no longer indulges in his usual activities. • The client attempted suicide one month ago. • The client states, "I have no interest in doing anything." Explanation: Still grieving the loss of his wife after one year is a normal manifestation of grief. Keeping a picture of his wife is also normal. No longer indulging in usual activities, attempting suicide, and stating that he has no interest in doing anything are signs of depression and unresolved grief

A client diagnosed with advanced lung cancer has a nursing diagnosis of ineffective coping. What assessment data would provide evidence to the nurse for this diagnosis? a) The client asks about hospice services. b) The client makes funeral plans. c) The client states, "I hope that I am able to attend my daughter's wedding." d) The client states, "I am sure the doctors have misdiagnosed me."

The client states, "I am sure the doctors have misdiagnosed me." Correct Explanation: Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.

The nurse is caring for a client who was divorced from her spouse 2 weeks ago. The nurse identifies a possible nursing diagnosis of "Risk for loneliness." What assessment data would lead the nurse to revise the nursing diagnosis? a) The client states, "Now that I am divorced, I will have to work two jobs just to pay my bills." b) The client states, "I can't believe that he divorced me after 20 years of marriage." c) The client states, "I feel like I can finally get along with my life now that the divorce is final." d) The client states, "I am afraid that I have been drinking too much just to fill my time."

The client states, "I feel like I can finally get along with my life now that the divorce is final." Explanation: The client's statement of being able to continue with her life now that the divorce is final evidences that the client views the finality of the divorce as a relief. Since the client is eager to move on, the nurse would lead the nurse to decide that "Risk for loneliness" is inappropriate in this case. The client's statement of disbelief, alcohol abuse, and financial difficulties indicate difficulty in coping with the divorce and would provide more evidence for the diagnosis

A nursing diagnosis of "Complicated grieving" has been identified for a client whose spouse died one year ago. What assessment data would be appropriate evidence to justify this diagnosis? (Select all that apply.) a) The client states, "I have no interest in doing anything." b) The client attempted suicide one month ago. c) The client states, "I miss my wife every day." d) The client no longer indulges in his usual activities. e) The client keeps a picture of his wife at the bedside

The client states, "I have no interest in doing anything." • The client attempted suicide one month ago. • The client no longer indulges in his usual activities. Correct Explanation: Still grieving the loss of his wife after one year is a normal manifestation of grief. Keeping a picture of his wife is also normal. No longer indulging in usual activities, attempting suicide, and stating that he has no interest in doing anything are signs of depression and unresolved grief.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially? a) The client will identify two positive qualities. b) The client will explore her strengths. c) The client will discuss her feelings related to her losses. d) The client will prioritize problems.

The client will discuss her feelings related to her losses. Correct Explanation: The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other childbirths were like this." Which factor is most important for the nurse to consider when responding to the client? a) This type of birth was necessary to save the client's life. b) The client's feeling of grief is a normal reaction. c) The client will most likely have postpartum blues. d) Maternal-infant bonding is likely to be difficult.

The client's feeling of grief is a normal reaction. Correct Explanation: Feelings of loss, grief, and guilt are normal after a cesarean birth, particularly if it was not planned. The nurse should support the client, listen with empathy, and allow the client time to grieve. The likelihood of the client experiencing postpartum blues is not known, and no evidence is presented. Although maternal-infant bonding may be delayed owing to neonatal complications or maternal pain and subsequent medications, it should not be difficult. Although the nurse is aware that this type of birth was necessary to save the client's life, using this as the basis for the response does not acknowledge the mother's feelings.

A patient who was brought to the emergency room for gunshot wounds dies in intensive care 15 hours later. Which statement concerning the need for an autopsy would apply to this patient? a) The physician should be present to prepare the patient for an autopsy. b) The closest surviving family member should be consulted to determine whether an autopsy should be performed. c) An autopsy should not be performed because the nature of death has been established. d) The coroner must be notified to determine the need for an autopsy.

The coroner must be notified to determine the need for an autopsy. Explanation: If death is caused by accident, suicide, homicide, or illegal therapeutic practice, the coroner must be notified, according to law. The coroner may decide that an autopsy is advisable, and does not need the permission of the family for the autopsy to be performed. The physician does not need to be present during the autopsy, only the designated person performing the autopsy (medical examiner or pathologist)

Which of the following does not coincide with Kübler-Ross's stages related to a dying client? a) The dying client usually exhibits anger first. b) Some client regress, then move forward again. c) The client may be in several stages at once. d) Clients don't always follow the stages in order.

The dying client usually exhibits anger first. Correct Explanation: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the neonate's father seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which interpretation of his behavior is most appropriate? a) The father is exhibiting diplaced anger at the nursing staff. b) The father needs antidepressants. c) The father has depression because of grieving. d) The father denies the seriousness of his child's condition.

The father has depression because of grieving. Explanation: During the depression stage of grief, hopelessness, powerlessness, and despair are common. Some depressed people put their feelings into words; others withdraw, becoming noncommunicative and indicating a wish to be left alone. A parent in denial would postpone recognizing the child's condition and attempt to ignore its reality or seriousness. A parent in the anger stage would exhibit resentment, bitterness, or rage and might blame the health care team for the child's condition. There is no indication that the neonate's father needs antidepressants

A nurse is caring for a client with vertigo. During data collection, the nurse finds multiple bruises on the client's arms and back; and suspects the client is being abused. When questioned, the client denies any abuse by the daughter she lives with. Despite the client's denial, which rationale would the nurse use for reporting the suspected abuse? a) The client does not want anyone to know what is happening in her home. b) The nurse has a legal and ethical responsibility to report the suspected abuse. c) The nurse wants her peers to see her as a hero. d) The client is ashamed to admit that her daughter is beating her.

The nurse has a legal and ethical responsibility to report the suspected abuse. Correct Explanation: Nurses are legally and ethically responsible to report suspected abuse. Because nurses are legally obligated, it does not depend upon the client?s fear or reluctant to report the abuse. Being labeled a hero is not the correct rationale for reporting suspected abuse.

A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply. a) The child does not fully understand the concept of death. b) The child is thinking about the future and knows he may not be able to participate. c) The death of a child may have long-term disruptive effects on the family. d) The parents may be at different stages in dealing with the child's death. e) Whispering in the child's room will help the child to cope. f) The dying child may become clingy and act like a toddler.

The parents may be at different stages in dealing with the child's death. • The child does not fully understand the concept of death. • The dying child may become clingy and act like a toddler. • The death of a child may have long-term disruptive effects on the family. Correct Explanation: When dealing with a dying child, parents may be at different stages of grief at different times. The child may regress in behaviors. The stress of a child's death commonly results in divorce of parents and behavioral problems in siblings. Preschoolers see illness and death as a form of punishment. They fear separation from parents and might worry about who will provide care for them. Preschoolers have only a rudimentary concept of time; thinking about the future is typical of an adolescent facing death, not a preschooler. Whispering in front of the child only increases fear of death

A nurse is developing a teaching plan for a terminally ill client and his family about about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? a) Each client experiences each of the stages. b) Most clients reach acceptance by the time of death. c) Typically, the stages occur in succession. d) The stages are applicable to any loss.

The stages are applicable to any loss. Explanation: The five stages of dying describe the five emotional reactions applicable to the experience of any loss. Not every client or family member experiences every stage. Many clients never reach a stage of acceptance. Clients and family fluctutate on a sometimes daily basis in their emotional responses

Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate? a) Most clinicians are very open to talking about disease and dying with clients. b) There remains a conspiracy of silence about dying despite progress in the area. c) Clients, for the most part, would gain hope if they were told about a poor prognosis. d) Clients would ask for information if they really had a desire to know.

There remains a conspiracy of silence about dying despite progress in the area. Correct Explanation: Despite the progress on many fronts associated with attitudes toward death and dying, there still is a belief in a conspiracy of silence about dying. Although a growing number of clinicians are becoming more comfortable with assessing clients' and famlies' information needs, many still avoid the topic in the hope that the client will ask or find out on his or her own. In addition, there are misconceptions that clients would subsequently lose all hope, give up, or be psychologically harmed by disclosure of a serious or terminal illness and that clients would ask for information if they really wanted to know

The husband of a patient who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing? a) Inhibited grief b) Normal grief c) Unresolved grief d) Anticipatory grief

Unresolved grief Correct Explanation: In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life and the meaning of death)

You are the nurse who is caring for 42-year-old Jack, who is admitted after taking an overdose of sleeping pills. He is withdrawn and declines to eat or engage in conversation, except to say he is a failure at everything. You are aware that potential causes of poor self-concept at this age can be related to which of the following? Choose all that apply. a) Failure to accept role responsibility b) Failure to develop meaningful goals c) Inability to resolve child versus adult roles d) Inability to accept bodily changes e) Unsatisfying career choice

Unsatisfying career choice • Failure to accept role responsibility • Failure to develop meaningful goals Explanation: The adult can have poor self-concept related to failure to accept role responsibilities, such as parenting or failure to develop meaningful goals and therefore just drifting through life. An unsatisfying career or job can also cause an adult to have a poor self-concept

A nurse is working with a dying client and the client's family. Which communication technique is most important to use? a) Avoid asking for more information from the client and family members. b) Allow the family to initiate communication when they are ready. c) Offer the family different coping mechanisms. d) Use active listening and silence when communicating.

Use active listening and silence when communicating. Correct Explanation: When working with a dying client and the client's family, the nurse should use active listening and silence to assess their feelings, coping skills, and immediate and long-term needs. Active listening also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client or family on the defensive. Initiate the conversation whenever possible and assess the family and client's coping mechanisms, including what has worked for them in the past. If the nurse is uncertain how to respond, the nurse should ask for more information or clarification from the family not avoid speaking to them

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client? a) lights that can be dimmed from outside the room b) a security window in the door or a room camera c) a staff member to stay in the room with the client d) a prescription for the seclusion before it is initiated

a security window in the door or a room camera Explanation: When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated

A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which response? a) a phase of rebellion b) a reaction to sensory overload c) a response to too much attention d) a stage of grief reaction

a stage of grief reaction Correct Explanation: After a catastrophic injury, individuals commonly experience grief. Initially, the person experiences denial, the most common response. With gradual awareness of the situation, anger commonly occurs. The child is demonstrating anger, not rebellion, as he gradually becomes aware of his situation. Rebellion is the child's way to maintain autonomy and individuality. It is a reaction to rigid rules. Examples include refusing to follow a treatment protocol when the child had no input and running away. Sensory overload would cause the child to be irritable and tired and to have difficulty sleeping. Too much attention usually would lead to irritability, difficulty sleeping, and mood swings

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." The nurse should: a) contact the primary care provider for advice related to the client's visitation. b) allow the client to see the baby through the nursery window. c) tell the client that it would be best if she did not see the baby. d) allow the client to see and hold the baby for as long as she desires.

allow the client to see and hold the baby for as long as she desires. Correct Explanation: The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the primary care provider and social worker. Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client. Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby. Contacting the primary care provider for advice related to the client's visitation is not necessary.

When developing appropriate assignments for the staff, which client should the nurse manager judge to be at highest risk for suicide completion? a) a 15-year-old girl of African descent whose boyfriend broke up with her b) a 52-year-old Asian man who was terminated from his job because of downsizing c) an 85-year-old Caucasian man who lives alone after his wife's death d) a 34-year-old single Latino woman who has recently been diagnosed with cancer

an 85-year-old Caucasian man who lives alone after his wife's death Correct Explanation: High-risk factors that have been related to suicide include hopelessness, Caucasian race, male gender, advanced age, living alone, previous suicide attempts, family history of suicide attempts, family history of substance abuse, general medical illnesses, psychosis, and substance abuse. The highest suicide rate is among people over the age of 65, particularly Caucasian males age 85 and over. Psychiatric diagnosis is considered to be the most reliable factor for suicide, especially for those with depression, schizophrenia, and substance disorders. Therefore, an 85-year-old Caucasian male who lives alone after his wife's death is at high risk for suicide completion

The client who is in end stages of cancer is requesting spiritual support. The nurse should: a) inform the family and ask for their suggestions. b) help the client reflect on past accomplishments. c) ask the client what spiritual activities would be most helpful. d) call a chaplain and set up an appointment for spiritual guidance.

ask the client what spiritual activities would be most helpful. Explanation: It is important to allow the client to choose his or her own form of spiritual support and the nurse can begin by asking the client what would be most supportive now. The client must be consulted before referral to a chaplain is made. Reflection on past accomplishments may be comforting to the client, but it does not directly address spiritual concerns. The client is able to communicate with the nurse, and discussing the conversation with the family does not respect the client's right to privacy

A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should first: a) refer the family to pastoral care services. b) suggest that the health care provider (HCP) tell the children about the seriousness of their mother's illness. c) begin education about strategies for communication with his children. d) encourage the husband to come to terms with his own grief.

begin education about strategies for communication with his children. Explanation: Without clear, consistent communication, the parent-child relationship may become strained during the illness and subsequent death of a parent. A great number of parents do not know how to communicate with their children, especially about difficult emotional topics at a time when they are also under great emotional stress. The nurse should begin by providing information and developmentally appropriate books about the grieving process for children. Referral to pastoral care services may be appropriate; however, the nurse's direct intervention of beginning education about strategies for communication will be of immediate and long-term benefit. The grieving process cannot be rushed for the husband, nor should an opportunity for the father and children to communicate and grieve together be delayed. Excluding children from participating in the grieving ritual does not shield them from the sorrow and sadness, and having the HCP tell the children does not promote health communication between the father and the children

The most cost-effective suggestion for bereavement support for the hospice nurse to give a woman whose husband died 3 months ago and her three young children would be to: a) seek group counseling support for the three children. b) request individual counseling and medication to manage depression. c) remind her gently that bereavement care before death minimizes grieving. d) continue her bereavement support through hospice.

continue her bereavement support through hospice. Explanation: Bereavement support after death usually continues for about 1 year or as needed at little or no cost to the remaining family. Mutual support groups by nonprofessionals are usually free or inexpensive but are not necessarily appropriate for young children. Professional individual counseling and medication are expensive, and medication may not be appropriate for young children. To remind someone of what she should have done before the death is not helpful at this time.

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether the client wants to file a report, the nurse's next priority is to offer which intervention to the client? a) crisis intervention b) legal assistance c) medication for disturbed sleep d) a rape support group

crisis intervention Explanation: The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol

At an emergency shelter, an earthquake victim tells the nurse that he is going to spend the night in his own bed at home. Which defense mechanism is the client exhibiting? a) denial b) intellectualization c) undoing d) rationalization

denial Correct Explanation: Denial is an unconscious refusal to admit an unacceptable idea or behavior. It protects the client in this crisis situation by blocking out the earthquake from conscious awareness.

When obtaining a nursing history from parents who are suspected of abusing their child, which characteristic about the parents should the nurse particularly assess? a) ability to relate the child's developmental achievements b) attentiveness to the child's needs c) self-blame for the injury to the child d) difficulty with controlling aggression

difficulty with controlling aggression Explanation: Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information

When obtaining a nursing history from parents who are suspected of abusing their child, which characteristic about the parents should the nurse particularly assess? a) ability to relate the child's developmental achievements b) self-blame for the injury to the child c) difficulty with controlling aggression d) attentiveness to the child's needs

difficulty with controlling aggression Explanation: Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information

A client who comes to the crisis center in a very distressed state tells the nurse, "I just cannot get over being fired last week. I have asked for help. I have talked to friends. I have tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use? a) unemployment assistance b) referral for counseling c) support system assessment d) emotion management

emotion management Explanation: Letting the client express his feelings (emotion management) is essential before trying to solve the problem or deciding what kind of referral is appropriate. A referral for counseling, assessment of the client's support system, and unemployment assistance may be appropriate after the client's anxiety is reduced

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? a) giving the child's drawings to the abuser b) reporting the abuse to a prosecutor c) engaging in play therapy d) role-playing

engaging in play therapy Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is mandatory, but does not help the child express feelings. (less)

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: a) ask the client if her family agrees with her decision. b) contact the client's minister to discuss the client's options related to the pregnancy. c) advise the client that the prolonged neonatal death will be very painful for her. d) explore the nurse's own feelings about the issues of anencephaly and organ donation.

explore the nurse's own feelings about the issues of anencephaly and organ donation. Correct Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some of these infants live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy. Contacting the client's minister to explore the client's options is not appropriate. As a devout Baptist, the client probably has already discussed the matter with her minister. Telling the client that the neonatal death will be prolonged and painful to her is not helpful. Death may occur very soon after birth. Asking the client about her family's opinion does not help the support the client's decision.

A client who has been physically abused by her spouse agrees to meet with the nurse. Before the nurse terminates the meeting with the client, the nurse should: a) advise the client to leave her husband. b) give the client the telephone numbers of a shelter or a safe house and the crisis line. c) tell the client not to do anything that could upset her husband. d) ask the client what she could do to de-escalate the situation at home.

give the client the telephone numbers of a shelter or a safe house and the crisis line. Correct Explanation: The nurse should provide the client with resources or support systems to turn to when the next battering incident occurs. It is inappropriate to advise the client to leave her husband. The client should not be pushed or coerced into leaving her husband until she is ready. Telling the client not to do anything to upset her husband places blame for the violence on the client. Asking the client what she could do to de-escalate the situation at home indirectly confers blame on the client.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: a) implement measures to facilitate the attachment process. b) provide emotional support so the family can adjust to the birth of an infant with health problems. c) help the family prepare for the infant's imminent death. d) prepare the family for the extensive surgical procedures the infant will require.

help the family prepare for the infant's imminent death. Correct Explanation: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive

When planning the care for a client who is being abused, which measure is most important to include? a) explaining to the client the client's personal and legal rights b) teaching the client about abuse and the cycle of violence c) helping the client develop a safety plan d) being compassionate and empathetic

helping the client develop a safety plan Correct Explanation: The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have? a) sleep disturbance b) impulsive acts of aggression c) difficulties with speech d) unable to recognize objects by touch

impulsive acts of aggression Explanation: Impulsive acts of aggression and violence have been linked to dysregulation of the amygdala. The hypothalamus regulates basic human activities such as sleep-rest patterns. The parietal lobe contains the primary somatosensory area. The temporal lobes contain the primary auditory areas

Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness? a) reliving the pleasant memories of days gone by b) living each day as it comes as fully as possible c) planning ahead for the remaining good times that will be spent together d) expecting the worst and being grateful when it does not happen

living each day as it comes as fully as possible Correct Explanation: When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? a) authoritarian b) parental c) controlling d) matter-of-fact

matter-of-fact Correct Explanation: For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. Use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase his trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry

In working with a rape victim, which intervention is most important? a) periodically reminding the client that she did not deserve and did not cause the rape b) telling the client that the rapist will eventually be caught, put on trial, and jailed c) recommending that the client resume sexual relations with her partner as soon as possible d) continuing to encourage the client to report the rape to the legal authorities

periodically reminding the client that she did not deserve and did not cause the rape Correct Explanation: Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: a) raccoon's eyes and Battle's sign. b) motor loss in the legs that exceeds that in the arms. c) nuchal rigidity and Kernig's sign. d) pupillary changes.

raccoon's eyes and Battle's sign. Correct Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation

The client has been diagnosed with a disease that requires a risky treatment for survival. The client is indecisive about treatment and states, "I don't know what to do." The nurse determines the most appropriate outcome is that the client will a) have the healthcare provider make the treatment decision. b) report feelings of peace about decision regarding treatment. c) identify and use appropriate coping strategies. d) express feelings, needs, and concerns about treatment.

report feelings of peace about decision regarding treatment. Explanation: The situation is about the client's inability to make the decision regarding treatment. The option that most addresses this is the client reporting feelings of peace about treatment decision. It is inappropriate for the healthcare provider to make treatment decisions.

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? a) unbalanced power ratio b) dysfunctional feeling tone c) tight, impermeable boundaries d) role stereotyping

role stereotyping Correct Explanation: The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief? a) bargaining b) shock c) anger d) denial

shock Explanation: The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition

The nurse judges a client to no longer need constant one-to-one observation for self-directed violence when the client exhibits which behavior? a) stops putting his head in the toilet to drown himself b) eats his meals in the dining room c) begins to interact with the nurse d) displays a sudden elevation in mood

stops putting his head in the toilet to drown himself Explanation: The nurse judges the client to no longer require constant one-to-one observation when the client stops putting his head in the toilet to drown. Interacting with the nurse does not indicate anything about the client's potential for self-directed violence. A sudden elevation in mood may indicate relief about ambivalent feelings and thoughts about killing himself and may be a signal that a suicide attempt is imminent. Eating meals in the dining room does not indicate anything about the client's potential for self-directed violence.

The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: a) administering pain medication promptly when the child requests it. b) using an age-appropriate tool for effectively assessing pain. c) striving to prevent pain by routine administration of pain medication. d) alternating stronger opioid pain medications with nonopioid agents.

striving to prevent pain by routine administration of pain medication. Correct Explanation: When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication promptly, the goal of treatment should be to prevent pain rather than simply respond to it. Assessing pain with an age-appropriate tool is important; however, the effective assessment of pain shouldn't take precedence over the effective treatment of pain. Alternating stronger opioid medications with nonopioid medications may be effective, but the nurse should individualize the treatment to meet the child's needs

The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: a) alternating stronger opioid pain medications with nonopioid agents. b) striving to prevent pain by routine administration of pain medication. c) administering pain medication promptly when the child requests it. d) using an age-appropriate tool for effectively assessing pain.

striving to prevent pain by routine administration of pain medication. Correct Explanation: When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication promptly, the goal of treatment should be to prevent pain rather than simply respond to it. Assessing pain with an age-appropriate tool is important; however, the effective assessment of pain shouldn't take precedence over the effective treatment of pain. Alternating stronger opioid medications with nonopioid medications may be effective, but the nurse should individualize the treatment to meet the child's needs

The client is admitted to the hospital because of threatening, aggressive behavior toward the client's family. Which factor is most important for the nurse to consider when assessing the angry client's potential for violence? a) the time of day and level of activity on the unit b) the attitude of the staff toward the angry client c) the client's past history of violent behavior d) the staff-to-client ratio

the client's past history of violent behavior Correct Explanation: The client's past history of violent behavior is the most accurate predictive factor. Violent behavior is more likely when there is a demand for high activity; however, this is not the strongest risk factor. There is an increased chance of violent behavior when the staff feels hopeless about a client because the client can recognize their feelings and may be unwilling to learn adaptive coping. However, this is not the strongest risk factor. With inadequate staffing, the chance for violent behavior increases because timely intervention before escalation of agitation may not be possible. However, this is not the strongest risk factor.

The nurse is aware that there is a potential for errors in the certification of death when: a) the patient had a condition that has the potential to temporarily suspend life process. b) the patient was younger than 12 years of age or older than 75. c) the patient was in good health prior to an accident or medical incident that caused death. d) the patient lived with numerous comorbidities prior to death.

the patient had a condition that has the potential to temporarily suspend life process. Explanation: Errors in certification of death have the potential to occur in conditions that might not permanently suspend life processes, such as from hypothermia, drug or metabolic intoxication, or circulatory shock. There is also a risk of error in children under 5 years of age. Previous good health or multiple comorbidities do not present a greatly increased risk of error when determining death.

The nurse notices that the patient shows signs of depression and often is found crying quietly in her room. Based on what the nurse recalls about violence against women the nurse suspects the following? a) the patient has anxiety related to being in the hospital b) the patient is a victim of sexual harrassment c) the patient has recently suffered a personal loss d) the patient is a victim of date rape

the patient is a victim of date rape Correct Explanation: Victims of sexual assault are 3 times more likely to suffer from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide. Clearly, nurses need to be alert to evidence of sexual abuse while taking the history and conducting physical examinations. Neither anxiety or suffering a personal loss are factors related to violence against women. Harassment is any annoying or distressing comment or conduct that is known or should be known to be unwelcome

A client recently diagnosed with lung cancer tells the nurse that she has been having difficulty sleeping and is often preoccupied with thoughts about how her life has changed. She says, "I wish my life could just go on the way it was." Which issue should the nurse discuss with the client first? a) understanding grief b) managing insomnia c) relieving anxiety d) preparing a will

understanding grief Explanation: The client is grieving and is telling the nurse that she grieves for the changes occurring in her life since her cancer diagnosis. The nurse can discuss the grief process with the client and offer support at this time. While the client does have insomnia and is anxious, the priority is to help the client manage her grieving. It is premature to discuss preparing a will.

Based on a client's history of violence toward others and inability to cope with anger, what should the nurse use as the most important indicator of goal achievement before discharge? a) verbalization of feelings in an appropriate manner b) acknowledgment of the client's angry feelings c) development of a list of how anger has been handled in the past d) ability to describe situations that provoke angry feelings

verbalization of feelings in an appropriate manner Correct Explanation: Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that behavior has changed. Asking the client to list how anger has been handled in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others

An 16-year-old male is admitted to the facility after acting out his aggressions inappropriately at school. To better understand possible contributing factors, the nurse should assess for: a) passive parents. b) a single-parent family. c) viewing of televised violence. d) an internal locus of control.

viewing of televised violence. Explanation: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence

When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be especially cautious about which client behavior? a) bizarre behavior b) visual hallucinations c) loud screaming d) violent behavior

violent behavior Correct Explanation: The nurse must be especially cautious when providing care to a client who has taken phencyclidine (PCP) because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.

The nurse is encouraging an unlicensed assistive personnel (UAP) to interact with a dying client and family. The nurse should help the UAP understand that: a) the family members who are present can provide essential care. b) when health care personnel do not understand their own feelings about death and dying, they often avoid the client. c) the dying person requires minimal physical care to be comfortable, and it is not necessary to provide daily care. d) to protect a person's right to die with dignity, it is best to avoid interrupting the client.

when health care personnel do not understand their own feelings about death and dying, they often avoid the client. Correct Explanation: Health care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understand their own feelings about dying.

Examples of child maltreatment include A calling the child stupid for climbing on a fence and getting injured. B giving the child a time-out for misbehaving by hitting a sibling. C failing to buy a desired toy for Christmas. D spanking an infant who won't stop crying. E watching pornographic movies in a child's presence. F withholding meals as punishment for disobedience.

A, D, E, F

A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? a) "Any information that can identify a person is considered a breach of client privacy." b) "All aspects of the clinical experience are confidential and should not be discussed." c) "You may continue to post about client you cared for during clinicals, as long as you do not use the client's name." d) "The information being posted on Facebook is inappropriate. Make sure to discuss information about client's privately with friends and family."

"Any information that can identify a person is considered a breach of client privacy." Correct Explanation: Any information that can identify a person is considered confidential. A medical condition may identify a client that was cared for, especially if the location of the clinical site and unit was disclosed in the post. Discussion of clinical experience can be used for teaching purposes or seeking advice on care. No care should be discussed, even privately, with friends and family.

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which of the following statements by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death? a) "The process is the same from person to person." b) "The duration of all stages is a few hours." c) "Sometimes a person returns to a previous stage." d) "Each stage of dying must be completed prior to moving to the next stage."

"Sometimes a person returns to a previous stage." Explanation: Kübler-Ross (1969) studied the responses to death and dying. Her findings are as follows: Sometimes a person returns to a previous stage, the stages of dying may overlap, the duration of any stage may range from as little as a few hours to as long as months, and the process varies from person to person

A client states, "I have never taken a yellow pill before for my blood pressure. Why are you giving me this pill?" After verifying that the nurse has prepared the correct medication, which of the following would be an accurate statement by the nurse? a) "This is the same medication that you take at home but in generic form." b) "We use all kinds of brands at the hospital so I am sure it is correct." c) "You can refuse to take this medication if you wish." d) "I think you must be confused; this is the right medication."

"This is the same medication that you take at home but in generic form." Correct Explanation: Once the nurse has verified that the medication is correct, the client can be informed that it looks different because it is in generic form. The other options may hinder the development of trust in the nurse. Stating that the client can refuse the medication is not appropriate in this situation.

A worried mother confides in the nurse that she wants to change primaryhealth care providers (HCP's) because her infant is not getting better. What is the nurse's best response? a) "Your infant's condition takes time to heal." b) "I know you are worried, but the primary care provider has an excellent reputation." c) "This primary care provider has been on our staff for 20 years." d) "You always have an option to change. Tell me about your concerns."

"You always have an option to change. Tell me about your concerns." Correct Explanation: Asking the mother to talk about her concerns acknowledges the mother's rights and encourages open discussion. The other responses negate the parent's concerns.

A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, "You look anorexic." Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition? a) "Your body is using protein and fat for energy instead of glucose." b) "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism." c) "You may be having undiagnosed infections causing you to lose extra weight." d) "I will refer you to a dietician who can help you with your weight."

"Your body is using protein and fat for energy instead of glucose." Correct Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? a) Calcium: 10 mg/dL b) Magnesium:2 mEq/L c) Sodium: 138 mEq/L d) Potassium: 5.8 mEq/L

Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.

Rando's six Rs of grieving tasks include: A React B Read C Readjust D Recover E Reinvest F Restitution

A, C, E

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? a) Asking a security officer to assist in giving the client a shower b) Accepting these fears and allowing the client to take a sponge bath c) Explaining that other clients are complaining about the client's body odor d) Dismantling the showerhead and showing the client that there is nothing in it

Accepting these fears and allowing the client to take a sponge bath Correct Explanation: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.

Which of the following assessment findings might indicate elder self-neglect? A Hesitancy to talk openly with nurse B Inability to manage personal finances C Missing valuables that are not misplaced D Unusual explanations for injuries

B

Which of the following give cues to the nurse that a client may be grieving for a loss? A Sad affect, anger, anxiety, and sudden changes in mood B Thoughts, feelings, behavior, and physiologic complaints C Hallucinations, panic level of anxiety, and sense of impending doom D Complaints of abdominal pain, diarrhea, and loss of appetite

B

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform post-mortem care for the client. Which of the following interventions should the nurse perform when providing post-mortem care? a) Place a rolled towel under the head. b) Avoid replacing dentures in the mouth. c) Apply hairpins and clips. d) Cleanse drainage from the skin.

Cleanse drainage from the skin. Correct Explanation: The nurse should cleanse secretions and drainage from the skin to ensure delivery of a hygienic body. The dentures should be replaced in the mouth as they maintain the natural contour of the face. A small rolled towel is placed beneath the chin of the client to close the mouth; it is not placed under the head. The nurse should remove all hairpins or clips to prevent accidental trauma to the client's face

A nurse caring for an elderly patient who has dementia observes another nurse putting restraints on the patient without a physician's order. The patient is agitated and not cooperating. What would be the best initial action of the first nurse in this situation? a) Contact the physician for an order for the restraints. b) Confront the nurse and explain how this could be dangerous for the patient. c) File an incident report and have the second nurse sign it. d) Report the nurse applying the restraints to the supervisor.

Confront the nurse and explain how this could be dangerous for the patient. Explanation: Confronting the nurse and explaining the danger for the patient is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance and it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the patient.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? a) Determine where the client is regarding the stages of dying and discuss the findings with the family. b) Explore other ways to control symptoms and address the family's concerns more effectively. c) Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. d) Provide support for the family and encourage the client to become more actively involved in the care.

Explore other ways to control symptoms and address the family's concerns more effectively. Correct Explanation: Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate and to support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority

A client is being discharged from the hospital with terminal brain cancer and a life expectancy of 1 month. When planning this client's discharge, it is most important for the nurse to include a referral to which agency? a) Support group b) Outpatient rehab c) Hospice d) Home health

Hospice Correct Explanation: Hospice is care provided for people with limited life expectancy, often in the home. A support group would be appropriate, but not as high in priority as hospice. Home health and outpatient rehab would not be appropriate for this client.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses? a) Autocratic b) Democratic c) Laissez-faire d) Transformational

Laissez-faire Explanation: In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. Autocratic leadership, also called directive leadership or authoritarian leadership, involves the leader assuming control over the decisions and activities of the group. Transformational is often described as charismatic, transformational leaders are unique in their ability to inspire and motivate others. Democratic leadership, also called participative leadership, is characterized by a sense of equality among the leader and other participants

A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain? a) Suggest alternating side-lying positions to lessen the back pain. b) Reinforce the importance of changing positions and the possibility of pressure ulcer formation. c) Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. d) Encourage the client to take the medications to provide optimal rest.

Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. Correct Explanation: It is important to respect the client's decision and to try other supportive measures to alleviate the pain.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? a) Teaching the client about her right to autonomy. b) Respecting the client's desire to have the uncle make choices on her behalf. c) Holding a family meeting and encouraging the client to speak on her own behalf. d) Revisiting the decision when the uncle is not present at the bedside.

Respecting the client's desire to have the uncle make choices on her behalf. Correct Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. Which of the following should happen in this case? a) The wishes of his family should be followed. b) Pharmacologic interventions should not be initiated. c) The client should be treated with antibiotics for pneumonia. d) The client should be resuscitated if he experiences respiratory arrest.

The client should be treated with antibiotics for pneumonia. Correct Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice

The nurse is managing the care of a terminally ill client whose spouse insists that all measures be continued. The nurse speaks to the spouse about obtaining a hospice consult. This is an example of "ethical" what? a) Sensibility b) Valuing c) Accountability d) Discernment

Valuing Explanation: Ethical valuing is the belief about worth, as in speaking to the spouse and placing value on the life and wishes of the client. The other choices do not define valuing.

A client with severe and persistent depression can't decide if he'll undergo electroconvulsive therapy (ECT). His family asks a nurse to convince him that this treatment modality would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make? a) "The client, treatment team, and family must meet to discuss this treatment option." b) "You must make the client aware of the moral aspects of refusing treatment." c) "In a situation like this, the family should obtain legal counsel for the client." d) "You must have the client sign a statement that he understands the treatment benefits but still declines the treatment."

You selected: "The client, treatment team, and family must meet to discuss this treatment option." Correct Explanation: When a client is undecided about treatment, the best approach is to assemble the client, his family, and appropriate health care providers to discuss what option serves the client's best interests while acknowledging his right to refuse treatment. Because the client has the right to refuse treatment, there's no need for the family to obtain legal counsel or for the client to sign any refusal-of-treatment forms. Neither family members nor health care providers should coerce the client to reconsider his position under the guise of addressing the ethical aspects of treatment.

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? a) "Do you want to rescind the DNR, or just change it?" b) "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." c) "Have you talked this over with your family?" d) "You know that we will do everything needed to keep you comfortable even though you have the DNR in place."

"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Correct Explanation: Telling the client that it is not a problem to rescind the order is the best response. The client is allowed to rescind a DNR order at any time. The client makes the decision about a DNR order with input from the physician; he does not need to talk to his family. The client needs to have more information regarding the specifics of the nurse's question, but has the right to either rescind or change it at any time

The psychiatrist is evaluating a client who has recently learned she has a terminal illness. Which of the following statements indicates to the psychiatrist that the client is in the Kübler-Ross stage of bargaining? a) "Why is this happening to me—I quit smoking." b) "Just let me go on vacation with my wife; then I'll be satisfied." c) "I know that my family will be taken care of. I am at peace." d) "I waited years to see my grandchildren and now I won't see them."

"Just let me go on vacation with my wife; then I'll be satisfied." Correct Explanation: According to Kübler-Ross, the five stages of dying, with common reactions are denial, anger ("why me" questions), bargaining (the client tries to barter for more time ("just let me go on vacation..."), depression ("I waited years to see my grandchildren and now I won't"), and acceptance ("I am at peace.")

Which of the following is true about domestic violence between same-sex partners? 1 Such violence is less common than that between heterosexual partners. 2 The frequency and intensity of violence are greater than between heterosexual partners. 3 Rates of violence are about the same as between heterosexual partners. 4 None of the above.

3

Nursing interventions that are helpful for the grieving client include: A Allowing denial when it is useful B Assuring the client that it will get better C Correcting faulty assumptions D Discouraging negative, pessimistic conversation E Providing attentive presence F Reviewing past coping behaviors

A, C, E, F

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which of the following would be an example of assisted suicide? a) Administering a lethal dose of medication b) Neglecting to resuscitate a patient with a "do not resuscitate" status c) Granting a patient's request not to initiate enteral feeding when the patient is unable to eat d) Administering a morphine infusion

Administering a lethal dose of medication Correct Explanation: Assisted suicide refers to providing another person the means to end his or her own life. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he will not be monitored as closely as he was in the CCU. How can the nurse allay his fears? a) Obtain an order for an antianxiety medication. b) Remind the client he would not have been moved out of CCU if he was not stable. c) Assign the same nurse to the client when possible. d) Move the client to a room far from the nurses' station to reduce his exposure to noise.

Assign the same nurse to the client when possible. Correct Explanation: Assigning the same nurse to the client when possible provides continuity of care and stability, thereby reducing his anxiety. An anxiolytic might be counter-productive and "overkill," he needs reassurance first. The client might have been the "most stable" choice in the event of an urgent need for a CCU bed. A room close to nurses' station would provide this client with a sense of security because the nurses are close by in the event of an emergency

Which of the following is the best action for the nurse to take when assessing a child who might be abused? A Confront the parents with the facts and ask them what happened. B Consult with a professional member of the health team about making a report. C Ask the child which of his parents caused this injury. D Say or do nothing; the nurse has only suspicions, not evidence.

B

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which of the following signs indicates approaching death? a) Client is calm and peaceful b) Arms and legs are warm to touch c) Breathing becomes noisy d) Frequency of urination decreases

Breathing becomes noisy Correct Explanation: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch and not warm because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response? a) Instruct the mother on the importance of the medication. b) Ask the mother if she has considered using any medical assistance programs in her community. c) Consult with the social worker. d) Confer with the HCP about whether a less expensive drug could be prescribed.

Confer with the HCP about whether a less expensive drug could be prescribed. Correct Explanation: The nurse must act as an advocate for the client when the client cannot afford treatment. It may be possible to substitute a less expensive antibiotic. Correct procedure includes contacting the HCP to explain the mother's economic situation and request a substitution. For example, amoxicillin is more economical than azithromycin. If it is not possible to use another antibiotic, then the nurse can explore other avenues with the mother and/or social worker

Physiologic responses of complicated grieving include A tearfulness when recalling significant memories of the lost one. B impaired appetite, weight loss, lack of energy, palpitations. C depression, panic disorders, chronic grief. D impaired immune system, increased serum prolactin level, increased mortality rate from heart disease.

D

The nurse is assessing a patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief and intense sadness. Based upon this assessment data, the nurse will document that the patient is in what stage of death and dying? a) Anger b) Depression c) Denial d) Acceptance

Depression Correct Explanation: Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life

A nursing student is studying the principle of autonomy. Which of the following examples most accurately depicts this principle? a) Describing surgery to a client before the consent is signed b) Administering a morning dose of insulin before breakfast c) Transporting a client to a scheduled physical therapy appointment d) Changing a dressing on a wound as needed

Describing surgery to a client before the consent is signed Correct Explanation: Describing surgery to a client before a consent is signed provides the client with all of the information needed to make an informed decision, thus an autonomous one. The other choices are not reflective a client decision making.

A client with a terminal illness is being cared for at home. When caring for a client who is in home care, the nurse discusses the importance of respite care. Which of the following interventions leads to respite care? a) Sharing responsibilities within the immediate family b) Securing home equipment c) Encouraging the caregiver to identify surrogate caregivers d) Arranging for home nursing visits

Encouraging the caregiver to identify surrogate caregivers Explanation: The nurse should encourage the caregiver to identify volunteers who will care for the client and allow the primary caregiver to enjoy brief periods away from home, as caring for the client can be very stressful. Arranging for home nursing visits and securing home equipment are all activities performed by the nurse caring for the client in home care but are not related to respite care. Sharing responsibilities within the immediate family of the client may improve the client's care, but will not necessarily lead to respite for the caregivers unless time away from responsibility is allowed for

A 75-year-old woman had surgery for her hip fracture yesterday. She is under stress due to pain, sleep deprivation, and hospital surroundings. The nurse caring for her implements a proactive approach to pain management. Plans include frequent communication to establish an acceptable pain rating, conducting hourly pain assessments, and hourly evaluation of the patient's pain control. In addition to improved patient outcomes, how else might the hospital benefit from the nurse's actions? a) Improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores b) Improved Quality and Safety Education for Nurses (QSEN) survey scores c) Additional funding from the Institute for Healthcare Improvement (IHI) d) Continued accreditation from The Joint Commission

Improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores Correct Explanation: HCAHPS survey measure patients' satisfaction with the quality of the nursing care they receive, including their satisfaction with their communication with the nurses, the responsiveness of the hospital staff, the quietness of the environment, their pain management, communication about their medications, and their discharge information. Institute for Healthcare Improvement (IHI) is a nonprofit organization whose mission is adapted from the IOM's six aims for improvement. IHI is not a funding source for hospitals. Accreditation from The Joint Commission has a larger scope outside of pain management measures. QSEN prepares future nurses with the knowledge, skills, and attitudes (KSA) required to continuously improving the quality and safety of the health care system.

A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP? a) Reassign the UCP to a client requiring basic tasks that the UCP has mastered. b) Provide the UCP with a list of resources to guide the implementation of care. c) Supervise the UCP during the treatments involving sterile technique. d) Make sure the UCP has practiced sterile technique on at least one other occasion.

Reassign the UCP to a client requiring basic tasks that the UCP has mastered. Correct Explanation: The nurse is accountable for the delegation of tasks to UCPs. The nurse delegates tasks to UCPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UCPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UCP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UCP has the knowledge and skill to provide the care or carry out the task.

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment? a) Recognize her limitations and ask another nurse to assist her if she becomes too emotional. b) Recognize that she may be faced with this issue again and care for the client. c) Recognize the issue and care for the client to the best of her ability. d) Recognize her limitations and ask for another nurse to be assigned.

Recognize her limitations and ask for another nurse to be assigned. Explanation: The nurse should keep the client's best interests in mind. If the nurse feels that her emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised

With the help of the nurse, the parents of an infant who died shortly after birth arrange for a funeral service. What stage of grief, according to Engel, involves the rituals surrounding loss, including funeral services? a) Resolving the loss b) Shock and disbelief c) Developing awareness d) Restitution

Restitution Correct Explanation: Restitution is the stage of grief that involves the rituals surrounding loss; with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Shock and disbelief involve the person being in denial or having a numbed response to the death. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying Resolving the loss involves dealing with the void left by the loss

A nurse is caring for a client with advanced heart failure. He can't care for himself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses his desire for "nature to take its course." The client's family is pleading with him to have a feeding tube inserted. What is the most appropriate action for the nurse to take? a) Talk with the client's family about the client's right to decide for himself. b) Schedule feeding tube placement and hope that she can persuade the client to agree to it. c) Schedule a conference to help the client and his family reach a consensus about the feeding tube. d) Ask a priest to talk with the client about the importance of preserving life.

Talk with the client's family about the client's right to decide for himself. Correct Explanation: Advocating for a client's wishes is a key nursing role. It's especially important when a client's family disagrees with his wishes. The nurse should be sure that the client has all the information he needs to make an informed decision. Then she should support his decision. She shouldn't contact a clergyman without the client's consent, call a family conference, or schedule intubation in violation of the client's wishes.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which of the following cases may require the service of a coroner? a) The client was being administered oxygen therapy. b) The client is elderly with a history of hypertension. c) The client did not have any recent medical consultation. d) The client was diagnosed with acute renal failure.

The client did not have any recent medical consultation. Correct Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner`

While applying dressings to a client's wound, the nurse teaches the client about his wound care. To promote the most effective teaching-learning relationship with this client, which of the following would be most important for the nurse to keep in mind? a) Nurses barter knowledge of medication with the client for compliance b) Nurses are experts who generously bestow knowledge upon clients c) The nurse and client relationship is based on mutual sharing and negotiation d) Nurses have control over the client because of their knowledge and expertise

The nurse and client relationship is based on mutual sharing and negotiation Correct Explanation: When providing nursing care, the teaching-learning relationship between the nurse and client is special, characterized by mutual sharing, advocacy, and negotiation. Effective learning occurs when clients and healthcare professionals are equal participants in the teaching-learning process. Unlike some traditional views, nurses are not experts who generously bestow knowledge upon clients, nor do they barter knowledge for compliance. Both images represent the relationship as a power imbalance in which nurses, because of their knowledge and expertise, control the situation

When a client wants to read the medical record, the nurse should: a) answer any questions the client has without giving the client the medical record. b) call the health care provider (HCP) to obtain permission. c) tell the client to read the medical record when the health care provider (HCP) makes rounds. d) give the client the medical record and answer the client's questions.

give the client the medical record and answer the client's questions. Explanation: The client should be allowed to see the medical record. As a client advocate, the nurse should answer questions for the client. The nurse helps the client become a primary partner in the health team. The HCP should not need to give permission for the client to see the medical record. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing the medical record.

While teaching about advance care planning, which fact is important for the nurse to share with a client who has been diagnosed with a terminal illness? a) A durable power of attorney for health care appoints an agent the person trusts to make decisions. b) The Patient Self-Determination Act of 1990 requires hospital clients to have an advance directive. c) Living wills provide specific instructions related to the client's personal property upon death. d) Advance directives must be completed 30 days prior to hospitalization in order to be valid.

A durable power of attorney for health care appoints an agent the person trusts to make decisions. Correct Explanation: Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care if certain circumstances arise. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. In the United States, the Patient Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives. Advance directives do not have to be completed prior to hospitalization in order to be valid

Upon interviewing the client, the nurse finds that the client is providing care for her mother who is terminally ill. The client is depressed and already mourning the loss. Which nursing diagnosis would be most appropriate for the client? a) Dysfunctional grieving b) Normal grieving c) Anticipatory grieving d) Prolonged grieving

Anticipatory grieving Correct Explanation: Anticipatory grieving is the most appropriate nursing diagnosis for this client. It comprises the intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of loss. Normal grieving, dysfunctional grieving, and prolonged grieving are inappropriate diagnoses because they can only happen after the actual loss

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond? a) Ask the client to discuss the decision with family members. b) Discuss with the client the reasons for declining surgery. c) Review with the client the risks and benefits of surgery. d) Notify the physician of the client?s refusal.

Discuss with the client the reasons for declining surgery. Explanation: The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete

Which of the following manifestations of grief by the client who lost his wife 3 years earlier is considered abnormal? a) Talking about his wife's absent-mindedness b) Telling the nurse how his life has changed c) Showing a photograph of the decedent d) Leaving the wife's room and belongings intact

Leaving the wife's room and belongings intact Correct Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief but considered most of the manifestations to be abnormal if they continue beyond 3 years

The nurse is managing the care for a post operative client. How does the nurse demonstrate advocacy? a) Limiting visitors due to client complaining of pain b) Changing the channel on the television while providing care c) Turning and positioning the client every four hours d) Administering pain medication when the pain level reaches 9/10

Limiting visitors due to client complaining of pain Explanation: Limiting visitors is an example of advocacy as this intervention is based on the best interest and welfare of the client. The other choices do not describe safe, competent, and comforting care

The nurse needs to perform an admission assessment on a patient that does not speak the same language as the nurse. The patient's wife is fluent in both the language of the nurse and the patient. When completing the physical assessment is critical in planning patient care, how should the nurse proceed? a) Obtain a translator to assist with interpretation during admission assessment b) Plan nursing care on the objective physical findings from the admission assessment c) Ask the patient's wife to assist with interpretation during the admission assessment d) Complete the admission assessment, provide patient privacy, and document the language barrier

Obtain a translator to assist with interpretation during admission assessment Correct Explanation: Translation services should be provided for non-English-speaking patients. Asking the patient's wife violates the patient's confidentiality. Physical findings alone are not sufficient; the nurse must understand the patient's interpretation of the physical findings to provide culturally competent nursing care. Completion of the admission assessment in privacy and documenting the language barrier does not address the need for interpretation of the patient's history, perception, and description of assessment findings

The family of a patient with a severe traumatic brain injury is considering the withdrawal of his mechanical ventilation. What is the nurse's primary role in the preparation for terminal weaning? a) Preparing the bedside for postmortem care b) Assisting with pulmonary resuscitation if the patient is unable to breathe independently c) Assisting with chest physiotherapy before and after ventilation ceases d) Teaching the family what to reasonably expect after ventilation is discontinued

Teaching the family what to reasonably expect after ventilation is discontinued Correct Explanation: The nurse's role surrounding terminal weaning is to educate and assist as needed in the decisional process. It would be premature and possibly upsetting to prepare the bedside in anticipation of postmortem care. Chest physiotherapy and resuscitation would not typically be attempted in cases of terminal weaning

Mr. Cooney, age 85, is in advanced stages of pneumonia with a no-code order in his chart. Which of the following nursing care actions will help establish a trusting nurse-patient relationship? a) The nurse discusses the patient's fears and doubts openly and serves as a nonjudgmental listener. b) The nurse arranges a visit from a spiritual advisor for dying patients, regardless of the patient's wishes, to provide hope in the face of death. c) The nurse reduces verbal and nonverbal contact with the patient to avoid confusing him. d) The nurse avoids providing counseling and death education because it is not within the scope of professional nursing practice.

The nurse discusses the patient's fears and doubts openly and serves as a nonjudgmental listener. Correct Explanation: Being a good listener and encouraging the patient to discuss their fears and doubts without casting judgment helps in establishing a trusting nurse-patient relationship. Reducing contact with the patient is inappropriate and would not aid in avoiding confusion. Counseling and death education are in the scope of nursing practice. The nurse must follow the wishes of the patient regarding spiritual care.

A hospice nurse has developed a care plan for a patient with liver cancer. The care plan focuses on providing palliative care for this patient. The goal of palliative care is best described as providing patients with life-threatening illnesses the best quality of life through: a) aggressive management of symptoms. b) treatment of the disease process. c) eliminating all forms of medical and nursing care. d) providing counseling related to the stages of death and dying.

aggressive management of symptoms. Correct Explanation: The goal of palliative care is to provide patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. Palliative care is sometimes called hospice care

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: a) functional status before the stroke will help predict outcomes. b) the rehabilitation plan will be guided by it. c) the client can be expected to regain most functional status. d) it will help the client recognize physical limitations.

he rehabilitation plan will be guided by it. Explanation: The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor

When a client and family receive the initial diagnosis of colon cancer, the nurse can act as an advocate by: a) listening carefully to their perceptions of what their needs are. b) providing them with written materials about the cancer site and its treatment. c) helping them maintain a sense of optimism and hopefulness. d) determining their understanding of the results of the diagnostic testing.

listening carefully to their perceptions of what their needs are. Correct Explanation: The best nursing advocacy intervention is listening carefully to the client's and family's perceptions of their needs. Studies have demonstrated that these needs are not necessarily what the nurse thinks they are. Intervening without listening carefully may result in a lack of responsiveness to the real needs. Helping the client and family maintain a sense of optimism and hopefulness is appropriate but is not necessarily advocacy. Determining the client's and family's understanding of the results of the diagnostic testing and providing written materials about the cancer site and its treatment are examples of the nurse's role as educator.

The nurse is caring for an elderly comatose client in his home. The client is dying, and the client's family is providing some care. The family asks, "What else can we do?" The nurse encourages the family members to a) elevate the client's head to a semi-Fowler's position. b) speak to the client. c) provide ice chips for the client's dry mouth. d) bathe the client daily.

speak to the client. Correct Explanation: Dying clients may retain the sense of hearing until death ensues. Ice chips may be given to clients who are still able to swallow. This client cannot cooperate in swallowing. Position the comatose client in a semi-prone position to allow drainage of saliva. The client may need to be bathed frequently, not daily

The hospice nurse is visiting a new client. Which assessment questions are appropriate for the nurse to ask a client that has a terminal illness? (Select all that apply.) a) "What community resources might be of help to you?" b) "Do you have a will?" c) "How well do you think those around you are coping?" d) "Please describe what you have been told about your condition." e) "Have you had any previous experiences with the death of someone you love?"

• "Please describe what you have been told about your condition." • "What community resources might be of help to you?" • "How well do you think those around you are coping?" • "Have you had any previous experiences with the death of someone you love?" Explanation: Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the client's and family's knowledge, perceptions, coping strategies, and resources. Interview questions for these areas would include the following: adequacy of knowledge base ("describe your condition"), perceptions ("previous experience with death of someone you loved"), adequacy of resources ("community resources"), and adequacy of coping ("those around you coping"). Determining if a client has a will, to dispose of personal property, is not a priority assessment for the nurse.

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. a) Documenting a client's oral intake b) Assessing a client's pain c) Taking a client's vital signs d) Performing a blood glucose check e) Evaluating a client's response to a blood pressure medication

• Taking a client's vital signs • Performing a blood glucose check • Documenting a client's oral intake Correct Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed).

After the physician has discussed euthanasia with a terminal client and his family, the nurse assesses their understanding of the topic. Which of the following statements by the family indicates that learning has occurred? a) "It is alright to stop dialysis." b) "Passive euthanasia is taking specific steps to cause a client's death." c) "Allowing him to stop eating is a form of active euthanasia." d) "The doctor will give him a lethal dose of barbiturates."

"It is alright to stop dialysis." Explanation: Active euthanasia is taking specific steps to cause a client's death (lethal dose of barbiturates) and has been deemed both immoral and illegal in most states. Passive euthanasia is defined as withdrawing medical treatment (dialysis) with the intention of causing the client's death and is morally and legally justified. Allowing the client to stop eating would be a form of passive euthanasia

Which registered nurse should be assigned to the client who had a chest tube inserted yesterday? a) A registered nurse that use to work on the cardiovascular unit b) A charge nurse pulled from the psychiatric unit c) A registered nurse who worked as a head nurse on the orthopedic unit d) A licensed practical nurse with 10 years of experience

A registered nurse that use to work on the cardiovascular unit Correct Explanation: According to the National Council of State Boards of Nursing, delegation encompasses five rights — the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. The registered nurse is the most appropriate caregiver to assign to the client with a chest tube because the chest tube system requires frequent assessment and monitoring. In addition, the client may require immediate nursing intervention should the chest tube became obstructed or dislodged. It is not necessary for the charge nurse to care for this client

A client receiving chemotherapy for cervical cancer indicates that she has an advance directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the client's wishes, what should the nurse encourage the client to do? a) Discuss her end-of-life wishes with her family. b) Appoint a proxy who is not a family member. c) Obtain additional legal documents. d) Recommend that the client contact her attorney.

Discuss her end-of-life wishes with her family. Correct Explanation: Family opposition does not override an advance directive. However, the client should ensure that family members know what her wishes are, even if they do not agree with them. After discussing her wishes with her family, the client can decide if she should seek additional legal advice, obtain legal documents, or name an outside proxy

A nurse is assessing a dying patient for realism of expectations and perception of condition. Which interview questions address this concern? (Select all that apply.) a) What do you think may be happening in the midst of all of this? b) Have you had any previous experience with this condition before? c) Do you know how to contact your doctor and get answers to your questions? d) What have you been told about your condition? e) How do you see the next few weeks playing out? f) How well do you think those around you are coping?

Have you had any previous experience with this condition before? • How do you see the next few weeks playing out? • What do you think may be happening in the midst of all of this? Explanation: A focused assessment regarding realism of expectations and perception of condition include the following questions: Have you had any previous experiences with this condition or with the death of someone you love? What are your expectations in this case? How do you see the next few weeks (days) playing out? What are your fears, hopes, concerns, worries? What good do you think might be happening in the midst of all this? The objective is to discover whether the patient and family have unrealistic expectations or misperceptions about the diagnosis, prognosis, and care options that will interfere with their decision making and coping. Asking the patient if he knows how to contact his doctor, what he has been told about his condition, and how well others around him are coping don't address these objectives

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first? a) Prevent the client from leaving. b) Notify the physician. c) Call a security guard to help detain the client. d) Have the client sign an AMA form.

Notify the physician. Explanation: If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

The emergency department (ED) nurse accepts an unconscious client brought in by ambulance. The client's family presents a durable power of attorney for health care for the client. Which of the following actions should the nurse take? a) Initiate a slow code in the case of cardiopulmonary or respiratory arrest b) Communicate to other ED staff that there should be no attempts to resuscitate the client c) Initiate active euthanasia d) Obtain contact information for the person designated to make decisions for the client

Obtain contact information for the person designated to make decisions for the client Correct Explanation: Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care should certain circumstances develop. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. In this case of an unconscious client, the nurse would want to obtain contact information for the person designated by the client as decision maker. The durable power of attorney does not give direction regarding medical care (the other options)

The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take? a) Admit the mother to a private room on the postpartum unit. b) Ask the nurse in labor and birth to discharge the mother as soon as she is physically able to leave. c) Request a room for this client on a unit without newborns. d) Talk to the mother first and decide on a location that is mutually agreeable.

Talk to the mother first and decide on a location that is mutually agreeable. Correct Explanation: The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future needs of the client experiencing this type of loss as the client may or may not be thinking well or clearly at the moment. The postpartum unit is full of sounds of infants, and although being in a room by herself may support the need for separation, it is often in the best interest of the client to locate her away from the noise of the babies. Placing the client on another unit will remove her from the support she is seeking. On the other hand, she will not be hearing crying infants. This has often been the location for someone experiencing a loss. Discharging the mother home as soon as she is stable physically is also a possibility, but the nurse must also assess the client's emotional stability and preferences for grieving

A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? a) Ask the physician if the client can take fewer pills each day. b) Come to the client's house each morning to prepare the daily allotment of medications. c) Ask the client's family to take turns coming to the house at each administration time to assist the client with his medications. d) Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications.

Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. Correct Explanation: The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots. Family members can't be expected to come to the client's house four times each day to administer medications. The physician shouldn't change the dosing regimen just for convenience. The home care nurse can't visit the client each morning to prepare the daily medication regimen.

Nurses who value patient advocacy follow what guideline? a) They choose the claims of the patient's well-being over the claims of the patient's autonomy. b) They value their loyalty to an employing institution or to a colleague over their commitment to their patient. c) They make decisions for patients who are uninformed concerning their rights and opportunities. d) They give priority to the good of the individual patient rather than to the good of society in general.

They give priority to the good of the individual patient rather than to the good of society in general. Correct Explanation: Advocacy is the protection and support of another's rights. If the nurse values patient advocacy, the nurse would give priority to the good of the individual client rather than to the good of society in general. The nurse would not be demonstrating advocacy if the nurse values the loyalty to an employing institution or to a colleague over their commitment to their client. The nurse demonstrating patient advocacy would not choose the claims of the client's well-being over the claims of the client's autonomy. The nurse would not make decisions for clients who are uninformed concerning the client's rights and opportunities

The husband of a patient who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing? a) Normal grief b) Unresolved grief c) Inhibited grief d) Anticipatory grief

Unresolved grief Correct Explanation: In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life and the meaning of death)

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to: a) administer oxygen to the infant while awaiting the physician's orders. b) contact the nursing supervisor for assistance. c) ask to see a copy of the advance directive. d) provide palliative care for the infant and his family.

ask to see a copy of the advance directive. Explanation: In order to have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate for her to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.