Lesson 4: Psychosocial Integrity
A postpartum Hispanic client refuses hospital food because it is "cold." What action should the nurse take initially? a. Ask the client what foods are acceptable or are unacceptable b. Encourage the client to eat for healing and strength c. Schedule the dietitian to meet with the client as soon as possible d. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
a. Ask the client what foods are acceptable or are unacceptable - Many Hispanic clients subscribe to the rebalancing of "hot" and "cold" in the postpartum period. After giving birth, when a woman has lost blood, she is considered to be in a cold state; therefore, she needs to restore her humoral balance. What defines "cold" and "hot" can best be explained by the client and this needs to be incorporated into the plan of care. Note that the correct response allows for client feedback; this is the only client-centered option.
A 30-year-old client at 39-weeks gestation has just delivered and experienced a fetal demise. The client's partner is at the bedside. Which of the following nursing actions are appropriate at this time? (Select all that apply.) a. Ask the parents if there are any special religious or cultural rituals for neonatal death b. Clean and wrap the baby and offer it to the parents to view or hold when desired c. Stay with the parents and offer supportive care to both of them d. Place the infant on the maternal abdomen, skin-to-skin e. Offer the option of an autopsy to the parents at this time
a. Ask the parents if there are any special religious or cultural rituals for neonatal death b. Clean and wrap the baby and offer it to the parents to view or hold when desired c. Stay with the parents and offer supportive care to both of them - Staying with the parents at this moment and offering physical and emotional support is appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and respect for the baby and to offer everyone the opportunity to view and/or hold the infant as they desire. Placing a newborn on the mother's abdomen would be appropriate for a live birth, but inappropriate for this situation. The nurse must ask if there are cultural or religious rituals they would like for their infant. Although an autopsy should eventually be discussed, it would not be appropriate immediately after the birth.
The client is transported to the emergency department with minor injuries suffered during a home fire. The client experiences intense anxiety after learning his home was completely destroyed. What is the most important initial intervention for this client? a. Determine available community and personal support resources b. Provide a brochure on methods to promote relaxation c. Suggest that the client rent an apartment with a sprinkler system d. Explore the feelings of grief associated with the loss
a. Determine available community and personal support resources - Although the sudden loss of a home can cause significant emotional distress, the most important initial intervention focuses on identifying community resources and obtaining assistance for housing and other immediate needs. Information on home safety, relaxation exercises and grief counseling can wait until the client's basic need for shelter is met.
A client diagnosed with a terminal condition is admitted to the nursing unit. What should be the initial action taken by the nurse? a. Ensure the client is free from pain, nausea or dyspnea b. Discuss the options for advanced directives with the client and the family c. Refer the client's family to the chaplain d. Collaborate with the multidisciplinary team members
a. Ensure the client is free from pain, nausea or dyspnea - Keep in mind the nursing process where the client is the center of attention. Also, recall that physiological needs are priority to psychosocial needs. Thus, the client should be kept as comfortable as possible. After the physiological needs are met, any of the other choices would be appropriate with the discussion of the advanced directives being first. This would not be the initial action because a "discussion" may take some time and the client needs would be ignored during any discussion.
A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? a. Interview the client privately b. Ask the client if there are any old injuries c. Refer the client to a victim advocate d. Photograph the specific injuries and include with documentation
a. Interview the client privately - It is critical to separate the client from anyone who came in with the client, whether it be a partner or friend, and interview the client in privacy. With the use of the nursing process, the nurse's first action when a client is unstable or has potential problems is further assessment of the situation. The correct answer is the one most focused on gathering more information. During the private intake assessment the nurse would possibly institute the other actions in the remaining options.
A nurse is caring for a client who is experiencing alcohol withdrawal symptoms. Which nursing considerations are most appropriate? (Select all that apply.) a. Monitor vital signs b. Take seizure precautions c. Apply restraints d. Orientate the client frequently e. Provide prescribed medication as needed f. No visitors allowed during rehabilitation
a. Monitor vital signs b. Take seizure precautions d. Orientate the client frequently e. Provide prescribed medication as needed - There are multiple interventions that nurses must consider when caring for a patient who is going through alcohol withdrawal. Vital signs may become unstable and the heart rate often becomes irregular. Seizures are common in clients withdrawing. Generalized tonic-clonic seizures are most common. Often clients become confused and disorientated and it is necessary for the nurse to frequently orientate them. Administering medications such as benzodiazepines, anticonvulsants and/or thiamine will help with symptom management. A nurse would only apply restraints if the patient was in danger of harming themselves or others and a strict protocol would apply (please refer to your organization's policy manual). Finally, a no-visitor policy would not be appropriate and is rarely enforced unless there is a special circumstance.
An 8 year-old child is admitted to the children's inpatient mental health unit. After the mother's departure, the client cries and refuses to eat dinner. Which of the following nursing actions is most appropriate? a. Offer to play with the child b. Explain that the parent will be upset if the child does not cooperate c. Tell the child that privileges will be denied for uncooperative behavior d. Remind the child of the expectation to eat some or all of the dinner
a. Offer to play with the child - Play can be used as a distraction and it also facilitates the development of a safe relationship. Play also helps children express their feelings more easily (through toys instead of words.) Setting limits is necessary, but this can be done later. Children must learn responsibility for their own behavior; it is not therapeutic to say their behavior will upset their parents.
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The nurse should respond with which statement? a. "I must document and report any information." b. "I can't make such a promise." c. "That depends on what you tell me." d. "I must report everything to the treatment team."
b. "I can't make such a promise." - Secrets, inappropriate in therapeutic relationships, are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others on the unit. The nurse should honor and help clients to understand the rights, limitations and boundaries regarding confidentiality and professional relationships
A client of Hispanic heritage refuses emergency unit treatment until a curandero is called. What should the nurse understand about the practices of a curandero? a. The client believes in witchcraft b. A curandero uses holistic healing practices c. Herbal preparations will be used d. A curandero offers spiritual advising
b. A curandero uses holistic healing practices - A curandero is a folk healer (or shaman) who uses a holistic approach that includes herbs, aromas and rituals, to treat the ills of the body, mind and spirit. Many times, the curandero works with traditional Western health care providers to restore health.
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to which focus? a. Yin, the negative force that represents darkness, cold and emptiness b. A failure to keep the physiological processes of life in balance with nature and others c. Yang, the positive force that represents light, warmth and fullness d. The use of improper hot foods, herbs and plants
b. A failure to keep the physiological processes of life in balance with nature and others - Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Under normal conditions, there is a dynamic equilibrium of these two physiological processes. Yin is the negative force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness. Yang is the positive force that represents light, warmth and fullness. Illness occurs when the balance between yin and yang is broken.
A 65-year-old Hispanic-Latino client diagnosed with prostate cancer rates his pain as a six on a 0-10 scale. Other than Ibuprofen (Motrin), the client refuses all pain medication even though Motrin does not relieve his pain. What should be the next action for the nurse to take? a. Talk with the client's family about the situation b. Ask the client about the refusal of certain pain medications c. Report the situation to the primary care provider d. Document the situation in the progress notes
b. Ask the client about the refusal of certain pain medications - Belief regarding pain is one of the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Nurses should investigate the meaning of pain to each client within a cultural explanatory framework. After this initial assessment is done the other options would most likely be implemented.
A new nursing assistant is instructed to weigh clients diagnosed with anorexia nervosa only if the clients wear a gown with underwear but no street clothing. What is the rationale for this intervention? a. Symbolically removes barriers between the client and staff b. Eliminates the risk of hiding objects in clothing or shoes c. Promotes feelings of success with gaining weight d. Allows the nursing assistant to better assess the client's skin
b. Eliminates the risk of hiding objects in clothing or shoes - Some of the goals of treating anorexia nervosa are to restore clients to a healthy weight and to normalize eating patterns. Clients should be weighed in the morning, after they have voided. They are only to wear a (hospital) gown and underwear; wearing street clothing allows the client to hide objects in pockets (or shoes) that will add weight. Some therapists believe the client should initially be weighed "blind" (backing up onto the scale) so they can't see the numbers. Regardless of how it's done, being weighed is anxiety-provoking for the client. Recall that nursing assistants cannot assess clients.
A client who is thought to be homeless is brought to the emergency department (ED) by the police. The client is unkempt, has difficulty concentrating, is unable to sit still, and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? a. Allow the client to randomly move about the holding area until a hospital room is available b. Locate a room that features minimal stimulation during the admission process c. Isolate the client in a secure room until control is regained by the client d. Engage the client in an activity that requires focus and individual effort
b. Locate a room that features minimal stimulation during the admission process - To be placed in a room with minimal stimulation allows the client with moderate anxiety or agitation to have human contact in an environment that does not exacerbate the condition. It also facilitates efficiency in the initial screening and admission process to the ED. By preventing behavioral escalation, this approach promotes safety for the client and staff.
The nurse is meeting a client for the first time. The client has told the nurse that he does not take his medication as prescribed. Which is the best response: a. You must take your medication otherwise your condition will worsen b. Tell me more about why you are not taking the medication as prescribed c. If you continue to be non-compliant there is nothing more we can do for you d. If the medication is too expensive we can call your health insurance plan for you
b. Tell me more about why you are not taking the medication as prescribed - The nurse must explore the reasons for non-compliance before it can be addressed. Asking why is the starting point. Shaming a client is not therapeutic nor does it show a genuine concern for the client's well-being. The nurse also should not assume why a patient is non-compliant, as shown in the last answer.
The nurse is caring for a client who has expressed some anxiety about their upcoming surgery. The most appropriate therapeutic response would be: a. "You should read more about the procedure before you worry." b. "You will feel much better after the surgery." c. "Tell me more about how you are feeling." d. "Don't think about all the things that could go wrong. Stay positive."
c. "Tell me more about how you are feeling." - Therapeutic communication includes using silence, open-ended questions, clarification statements and reflection. In this question, the nurse is clarifying the client's feelings for better understanding. Responses to avoid include closed-ended questions, advice-giving, as seen in answer one, reassuring statements, as seen in answer two, arguing, asking why in a disapproving way and judgmental responses as demonstrated in answer four.
The nurse is assisting a client with substance use disorder (SUD) to deal with issues of guilt. Which response by the nurse would be best for this client? a. "You've caused a great deal of pain to your family and close friends. It will take time to undo all the things you've done." b. "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior." c. "What have you done that you feel most guilty about? What steps can you begin to take to help you lessen this guilt?" d. "Don't focus on the guilty feelings. These feelings will only lead to drinking and taking drugs."
c. "What have you done that you feel most guilty about? What steps can you begin to take to help you lessen this guilt?" - The correct response encourages the client to get in touch with his/her feelings and to utilize problem-solving steps to reduce guilt feelings; this is the only option that focuses on the client's actions. The other options are statements about general thoughts, with less focus on the client. Also note that three of the options are statements; if you have no idea about the correct answer, select the odd option (the question)
The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) a. 46-year-old with end stage liver disease, on a wait list for a donor organ b. 53-year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury c. 91-year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids d. 8-year-old client with acute myelogenous leukemia, for whom all treatment options have failed e. 72-year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy
c. 91-year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids d. 8-year-old client with acute myelogenous leukemia, for whom all treatment options have failed e. 72-year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy - Hospice care provides services for clients who are at the end of their life, usually with less than six months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care.
During an interview of a new admission, the nurse notices that the client is shifting positions, wringing the hands, and avoiding eye contact. It is important for the nurse to take which of these approaches? a. Assess the client for auditory hallucinations b. Recognize the behavior as a side effect of medication c. Ask the client what the client is feeling at this moment d. Refocus the discussion on a less anxiety-provoking topic
c. Ask the client what the client is feeling at this moment - An initial step in anxiety intervention is using the senses to observe, identify, and assess anxiety behaviors. The nurse then should seek client validation of the accuracy of observations and interpretations. The nurse should avoid drawing conclusions based on limited data. In the situation above, the client may simply need to use the restroom but be reluctant to communicate this elimination need!
The nurse is talking with a client who suddenly becomes tearful and stares out the window after seeing a rose on the lunch table. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client? a. Remind the client that the abuse is over b. Remind the client that the roses are a symbol of love c. Assess if the client is having a flashback d. Assess if the client should be left alone to think
c. Assess if the client is having a flashback - Clients who have experienced a traumatic experience such as sexual abuse often experience flashbacks as a result of a trigger. Triggers can be visual, auditory, tactile or olfactory.
A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior? a. Dissatisfaction with hospital care b. Anxiety related to being hospitalized c. Early stage of alcohol withdrawal d. Shock related to the injuries
c. Early stage of alcohol withdrawal - The client is exhibiting signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). Not being satisfied with the care, anxiety or shock related to the accident are unlikely to be the cause for the physical and behavioral manifestations that the client is exhibiting.
A 15 year-old is admitted with a fracture of the arm and is told that surgery is required. A nurse finds the child crying and unwilling to talk. What is the most appropriate approach by the nurse? a. Tell the child that the surgery will have no problems b. Try to distract the child with a hand-held electronic game c. Give the child some privacy d. Make arrangements for the friends to visit as soon as possible
c. Give the child some privacy - A 15 year-old needs the opportunity to express any emotions privately. A nurse should facilitate privacy in whatever manner possible.
The nurse has been caring for a client who was seriously injured in a bus accident. Several people were killed in the accident, including the client's son. The client's spouse has had several episodes of yelling at the staff and is now threatening legal action due to "inadequate care." What intervention should the nurse implement? (Select all that apply.) a. Notify the health care provider about the situation b. Active hospital security to respond to the incident c. Provide information about grief support groups d. Request a change in client assignment e. Allow the spouse to express their feelings
c. Provide information about grief support groups e. Allow the spouse to express their feelings - Parents of children who die are at greater risk for traumatic stress. Anger and frustration are common reactions when a person is experiencing grief. The nurse should allow the spouse to verbalize their feelings because this can help with the grief process. The nurse can provide both the client and spouse with referrals to grief support groups. Notifying the health care provider is not needed at this time. Presently, the spouse is not posing a danger to the client, staff or other visitors so security is not needed. Changing the patient assignment would not facilitate a therapeutic nurse-client relationship that's needed in this situation.
At the geriatric day care program, a client who has been diagnosed with a neurocognitive disorder (dementia) is crying and repeatedly saying: "I want to go home. Call my daddy to come for me." The nurse should take which action? a. Direct the client firmly to the assigned group activity b. Inform the client that the client must wait until the program ends at 5:00 pm to leave c. Tell the client you will call someone to come get the client and suggest the client to join an exercise group while waiting d. Give the client simple information about what the client will be doing that day
c. Tell the client you will call someone to come get the client and suggest the client to join an exercise group while waiting - Comfort and distraction are key approaches in validation therapy. They are the kindest and most effective actions for clients who have varying degrees of a neurocognitive disorder (formerly referred to as dementia.) The distressed, disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. However, reorientation is often ineffective when the client is upset. Environmental changes provoke stress and fear, especially in clients diagnosed with any degree of Alzheimer's disease.
A client who is a victim of domestic violence tells the batterer: "I need a little time away." How would the nurse expect that the batterer might respond? a. With a new commitment and an opportunity to seek counseling b. With acceptance, perceiving the comment as an indication that the relationship is in trouble c. With fear of rejection, resulting in increased rage toward the client d. With relief, welcoming the separation as a means to have more personal time
c. With fear of rejection, resulting in increased rage toward the client - Those that batter others commonly react to such statements or actions with fear of rejection, abandonment and loss. These types of actions by the recipient of the battering only serve to increase the batterer's rage at the partner.
A female client is admitted for a breast biopsy. She says, tearfully, to a nurse, "if this turns out to be cancer and I have to have my breast removed, my partner will never come near me." Which of these statements would be the best response by the nurse? a. "I hear you saying that you have a fear for the loss of love." b. "You sound concerned that your partner will reject you." c. "Are you wondering about the effects on your sexuality?" d. "Are you worried that the surgery will lead to changes?"
d. "Are you worried that the surgery will lead to changes?" - By simply asking about changes, the nurse is encouraging further discussion without focusing on a specific issue. This technique of therapeutic communication will allow the client to decide what to talk about next. It is best to allow the client to identify the exact nature of the problem.
The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic violence? a. "I have only been married for two months." b. "No one else in the family is as accident prone as I am." c. "I am determined to leave my house in a week." d. "I have tried leaving home, but have always gone back."
d. "I have tried leaving home, but have always gone back." - Persons being abused or neglected often develop a high tolerance for abuse. They commonly blame themselves for being abused or neglected. All members in the family are affected by the behaviors of abuse, even if they are not the actual object of the abuse. For these reasons, persons who have been abused or neglected often have an extensive history of being abused. They struggle for a long time before actions are taken to leave permanently.
The nurse is performing an initial assessment for sports physicals at a college clinic. An 18-year old male client reveals he has legally obtained medical marijuana for his migraine headaches. Which of the following is the priority teaching point? a. "There is a concern that marijuana impairs the structure of lung tissue." b. "Marijuana use may decrease the body's ability to resist infections." c. "Frequent use of marijuana may affect a student's short-term memory." d. "It is important to avoid driving while under the influence of marijuana."
d. "It is important to avoid driving while under the influence of marijuana." - According to current research, all of the responses are correct. The prescriber should have reviewed the risks of using medical marijuana. In this case, the nurse's priority is to address any immediate safety concerns that arise from an altered mental status while operating a vehicle.
A nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's remarks most likely indicate which finding? a. Word salad b. light of ideas c. Neologisms d. Loose associations
d. Loose associations - Though the client's statements are not typical of logical communication, the second and third remark contain elements of the preceding sentence (moon, walk). Neologisms refers to making up words that have personal meaning to the client. Flight of ideas defines nearly continuous flow of speech, jumping from one unconnected topic to another. Word salad refers to stringing together real words into nonsense "sentences" that have no meaning for the listener.
A nurse is caring for a patient with a personality disorder. He comments to the nurse that she "doesn't know what she is doing because all the other nurses let him take his coffee into his room. Most of them will even bring me coffee in my room!" The nurse recognizes that this is what type of behavior? a. Potential for violent behavior b. Potential for suicidal behavior c. Impulsive behavior d. Manipulative behavior
d. Manipulative behavior - Many clients with personality disorders have self-esteem issues related to dependency. Because of this, clients may manipulate staff in this way. Attempts to manipulate is an attempt to show superiority and deny one's own feelings.
The nurse assesses the use of coping mechanisms by an adolescent one week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be observed by the nurse? a. Denial, projection, regression b. Intellectualization, rationalization, repression c. Identification, assimilation, withdrawal d. Ambivalence, dependence, demanding
a. Denial, projection, regression - Helplessness and hopelessness may contribute to regressive, dependent behavior, which often occurs at any age with hospitalization. Denial or minimization of the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.
A client reports to the nurse that he must check to make sure that the iron is unplugged 10 times before leaving the house. The nurse understands that this is the client's attempt to: a. Create anxiety for others in the home b. Reduce personal anxiety c. Reduce anxiety for others in the home d. Create a safe environment for others in the home
b. Reduce personal anxiety - A client's motivation for the obsessive/compulsive checking of the iron is to decrease their own personal anxiety. The behavior is not motivated by malicious intention or safety awareness.
Behaviors of alcohol and drug abuse have outcomes of impaired judgment and increased risk-taking behavior. What nursing diagnosis best applies to this data? a. Risk for injury b. Risk for knowledge deficit c. Altered thought process d. Disturbance in self-esteem
a. Risk for injury - Accidents increase as a result of intoxication of substances. Studies indicate alcohol is a factor in more than 50% of motor vehicle fatalities, in 53% of all deaths from accidental falls, in 64% of fatal fires, and in more than 80% of suicides.
The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) a. Opioid analgesics b. Selective serotonin reuptake inhibitors (SSRIs) c. Eye movement desensitization and reprocessing (EMDR) d. Cognitive behavioral therapies
b. Selective serotonin reuptake inhibitors (SSRIs) c. Eye movement desensitization and reprocessing (EMDR) d. Cognitive behavioral therapies - The only two FDA approved medications for the treatment of PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil). There are other medications that are helpful for specific PTSD symptoms, but narcotics should not be used since they don't relieve psychogenic pain and there's a risk of dependence. Most people who experience PTSD undergo some type of psychotherapy, most commonly cognitive-behavioral therapy and/or group psychotherapy, EMDR and hypnotherapy.
The client reports seeing spiders crawling on the walls, over the bed, and on the food tray, but denies feeling spiders crawling on the skin. The nurse determines that there are no spiders in the room. Which of the following assessments should the nurse use to document these findings? (Select all that apply.) a. Delusional thinking b. Spiders reported to be crawling on surfaces c. Visual hallucinations d. Spiders not found in the room e. Incoherent speech f. Tactile hallucinations g. Spiders reported to be crawling on client
b. Spiders reported to be crawling on surfaces c. Visual hallucinations d. Spiders not found in the room - Charting should be factual and not judgmental. It is important to evaluate the client's statements. The nurse looks to see if there are indeed spiders in the room surfaces. When the client sees something that is not present, this is called a visual hallucination. Because this client did not feel crawling spiders, tactile hallucinations is not an acceptable answer.
A newly diagnosed schizophrenic client reports to the nurse that he thinks that the employees at the fitness center are conspiring to have his membership revoked. Which of the following responses by the nurse is the most therapeutic? a. "You know that is not true." b. "Why do you feel that way?" c. "Feeling this way must be frustrating and scary." d. "You must not have taken your medication yet."
c. "Feeling this way must be frustrating and scary." - Schizophrenic clients often feel as if they are being conspired against. The most therapeutic response focuses on empathy for the client. The client feels that these feelings are real and they can't articulate why they feel the way they do or if they are able, the explanation is delusional. Medication therapy is important with this client however medication therapy takes time to become therapeutic. Additionally, not having taken a medication dose "yet" does not explain the irrational thoughts.
A client with a diagnosis of depression has recently been acting suicidal and is now more social and energetic than usual. Smiling, the client tells a nurse, "I've made some decisions about my life." What should be the nurse's initial response? a. "Are you thinking about killing yourself?" b. "I'm so glad to hear that you've made some decisions." c. "You need to discuss your decisions with your therapist." d. "Have you been thinking about suicide again?"
a. "Are you thinking about killing yourself?" - Sudden mood elevation and energy may signal a higher risk of suicide. The nurse must validate suicidal ideation as a beginning step in evaluating degree of the risk. A more direct approach is used because a threat to harm exists in the client.
The nurse is preparing interventions for a client with major depression who has been showing signs of impaired social interaction. Which of the following nursing interventions is initially appropriate for this client? a. Provide activities that require minimal concentration b. Provide activates that require concentration for improved focus c. Provide activities that include group interaction d. Provide activities that promote community support
a. Provide activities that require minimal concentration - Depressed people lack concentration and memory. Initially providing activities that require minimal concentration are appropriate to provide the opportunity for success and improve self-esteem. Providing activities that involve concentration, group and community interaction are interventions that are appropriate, however not initially.
A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting or singing. Which of the following actions by the nurse is an example of cultural awareness? a. The nurse contacts social services to perform a home evaluation before the newborn is discharged. b. The nurse notifies the nursing supervisor to request that the parent stop chanting or singing because of noise concerns. c. The nurse begins a discussion with the client's parent by asking, "Tell me about other traditions that your tribe uses?" d. The nurse silently reflects about how her biases regarding Native Americans can influence how she approaches the client's parent.
d. The nurse silently reflects about how her biases regarding Native Americans can influence how she approaches the client's parent. - Native Americans encompass diverse tribal groups with differing practices, traditions and ceremonies. Tribal traditions may vary, but similarities across traditions include the use of sweating and purging, herbal remedies and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people and promote wholeness and healing.Cultural awareness can be defined as an in-depth self-examination of one's own background and recognizing one's biases, prejudices and assumptions about other people.
