NCO Stress and Coping

Which response would the nurse provide to a client who expresses malignancy fears associated with the pending bone biopsy report? "Worrying is not going to help the situation." "Let's wait until we hear what the biopsy report says." "It is very upsetting to have to wait for a biopsy report." "Operations are not performed unless there are no other options."

"It is very upsetting to have to wait for a biopsy report," addresses the fact that the client's feelings of anxiety are valid. Stating, "Worrying is not going to help the situation," or "Let's wait until we hear what the biopsy report says," does not address the client's concerns and may inhibit the expression of feelings. Telling the client that operations are not performed unless there are no other options is irrelevant and does not address the client's concerns.

Which nursing behavior helps establish rapport with survivors of a disaster? Evaluating Assessing Collaborating Active listening

Rapport can be established through active listening. Evaluating and assessment are steps in the nursing process and are not helpful to establish rapport. Collaboration is a behavior best used when working with others during the active stages of a disaster.

Which action would the nurse take when a disaster survivor receives a high score on one of the Impact of Event Scale-Revised (IES-R) subscales? Repeat the test. Refer for further evaluation. Nothing because this is an expected score. Assess for a history of abuse or neglect.

A high score on any IES-R subscale indicates a need for further evaluation. The test does not need to be repeated. A high score is not an expected score. A high score on all subscales requires evaluation for current or past trauma such as abuse or neglect.

A parent asks the nurse what to do when the toddler has temper tantrums. Which play materials would the nurse suggest that the child be offered as another means of expressing anger? Ball and bat Wad of clay Punching bag Pegs and pounding board

A pounding board with pegs to hammer into holes is a safe toy for toddlers because it is fairly large, easy to manipulate, and sturdy. It also provides an acceptable way for anger to be expressed. The child's motor and hand-eye coordination are too immature for the child to use a ball and bat. A wad of clay is not as effective for releasing anger as a pounding board. A punching bag is appropriate for an older child with more mature motor coordination to compensate for a moving object.

Which type of crisis is a 44-year-old single person experiencing when they lose their job and exhaust their savings and now feel despondent and hopeless? Subjective Situational Adventitious Maturational

A situational crisis involves an unanticipated loss that is apparent to others. Examples include loss of a job, death of a loved one, and a change in health status such as an amputation. A subjective (internal) crisis threatens a person's well-being but is not obvious to others. Examples of subjective crises include aging, lack of independence, and loss of faith. An adventitious crisis involves natural (e.g., hurricane, tsunami) or manmade (e.g., arson, terrorist attack) traumatic events. These crises often involve numerous losses. A maturational crisis occurs in response to stress as a person experiences a predictable change. Examples of maturational crises include adolescence, marriage, parenthood, and retirement.

Which action would promote psychological adjustment and early function after a teenager with a diagnosis of osteosarcoma has the affected leg amputated? Allow the client to change the first dressing. Help the client adjust to the temporary prosthesis. Assign the client to a room with another adolescent. Have the client meet with a member of a cancer survivor organization.

A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.

Which type of group is Alcoholics Anonymous (AA)? Social group Self-help group Resocialization group Psychotherapeutic group

AA is a self-help group of people who meet to attain and maintain sobriety. A social group centers on building interpersonal relationships through participation in mutual activities. A resocialization group centers on increasing social skills that may be diminished or lacking. A psychotherapeutic group treats mental and emotional disorders with the use of psychological techniques and always has a member of the health care profession as its leader.

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery? Explains the goals of the procedure Displays few signs of anticipatory grief Participates in learning perioperative care Verbalizes acceptance of permanent dependency needs

Active participation in learning self-care indicates emotional acceptance of the need for surgery and planning for the future after surgery. Explaining the goals of the procedure may indicate intellectual readiness but not necessarily emotional readiness. A client who displays no signs of grief with a loss like amputation may be in denial. The client need not be dependent permanently; verbalizing acceptance of permanent dependency needs indicates the need for more teaching and emotional support.

How do adolescents establish health identity during psychosocial development? Select all that apply. One, some, or all responses may be correct. By evaluating their own health with a feeling of well-being By fostering their independence within a balanced family structure By building close peer relationships to achieve acceptance in the society By achieving marked physical changes with masculine and feminine behaviors By having the ability to function normally in the absence of any disease or infirmity

Adolescents establish health identity by evaluating their own health with a feeling of well-being. They also establish health identity by being able to function normally in the absence of any disease or infirmity. An individual establishes family identity by fostering his or her independence within balanced family structure. By building close peer relationships, an adolescent establishes a group identity. The sound and healthy growth of adolescents, characterized by marked physical changes, helps build sexual identity.

Which rationale describes why steroids are administered to a client scheduled for a bilateral adrenalectomy? To foster accumulation of glycogen in the liver To increase the inflammatory action to promote healing To facilitate urinary excretion of salt and water after surgery To compensate for sudden lack of these hormones after surgery

Adrenal steroids help an individual adjust to stress. Unless received from external sources, there is no hormone available to cope with surgical stresses after an adrenalectomy. Glucose stores (glycogen) will be used by the body to adapt to surgery. Insulin is the hormone that facilitates conversion of glucose to glycogen. Steroids do not increase inflammatory reactions. Steroids will result in fluid retention, not loss.

Which therapeutic communication technique would be useful for a client with major depressive disorder? Select all that apply. One, some, or all responses may be correct. Reflecting Offering self Using silence Paraphrasing Asking open-ended questions Encouraging comparison

All Reflection helps clients better understand their own thoughts and feelings. Offering self means the nurse demonstrates interest and desire to understand. Silence gives clients time to collect their thoughts. Paraphrasing means to restate the basic content of a client's message in different, usually fewer, words. The nurse may confirm an interpretation of the client's message by using simple, precise, and culturally relevant terms, before the interview continues. Open-ended questions encourage clients to share information about experiences. Encouraging comparison brings out recurring themes and helps clients clarify similarities and differences.

Which type of crisis has occurred when a sudden terrorist act causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation? Situation-maturational Situational Maturational Adventitious

An adventitious crisis is a crisis or disaster that is unplanned and accidental; its subcategories include natural disasters, national disasters, and crimes of violence. A situational-maturational crisis is not a typical category in crisis theory. If 2 events occurred around the same time—for example, retirement (maturational crisis) and the unexpected death of a spouse (situational crisis)—the client would have to deal with both issues. A situational crisis results from an external source and the loss is often unexpected. A maturational crisis occurs as an individual moves into a new stage of development and prior coping styles are no longer effective; maturational crises are usually predictable.

Which feelings would be the basis for the ritualistic behavior seen in clients with obsessive-compulsive disorder? Anxiety and guilt Anger and hostility Embarrassment and shame Hopelessness and powerlessness

Anxiety and guilt would be the feelings for the basis of the ritualistic behavior. Ritualistic behavior seen in obsessive-compulsive disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt. Hopelessness and powerlessness are feelings in depression, not for the ritualistic behavior in obsessive-compulsive disorders.

A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. Which response would the nurse give? "Tell me what you know about Down syndrome." "I would just continue to rest and recover from your delivery." "You really need to pull yourself together for your baby." "Should I call in a chaplain or social worker for you?"

Asking the client what she knows about Down syndrome is an open-ended question that will facilitate teaching and open dialogue. Telling the client to just recover is not addressing the client's emotional adjustment. Chastising the client for emotional expression will block further dialogue. A chaplain or social worker is not needed at this moment but could potentially be used later.

Which action would the nurse take when a 3-year-old child whose parents have been unable to visit since the child has been in the hospital has become quiet and withdrawn? Bring the child a stuffed animal to cuddle. Contact the parent to encourage them to visit the child. Encourage the child to play games with the other children. Assign the same nurse to care for the child whenever possible.

Assigning the same nurse when possible ensures the presence of a familiar, consistent caregiver with whom the child can relate. Bringing the child a stuffed animal may provide some comfort, but the child needs to receive love and attention from an adult. Encouraging the parent to visit may increase the parents' guilt and anxiety; the data given indicate that the parents have been unable, not unwilling, to visit the child. Playing games with other children may provide some comfort, but the child still needs to receive love and attention from an adult.

Which source of stress would the nurse anticipate in a 4-year-old child? Attention Confusion Stranger anxiety Separation anxiety

Attention is a particular source of stress in 4-year-olds. A child in this age group likes to talk and is frustrated if ignored or put off. Confusion and stranger anxiety are sources of stress in 3-year-olds. Separation anxiety is a source of stress to 3-year-olds and 5-year-olds as well.

Which areas are sources of stress in 4-year-old children? Select all that apply. One, some, or all responses may be correct. School Attention Insecurity Activity level Separation anxiety

Attention, insecurity, and activity level are sources of stress in 4-year-old children. School and separation anxiety are sources of stress in 5-year-old children.

A pregnant client tells the nurse that she has two toddlers at home and that their father abandoned the family last month and she doesn't know what to do. Which conclusion would the nurse make about the client's emotional state? She is angry that the father has left. She feels overwhelmed by the situation. She is expressing ambivalence about her pregnancy. She is denying the reality of her pregnancy.

Because of the difficult home situation, this client is experiencing multiple stressors that could cause difficulty with coping. The client also directly tells the nurse that she doesn't know what to do, suggesting that she is overwhelmed with her situation. There is no information to support the conclusion that the client is angry or that she is ambivalent about the pregnancy. The client is attending the prenatal clinic, which indicates that she is aware of reality and is not in denial.

Which behavior is characteristic of panic during a crisis? Being physically immobile Sobbing for no apparent reason Difficulties with falling asleep Startling to loud noises and touch

Being unable to physically move is a psychomotor characteristic of extreme panic during a crisis. Sobbing, difficulties with sleep, and startling are associated with lower levels of anxiety.

Which action by the nurse would be therapeutic after obtaining the consent of an adolescent girl who is concerned about her body image after amputation of a leg for bone cancer? Encouraging her peers to visit Keeping her lower body covered Placing her in a room by herself Limiting her visitors to the family

Encouraging her peers to visit

Which explanation for the client's behavior would be useful to consider in planning care for a client who has been on hemodialysis for 2 years, communicates in an angry, critical manner, and does not adhere to the prescribed medications and diet? An attempt to punish the nursing staff A constructive method of accepting reality A defense against underlying depression and fear An effort to maintain life and to live it as fully as possible

Both hostility and noncompliance are forms of anger that are associated with grieving. The client's behavior is not a conscious attempt to hurt others but a way to relieve and reduce anxiety within the self. The client's behavior is a self-destructive method of coping, which can result in death. The client's behavior is an effort to maintain control over a situation that is really controlling the client; it is an unconscious method of coping, and noncompliance may be a form of denial.

Which statement best defines a crisis? A threat to equilibrium An imbalance of emotions Client's perception of the problem Circumstance that requires external resources

Caplan's theory states that a crisis is an internal disturbance caused by a stressful event that alters the usual way of coping with a threat to the self; this temporarily disturbs the person's equilibrium. Emotional instability may occur during a crisis, but many factors, such as past experience, availability of support systems, and use of coping mechanisms, will affect emotional state. The client's perception of problem is assessed in the first phase of crisis intervention; the assessment is then used to determine the effect of crisis and to plan interventions. External resources are identified and mobilized to assist in crisis resolution.

A child with cystic fibrosis (CF) has been admitted with a respiratory infection. The child has been very disruptive and angry with staff and parents. Which reason would the nurse suspect is the cause for the child's uncooperative behavior? Spoiled and needs to be adequately disciplined Resentful of the restriction of the hospitalizations Having a reaction to the new respiratory medications Angry about dietary restrictions related to the disease

Children with CF often become resentful of repeated hospitalizations, the disease itself, and restrictions on their activities. It is judgmental to assume that the child is spoiled, and the child has had dietary restrictions in place since diagnosis of the disease, so this is not a new issue. Although new medications may have side effects, they are rarely behavioral in nature.

Which goal is appropriate when treating anorexia nervosa? Select all that apply. One, some, or all responses may be correct. The development of a calorie-restricted diet plan The development of a regular exercise schedule The repairing of family interactions The reinstitution of normal nutrition to counteract a state of malnutrition The correction of deficits and distortions in psychological functioning via psychotherapy

Clients with anorexia nervosa have a pathological fear of becoming overweight. This is characterized by reduced nutritional food intake, causing progressive weight loss and malnutrition. These clients usually have impaired family interactions due to low self-esteem. The treatment goals should consist of repairing family interactions, reinstituting normal nutritional meals, and correcting deficits and distortions in psychological functioning.

The nurse should expect to take which action to help alleviate anxiety for a client scheduled for a colostomy? Administer the prescribed as-needed (PRN) sedative. Encourage the client to express feelings. Explain the post procedure course of treatment. Reassure the client that there are others with this problem.

Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus would be on the client, not others. Reassurance may cut off communication and deny emotions.

Which response would the nurse give when a client with varicose veins asks the nurse, "What can I do to help myself?"? "Limit walking to as little as possible." "Reduce fluid intake to 1 L of liquid a day." "Apply moisturizing lotion on your legs several times a day." "Put on compression hose before getting out of bed in the morning."

Compression hose provides external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. Because venous return is better at night when the legs are at the same level as the heart, the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin suppler, it will not treat enlarged and tortuous veins.

A coworker's mother died 16 months ago, and she now cries whenever someone uses 'mother' in casual conversation. Which conclusion would the nurse make about this behavior? Crying is an expected response to death. Excessive crying is an attention-seeking behavior. The coworker may need help with grieving. The coworker was extremely attached to her mother.

Crying is a release, but effective coping mechanisms should have developed. The coworker may need help with the grieving process. At 16 months after the death of a loved one, excessive crying is not an expected response. The nurse would not conclude that the coworker is seeking attention without conducting additional assessment. Concluding that the coworker was extremely attached to the mother is an unvalidated assumption.

Which aspect of the client's life is most important for the nurse to explore when obtaining a health history from a client newly diagnosed with cervical cancer? Sexual history Support system Obstetric history Elimination patterns

During a health crisis, the client will need support from significant others. The sexual history is important in diagnosis and the obstetric history and elimination patterns are important parts of the medical history; however, none are the priority at this time.

Which resources enable the family of a preschool-aged child to develop and adapt to stressors? Select all that apply. One, some, or all responses may be correct. Education Communication Problem-solving Prior experiences Adequate finances

Education, prior experiences, and adequate finances are all resources that enable families to develop and adapt to stressors. Although effective communication and problem-solving enable families to develop and adapt to stressors, these are not considered resources.

Which instruction would the nurse include when preparing discharge instructions for a client who will take enalapril for hypertension? "Change to a standing position slowly." "This may color your urine green." "The medication may cause a sore throat for the first few days." "Schedule blood tests weekly for the first 2 months."

Enalapril is classified as an angiotensin-converting enzyme (ACE) inhibitor. Like many antihypertensives, it can cause orthostatic hypotension. Clients should be advised to change positions slowly to minimize this effect. This medication does not alter the color of urine or cause a sore throat the first few days of treatment. Presently, there are no guidelines that suggest blood tests are required weekly for the first 2 months.

Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? Lack of interest in family and others Reliving the trauma in dreams and flashbacks Avoidance of situations that resemble the stress Blunted affect when discussing the traumatic situation

Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.

Which factor may influence an adolescent to begin smoking? Select all that apply. One, some, or all responses may be correct. Peer pressure Academic success Involvement in sports Imitating adult behavior of smoking Imitating lifestyles portrayed in movies and advertisements

Factors that influence an adolescent to smoke include peer pressure, imitating adult behavior of smoking and lifestyles portrayed in movies. Succeeding in academics and being involved in sports are considered protective against an adolescent's beginning to smoke.

A 28-year-old is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at the follow-up appointment? Focusing on the client's physical needs Encouraging the client to verbalize feelings about the loss Reminding the client that she will be able to become pregnant again Encouraging the client to think of herself, her husband, and their future

Focusing on the client's physical needs demonstrates understanding of grief work; however, the nurse would first help the client resolve the current problem. Although the client's physical needs are important, they comprise only a part of the necessary interventions; the client needs help to cope with her loss. Reminding the client that she will be able to become pregnant again does not demonstrate understanding of the grieving process; the current loss must be dealt with before the client can move on to planning for the future. Encouraging the client to think of herself, her husband, and their future does not demonstrate understanding of the grieving process; the current loss must be dealt with before the client can move on to planning for the future.

The nurse advises a client with anxiety to focus on a positive scene. Which relaxation technique is the nurse using? Biofeedback Meditation Guided imagery Progressive muscle relaxation

Guided imagery is the process of using pleasant images to help reduce stress and anxiety levels. Biofeedback uses precise measurements of specific indicators to help users learn to control them. Meditation is a discipline that trains the mind to produce calm and insight into one's life. It involves concentrating on a specific object or sound, such as breathing or a flickering candle, to quiet the mind. Progressive muscle relaxation is the deliberate tensing and relaxing of specific muscles to elicit the relaxation response.

A recently widowed client says, 'His death has complicated my life even more than the hassles he caused when he was alive!' Which term would best describe the marital relationship? Loving Long-term Ambivalent Subservient

If the relationship was ambivalent, the surviving spouse now has feelings of anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the subservient role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

Which factor is most critical for a single mother of 2 children who recently lost her job and does not know what to do? Developmental history of children Available situational supports Underlying unconscious conflict Willingness to restructure lifestyle

In a crisis intervention, the priority is to identify personal internal strengths and support systems. The nurse would ask about the children; developmental history could be an important issue (e.g., child with special needs). Identifying unconscious conflicts takes a long time and is a not a crisis intervention goal. Willingness to restructure lifestyle may be necessary, but this is not a priority goal.

Which information would the nurse include in the teaching plan for the client who is prescribed sumatriptan for migraine headache? It should be administered when headache is at its peak. It should be administered by deep intramuscular injection. Is contraindicated in people with coronary artery disease. Injectable sumatriptan may be administered every 6 hours as needed.

In addition to promoting therapeutic cerebral vasoconstriction, sumatriptan promotes undesirable coronary artery vasoconstriction. Coronary vasoconstriction may cause harm to the client with coronary artery disease. For maximum effectiveness, sumatriptan should be administered at the onset of migraine headache. Sumatriptan may be given orally, subcutaneously, or as a nasal spray. The maximum adult dose of sumatriptan is two 6-mg doses in a 24-hour period for a total of 12 milligrams. The two doses must be separated by at least an hour. The second dose should not be administered unless some response was observed with the first dose.

Which rationale explains the function of obsessions and compulsions for a client with an obsessive-compulsive disorder? Unconscious control of unacceptable feelings Intentional act to punish self for shortcomings Obedience to voices that direct behaviors Symbolic reenactment of punishing others

In carrying out the compulsive ritual, the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The compulsions do not fill the need to punish self or others. Hallucinations are not part of this disorder.

A parent with newly diagnosed ovarian cancer asks the nurse how they should answer if their child asks, "Are you going to die?" Which would the nurse advise the parent to answer? "No, but why do you ask that?" "I might, but can we talk about this later?" "Everyone dies, but I'll be around for a long time." "I don't know, but I'm going to try very hard to stay alive."

In the first discussion the mother should convey some facts, but not overload the child with details, and offer hope; honest answers are important for the child's sense of security and well-being. An 8-year-old child may not be able to respond to the "Why?" question and become anxious, overwhelmed, and defensive. Avoiding an answer may close off communication and increase feelings of uncertainty and anxiety. Promising to stay alive constitutes false reassurance because the mother's prognosis is uncertain at this time.

Which age group of hospitalized children will have the most difficulty with separation anxiety? 6 to 30 months 36 to 59 months 5 to 11 years 12 to 18 years

Infants and toddlers ages 6 to 30 months experience separation anxiety. Separation anxiety occurs in preschool and young school-aged children, but it is less obvious and less serious than it is in the toddler. The school-aged child is more accustomed to periods of separation from parents. Adolescents when hospitalized are often ambivalent about whether they want their parents with them. Peer group separation may pose more anxiety for the adolescent.

Which suicide method would indicate a low threat of lethality? Hanging Ingesting pills Jumping from a tall bridge Poisoning with carbon monoxide

Ingesting pills is considered the least lethal of these suicide methods, because it is considered slower. Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.

Place the five stages of grieving identified and described by Elisabeth Kübler-Ross in order of progression from first to last. 1.Denial 2.Bargaining 3.Anger 4.Depression 5.Acceptance

Initially when someone is coping with grief, there is a refusal to believe that the loss has occurred or is going to occur (denial), and individuals are in a state of shock. As awareness of the loss increases, people usually become angry and cannot understand why this is happening. Coping then moves into the stage of bargaining, in which the dying or grieving person attempts to avoid the loss by gaining more time. This is followed by depression, when loss and grief become undeniable. Finally, individuals may progress to the stage of acceptance after coming to terms with the loss.

Place the five stages of grieving identified and described by Elisabeth Kübler-Ross in order of progression from first to last. Denial Anger Bargaining Depression Acceptance

Initially when someone is coping with grief, there is a refusal to believe that the loss has occurred or is going to occur (denial), and individuals are in a state of shock. As awareness of the loss increases, people usually become angry and cannot understand why this is happening. Coping then moves into the stage of bargaining, in which the dying or grieving person attempts to avoid the loss by gaining more time. This is followed by depression, when loss and grief become undeniable. Finally, individuals may progress to the stage of acceptance after coming to terms with the loss.

Which defense mechanism would a nurse determine is being used by client who was recently diagnosed as having myelocytic leukemia and discusses the diagnosis by referring to statistics, facts, and figures? Projection Sublimation Identification Intellectualization

Intellectualization is the use of reasoning and thought processes to avoid the emotional aspects of a situation; this is a defense against anxiety. Projection is denying unacceptable traits and regarding them as belonging to another person. Sublimation is a defense wherein the person redirects the energy of unacceptable impulses into socially acceptable behaviors or activities. Identification is the reduction of anxiety by imitating someone respected or feared.

Which intervention is most important to assist a couple to cope with their feelings about the husband's terminal illness? Referring the husband to a psychotherapist for help in dealing with his anger Placing the couple in a couples' therapy group that addresses terminal illness Helping the couple express to each other their feelings about his terminal illness Encouraging the wife to verbalize her feelings to a therapist in individual therapy

It is important for the couple to discuss their feelings to maintain open communication and support each other. Referring the husband to the psychotherapist for help in dealing with his anger will not meet the needs of this couple. A couples' therapy group that addresses terminal illness may be useful in the future, but this couple need to work through their own feelings first. Encouraging the wife to verbalize her feelings during individual sessions will not directly improve communication between the husband and wife; this is the primary goal.

Which key factor would the nurse consider when assessing how a client will cope with body image changes? Suddenness of the change Obviousness of the change Extent of the change Perception of the change

It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

Which benefit would a client expect from joining a self-help group after being discharged from a mental health facility? Getting support from group members Learning about confrontation techniques Working on self-awareness exercises Practicing psychotherapy interventions

Members of a self-help group share similar experiences and can provide valuable understanding and support for each other. Although confrontation and self-awareness may occur, these are not the primary purposes of self-help groups. Self-help groups provide an opportunity for people to interact, but not to engage in professional psychotherapy.

Which statement reflects Neuman's theory? Developed from anthropology Views the client as an adaptive system Based on stress and the client's reaction to the stressor Defines the outcomes of the nursing activity based on humanistic aspects of life

Neuman's theory is based on stress and the client's reaction to the stressor. In this model, the client is the individual, group, family, or community. The system is composed of five concepts that interact with one another: physiological, psychological, sociocultural, developmental, and spiritual. Leininger's theory is based on anthropology. Roy's adaptation model views the client as an adaptive system. Jean Watsonu2019s theory of transpersonal caring defines the outcome of the nursing activity with regard to the humanistic aspects of life.

Which action will the nurse take when caring for a terminally ill client receiving a morphine drip that exceeds the typical recommended dosage whose spouse tells the nurse that the client is again uncomfortable and needs the morphine increased (The prescription states to titrate the morphine to comfort level)? Add a placebo to the morphine to appease the spouse. Discuss with the spouse the risk for morphine addiction. Assess the client's pain before increasing the dose of morphine. Check the client's heart rate before increasing the morphine to the next level.

Over time clients receiving morphine develop tolerance and require increasing doses to relieve pain, thus requiring continuing reassessments to ensure that the client does not have signs of toxicity such as respiratory depression. Adding a placebo to the morphine to appease the spouse will not meet the client's need for relief from pain. The client is terminally ill, so the risk for addiction is of no concern. The respiratory, not heart, rate is the significant vital sign to be monitored; morphine depresses the central nervous system, specifically the respiratory center in the brain.

Which response would the nurse give when an adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations? By withholding the medication to help prevent addiction By stating that the limb has been removed and that the pain is psychological By acknowledging that the pain is real and administering medication to relieve it By explaining that the phantom limb sensation will subside within a few more days

Pain medication is required, along with intensive supportive nursing care. To the client the pain is real, requiring pain medication; addiction is not a concern at this time. Explaining that the pain is psychological in origin does not help relieve the pain; medication and emotional support are required. The pain may not recede within a few days; pain medication should be administered.

Which intervention is most helpful for parents who just learned that their newborn baby has a heart defect? Have the parents talk with other parents. Explain the diagnosis in a variety of ways. Encourage the expression of their feelings. Assure the parents that surgery will correct the problem.

Parents need to express and deal with their feelings, after which they may be able to move toward other coping strategies. Having the parents talk with other parents does not focus on their present concern but could be useful sometime in the future. Explaining the diagnosis in a variety of ways might be useful if parents are having difficulties in understanding the health problem. Assuring the parents that surgery will correct the problem is premature and possibly false reassurance.

Which is the most appropriate nursing intervention when providing care for parents who have experienced a stillbirth? Giving a detailed explanation of what may have caused the stillbirth Providing the parents the opportunity to say goodbye to their newborn Explaining that an autopsy is not recommended in the setting of a stillbirth Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief

Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse would provide this opportunity. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question 'Why?' if there is a chance that the cause of death can be determined. Before the parents leave the hospital, arrangements for follow-up care should be made. This information should be provided immediately, because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs.

Which action by the nurse would be therapeutic after obtaining the consent of an adolescent girl who is concerned about her body image after amputation of a leg for bone cancer? Encouraging her peers to visit Keeping her lower body covered Placing her in a room by herself Limiting her visitors to the family

Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers and family.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. One, some, or all responses may be correct. Acute illness Pregnancy Drug abuse Chronic illness Sexual orientation

Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

Which information would the nurse provide to maintain a positive self-image during treatment of a 13-year-old with idiopathic scoliosis who is upset about the treatment regimen and is worried about being different from peers? Remind the client of consequences if he or she refuses treatment. Help investigate appropriate clothing to minimize appearance of the brace. Disregard negative characteristics and focus on positive attributes. Refer the client for psychological counseling until the treatment program is completed.

Rationale Clothes can be selected to minimize the appearance of a brace, especially if an effort is made to wear current styles. Reminding the child how they will look without treatment has a negative connotation that emphasizes the problem. Focusing only on positive attributes may be misinterpreted as unqualified praise; adults should give honest appraisals of both positive and negative attributes. There are no data to indicate that the child will not adjust to the treatment regimen

The nurse hears a child who was not invited to a sleepover say, 'I have better things to do than go to that sleepover.' Which defense mechanism would the nurse conclude the child is using? Denial Projection Regression Rationalization

Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation; the child is not avoiding the reality of the sleepover. Projection is blaming others for one's shortcomings; the child is not blaming others for not being invited to the sleepover. Regression is returning to an earlier more familiar mode of behavior; the child is not regressing.

A community health nurse makes a home visit to a disabled 13-year-old client who has a 6-month-old infant sister. The infant lies quietly in her crib and rarely smiles or vocalizes; it appears that the infant barely has her basic needs met. Which is the nurse's most appropriate action? Advise the parent that the infant will be delayed developmentally if not stimulated. Ask the disabled client to spend more time playing with the sister. Encourage purchasing toys that are appropriate for the infant's age level. Determine whether there is anyone who can help with chores and the infant's care.

Recruiting someone to help with chores and infant care will allow the parent time to rest and will provide the infant with care and attention. Making the parent feel guilty is not therapeutic and will increase anxiety. The disabled sibling requires attention, and this responsibility may cause jealousy, rivalry, and resentment. Toys need not be employed for sensory stimulation; household objects and quality human contact can serve as well.

Which therapeutic communication technique would be useful for a client with major depressive disorder? Select all that apply. One, some, or all responses may be correct. Offering self Using silence Paraphrasing Asking open-ended questions Encouraging comparison

Reflection helps clients better understand their own thoughts and feelings. Offering self means the nurse demonstrates interest and desire to understand. Silence gives clients time to collect their thoughts. Paraphrasing means to restate the basic content of a client's message in different, usually fewer, words. The nurse may confirm an interpretation of the client's message by using simple, precise, and culturally relevant terms, before the interview continues. Open-ended questions encourage clients to share information about experiences. Encouraging comparison brings out recurring themes and helps clients clarify similarities and differences.

An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parent asks whether this is abnormal or morbid behavior picked up from playing video games. Which is the best response by the nurse? "Playing video games can cause morbid behaviors." "Children handle the event of death more realistically than adults do." "School-aged children are inquisitive and ask a lot of questions about death." "Giggling, attracting attention, and playing are the usual ways of dealing with death."

School-aged children handle death by asking questions and gaining information. Playing video games does not change the essential ways in which children deal with the deaths of loved ones. Children are unable to understand the finality of death until they have reached school age; they begin to think about it in idealistic ways by adolescence. Giggling and playing are a preschooler's reactions to death.

Which behavior would the nurse expect a client to exhibit during the initial stage of grieving after learning that a tumor is malignant and has metastasized to several organs and that the illness is terminal? Crying uncontrollably Criticizing medical care Refusing to receive visitors Asking for a second opinion

Seeking other opinions to disprove the inevitable is a form of denial employed by individuals who have illnesses with a poor prognosis. If the client is crying, the client is aware of the magnitude of the situation and is past the stage of denial. Criticism that is unjust often is characteristic of the stage of anger. Refusing to receive visitors is most common during the depression experienced as one moves toward acceptance or during the acceptance stage.

Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? Sharing hope Sharing humor Sharing empathy Sharing observations

Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses would recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client communicate without the need for extensive questioning, focusing, or clarification.

Which strategy would the nurse use to help a depressed, withdrawn client who exhibits sadness through nonverbal behavior? Increase structured physical activity. Cope with painful feelings by sharing them. Decide which unit activities the client can perform. Improve the ability to communicate with significant others.

Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing of these feelings usually decreases depression. Increasing structured physical activity or deciding which unit activities the client can perform will do little to decrease the client's sadness and does not consider the client's low level of energy. Improving the client's ability to communicate with significant others may be important for the future, if a problem exists, but the sharing of painful feelings is more important than improving communication with significant others.

A client has terminal cancer after 7 years of chemotherapy and surgeries. The nurse enters the client's room and finds the client crying. Which is the correct intervention by the nurse? Sit down quietly next to the bed and allow the client to cry. Pull the curtain and leave the room to provide privacy for the client. Explain to the client that these feelings are expected, and they will pass with time. Observe the length of time the client cries and document the client's difficulty in accepting impending death.

Sitting down quietly next to the bed and allowing the client to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that these feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time the client cries is unimportant at this time. Assuming that the client is having difficulty accepting impending death is a conclusion without enough information.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention? Sitting quietly with the client Telling the client that crying is not helpful Suggesting that the client play a board game Recommending how the client can change this situation

Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

Which factors affect the stress that first responders feel after a mass casualty incident (MCI)? Select all that apply. One, some, or all responses may be correct. Age Gender Nature of event Coping mechanisms Psychological history

Stress that occurs for first responders after an MCI can persist for an extended period and is influenced, in part, by the nature of the event, the individual's age, preexisting coping mechanisms, role in the event, and medical and psychological history. Gender does not influence the effect that stress has on the first responder after an MCI.

Which suggestion would the nurse make for a client with heart failure? 'Take a hot bath before bedtime.' 'Avoid emotionally stressful situations.' 'Avoid sleeping in an air-conditioned room.' 'Exercise daily to a pulse rate of 100 beats/minute.'

Stressful situations increase the body's oxygen demands. Clients with a low cardiac reserve cannot tolerate extremes of temperature; a hot bath increases the body's oxygen demands. Hot, humid weather is detrimental for those with heart disease; these individuals should use an air conditioner. Clients with heart failure should exercise daily, but may not be able to tolerate high heart rates.

Which behavior indicates that the client has learned the most effective method to cope with anger? Goes for a long jog Talks about the anger Goes outside and screams Focuses on cause of anger

Talking about angry feelings is better than acting them out; this response indicates that the client has learned a positive coping method. Although taking a long jog or going outside to scream may help, these are isolated activities that do not permit sharing of feelings. Focusing on the cause may result in an escalation of angry feelings.

Which factor would be a major concern for a 15-year-old client who is undergoing chemotherapy for leukemia? Missing time at school Limiting social activities Being dependent while enjoying the sick role Feeling different regarding changes in body image

The 15-year-old is preoccupied with appearance. The side effects of the antineoplastics and prednisone may result in the adolescent feeling different, which affects body image. Although missing school may be a concern, it is typically not the primary concern. Although limitation of social activities is a concern, it is not the primary concern. Socialization can be facilitated. A 15-year-old enjoys and strives for independence and does not enjoy the sick role.

Which goal is the purpose of critical incident stress debriefing (CISD) after a disaster? Evaluate the outcomes of the care provided. Prevent post-traumatic stress disorder (PTSD). Ensure all documentation has been completed. Determine if role assignments need to be adjusted.

The CISD addresses precrisis through postcrisis interventions. After working through the turmoil and the emotional impact of the incident as well as the aftermath, the staff may find it difficult to "get back to normal." Without intervention during and after the emergency, they may develop PTSD. The CISD is not conducted to evaluate outcomes of care, ensure documentation is completed, or analyze role performance during the disaster.

Which statement regarding Roy's theory of nursing needs correction? The Roy adaptation model views the environment as an adaptive system. The need for nursing care occurs when the client cannot adapt to internal and external environmental demands. The goal of nursing is to help the client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

The Roy adaptation model views the client as an adaptive system. The need for nursing care occurs when a client cannot adapt to internal and external environmental demands. Roy's model believes the goal of nursing is to help a client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

Which approach would the nurse take for a client who was involved in a near-fatal automobile collision and arrives at the crisis center with reports of anxiety and flashbacks? Focusing on the present Identifying past stressors Discussing a referral for psychotherapy Exploring the client's history of mental health problems

The approach would be focusing on the present because the client is in a crisis. Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.

A client with untreatable metastasized cancer tells the nurse, 'I think they made a mistake. I don't think I have cancer. I feel too good to be dying.' Which stage of grief is the client experiencing? Anger Denial Bargaining Acceptance

The client has difficulty accepting the inevitability of death and attempts to deny the reality of it. In the anger stage, the client is angry about the impending death and strikes out with statements such as, 'Why me?' and 'How could God do this to me?' In the bargaining stage, the client attempts to bargain for more time; the reality of death is no longer denied, but the client tries to manipulate and extend the remaining time. In the acceptance stage, the client accepts the inevitability of death and quietly awaits it.

Which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with obsessive-compulsive disorder? Has overwhelming feelings of anxiety Resents the nurse's authoritarian manner Is clashing with the nurse's personality Reflects an aggressive characteristic

The client has overwhelming feelings of anxiety. The ritual reduces anxiety; when not permitted to complete the ritual, a client with an obsessive-compulsive disorder will experience increased anxiety, frustration, and anger, and he or she may act out. The client is experiencing anxiety not related to the nurse's manner, personality clash, or an aggressive characteristic.

The nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? Family in later life Family with adolescents Unattached young adult Launching children and moving on

The client is adjusting to a reduction in family size after the adult children have left home in search of work and is going through the launching children and moving on stage of the family life-cycle. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescence stage of the family life cycle involves establishing flexible boundaries to accommodate the growing child's independence. Individuals experiencing the unattached young adult stage begin to differentiate themselves from their families of origin.

Which intervention is the most important for a young female client who was raped 3 days ago and continually talks about the trauma of being sexually assaulted? Getting her involved with a rape therapy group Remaining available and supportive to limit destructive anger Exploring her feelings about men to promote future relationships Providing a safe environment that permits the ventilation of feelings

The client needs to be able to express her current feelings in a safe environment. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.

Which definition describes the defense mechanism of sublimation? Returning to an earlier, less mature stage of development Acting out a conscious behavior that is the opposite of an unconscious feeling Channeling unacceptable impulses into socially appropriate behavior Excluding from consciousness thoughts that are psychologically disturbing

The individual using sublimation attempts to fulfill desires by selecting a socially appropriate activity rather than one that is socially unacceptable. Returning to an earlier, less mature stage of development is regression. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling. Repression is excluding psychologically disturbing thoughts from the consciousness.

Which initial action would the nurse take for a newly admitted client who reports memory loss, nervousness, insomnia, and fear of leaving the house? Evaluate the client's adjustment to the unit. Provide the client with a sense of security and safety. Explore the client's memory loss and fear of going out. Assess the client's perception of reasons for the hospitalization.

The initial action is to provide the client with a sense of security and safety. The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. It is too early to evaluate the client's adjustment to the unit. Additionally, if the client is not provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

During the first meeting of a therapy group, members exhibit frequent periods of silence, tense laughter, and nervous movements. Which conclusion would the nurse make? The group requires an active leader who will intervene to relieve signs of obvious stress. The group process is unhealthy and there is unwillingness to openly relate. The members are displaying expected behaviors because relationships are not yet established. The behaviors should be immediately addressed so members will not become too uncomfortable.

The members have not established trust and are hesitant to discuss problems; the observed behaviors reflect anxiety and insecurity. These behaviors are expected in the early stage of group interaction and are not unhealthy; active leader intervention in not necessary. Calling attention to the behaviors or intervening is not necessary; these behaviors will subside as the group progresses.

Which action by the school nurse would be most important when monitoring an adolescent who has just returned to high school after a suicide attempt? Observe the adolescent interacting with friends. Request that teachers and friends report any changes in the client's behavior. Speak with the adolescent regarding feelings about returning to school. Tell the teachers what happened and ask them whether there are any problems.

The most important action is speaking to the adolescent because the best person to obtain data from is the adolescent. Speaking with the adolescent regarding feelings about returning to school shows the adolescent that the nurse is available and is interested and concerned. Observing the adolescent interacting with friends is appropriate, but it is not the most important because this does not provide the best information; the adolescent would provide the best information. Requesting that teachers and friends report any changes in behavior will place responsibility on others and may interfere with the adolescent's relationship with them. Also, it violates the adolescent's right to privacy. Telling the teachers what happened and asking whether there are any problems violates the adolescent's right to privacy.

Which theoretical care focus does the nurse use when helping a client with depression cope after a bilateral mastectomy? Comfort Adaptation Goal attainment Human becoming

The nurse is using the theoretical focus of adaptation. Helping the depressed client "cope" or adapt to the current stressor of bilateral mastectomy is an example of Roy's Adaptation Model (RAM) in clinical practice. Comfort is the focus of Kolcaba's theory describing that nurses facilitate health-seeking behaviors in clients by striving to relieve physical, emotional, social, environmental, and/or spiritual distress. King's theory focuses on goal attainment in which the nurse views a client as a unique personal system that is constantly interacting with other systems. Human becoming is a feature of Newman's Model of Unitary Beings in which nurses view clients as unique, dynamic energy fields in constant energy exchange with the environment.

In which stage of health behavior would the nurse suspect a client, who is ambivalent about making a change in health behavior, is in? Preparation Maintenance Contemplation Precontemplation

The nurse suspects the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward change, and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.

Which nursing intervention would help a client who exhibits physical symptoms when stressed? Limiting discussions about the problem Providing information regarding medical care Teaching the client how to eliminate stress at home Assisting the client in developing new coping mechanisms

The nurse would assist the client in developing new coping mechanisms. Until the client learns new ways of coping with stress and anxiety, this pattern of behavior will continue. Learning new ways of coping with stress will help break this physiological pattern. Limiting discussion will avoid the problem. Providing information about medical care will reinforce the sick role. A certain amount of stress is present in everyday family situations; the elimination of stress is impossible.

Which guideline would the nurse consider when caring for clients who are at risk for suicide? A client who fails in a suicide attempt will probably not try again. Formal suicide plans increase the likelihood that a client will attempt suicide. It is best not to talk to clients about suicide, because it may give them the idea. Clients who talk about suicide are not planning it; they are using the threat to gain attention.

The nurse would consider the following guideline: Formal suicide plans increase the likelihood that a client will attempt suicide. A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not necessarily just to receive attention; it is a cry for help.

Which response would the nurse make to the husband who told his suicidal wife that he would bring their 26-month-old daughter to visit and asks if that would be possible? "Probably so, but you'd better check with her primary health care provider first." "Of course! Children of all ages are welcome to visit relatives." "It could be very upsetting for your child to see her mother so depressed." "Tell me what your wife said when you offered to bring your child for a visit."

The nurse would determine whether the spouse has discussed the child visiting with the client before commenting further. The responses, "Probably so, but you'd better check with her primary health care provider first," and "Of course! Children of all ages are welcome to visit relatives," assume that the client has consented to the visit; this assumption may be incorrect. The response, "It may be very upsetting for your child to see her mother so depressed," makes an assumption that requires more data and discussion to validate.

Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior? Redirect the client's energy into activities to help others. Teach the client that the behavior is not serving a realistic purpose. Administer antianxiety medications that block out the memory of internal fears. Help the client understand that the behavior is caused by maladaptive coping with increased anxiety.

The nurse would help the client understand that the behavior is caused by maladaptive coping with increased anxiety. Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Redirecting the client's energy into activities to help others is inappropriate. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Although antianxiety medication can be given, it is not to block out the memory of internal fears. It is to help decrease the anxiety to manageable levels. However, antidepressants have been proven to be more helpful.

Which initial action would the nurse take for a nursing home resident with moderate Alzheimer disease who begins to engage in numerous acting-out behaviors? Assess the client's level of consciousness Identify the stressors that precipitate the client's behavior Observe the client's performance of activities of daily living Monitor the side effects associated with the client's medications

The nurse would initially identify the stressors that precipitate the client's behavior. If the areas that cause stress can be identified, the client would be better able to control the acting-out behavior. These clients may be confused or disoriented, but they usually do not experience an altered level of consciousness; an altered level of consciousness is associated with delirium, not dementia. Although the client's performance of activities of daily living may be observed, this is only one area of function that should be assessed and it is not the initial action. The initial action would focus on the acting-out behaviors. Although monitoring the side effects associated with the client's medications is important, it is not the initial action.

Which action would the nurse take for a client diagnosed with major depression who is tearful and refuses to eat dinner after a visit with a friend? Allow the client to skip the meal. Offer an opportunity to discuss the visit. Reinforce the importance of adequate nutrition. Provide the client with adequate quiet thinking time.

The nurse would offer an opportunity to discuss the visit. Offering to discuss the visit shows support and provides the client with an opportunity to discuss feelings. Allowing the client to skip dinner does not address the client's depression. Teaching about the importance of adequate nutrition is inappropriate when a client is emotionally distressed. Providing quiet thinking time will limit further communication and may imply rejection.

Which response would the nurse make to a client diagnosed with an obsessive-compulsive disorder, who on the day of a job interview, begins to display compulsive behavior? "Going for your interview must be upsetting you. Describe what you're feeling now." "It's important for you to overcome your anxiety. You should keep that appointment." "Your actions indicate that you want to delay the interview. Do you really want the job?" "This interview seems to upset you. Do you think you should look for another kind of job?"

The nurse would say, "Going for your interview must be upsetting you. Describe what you're feeling now." The client's behaviors are a defense against anxiety resulting from having to make decisions, which triggers old fears; the client needs support. Noting that it is important for the client to overcome the anxiety and encouraging the client to keep the appointment denies the client's overwhelming anxiety and shows a lack of realistic support. Asking whether the client really wants the job is judgmental; an increase in anxiety does not necessarily mean that the client does not want to attain the goal. The client should be encouraged to work through symptoms, not to avoid risk by looking for another kind of job.

Which response would the nurse make to a client with obsessive-compulsive disorder who says, 'I know that my hands aren't dirty, but I just can't stop washing them'? 'Let's talk about why you feel that you have to wash your hands.' 'You're getting better; you're beginning to understand your problem.' 'Don't worry about it; these actions are part of your illness, and the feelings will pass.' 'I understand that—maybe we can work together to limit the number of times you wash them.'

The nurse would say, 'I understand that—maybe we can work together to limit the number of times you wash them.' The nurse shows an understanding of the client's needs by not totally restricting the hand washing and by working with the client to set limits on the behavior. The use of 'why' should be avoided because it can be perceived as confrontational and at this time the client is still too anxious to be capable of coping with the reasons for hand washing. Continued hand washing does not reveal an understanding of the underlying problem, nor is it a sign of progress. Telling the client not to worry denies the client's feelings and may close off communication.

Which behavior is most commonly used by an individual with a phobic disorder? Rumination Desensitization Avoidance Confrontation

The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Rumination (continuously rethinking about an issue) is more common in depression. Desensitization is a therapy that is used to treat phobias by systematically exposing the individual to the phobic object using a series of small steps. People with phobias fear confrontation with the phobic object and are less likely to attempt this without the help of a therapist.

Which key factor assists the nurse in assessing how a client will cope with the body image change after an above-the-knee amputation? Extent of the change Suddenness of the change Obviousness of the change Personal perception of the change

The reality of a situation is not the important issue at this time, but the client's feelings or perceptions about the change are the most important determinant of the client's ability to cope. The extent of change is not relevant; what is relevant is whether the client perceives the change as enormous or less important. Although suddenness of the change may influence a person's coping ability, this is not the primary factor influencing a client's coping mechanisms with body image changes. Although obviousness of the change may influence a person's coping ability, this is not the primary factor influencing coping mechanisms with body image changes.

Which rationale supports giving the client diagnosed with obsessive-compulsive disorder time to perform a specific ritual? It demonstrates respect for the client's autonomy. This behavior is viewed as a result of anger turned inward. Denying this activity may precipitate an increased level of anxiety. Successful performance of independent activities enhances self-esteem.

The repeated thought or act defends the client against severe anxiety. Compulsive behaviors are not autonomous choices. The client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level. Anxiety reduction, not anger, is the motivation for performing the ritual. Rituals do not enhance self-esteem; the client may be ashamed of the rituals that cannot be stopped.

Which term would the nurse use to describe a client with schizophrenia who is vacillating between being happy and sad about going home? Double bind Ambivalence Loose association Inappropriate affect

The term to describe a schizophrenic client who is vacillating between being happy and sad about going home is ambivalence. The simultaneous existence of two conflicting emotions, impulses, or desires is known as ambivalence. A single communication containing two conflicting messages is known as a double-bind message. A lack of connections between thoughts is known as loose association. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.

Which response would the nurse use as a reply to a client diagnosed with sexual dysfunction who states, "Well, I guess my sex life is over"? "I'm sorry to hear that." "Oh, you have a lot of good years left." "You are concerned about your sex life?" "Have you asked your primary health care provider about that?"

The response "You are concerned about your sex life?" explores the meaning of the statement and allows further expression of concern. The response "I'm sorry to hear that" does not allow an explanation of feelings and cuts off communication. The response "Oh, you have a lot of good years left" lacks both empathy and understanding; it also cuts off communication. The response "Have you asked your primary health care provider about that?" shirks responsibility; the client may be embarrassed to ask the primary health care provider and needs the nurse to act as facilitator.

Which statement would the nurse use in response to the needs of a client with renal colic who frequently uses the call light and has many demands the night before scheduled extracorporeal shock-wave lithotripsy? "I know how you feel; I had this same procedure last year." "We'll take good care of you, so you have nothing to worry about." "You are facing a new experience tomorrow; tell me what concerns you have." "Your behavior tells me that you are scared of what you are facing tomorrow."

The response "You are facing a new experience tomorrow" acknowledges the client's situation and allows the client to discuss feelings and fears related to the surgery. The response "I know how you feel" is inaccurate; each client's experience is unique. The response "We'll take good care of you" minimizes the client's feelings and provides false reassurance. The phrase "Your behavior tells me" may not be an accurate interpretation of the client's behavior.

Which is the most therapeutic response by the nurse to a client who is joking about dying? 'Why are you always laughing?' 'Your laughter is a cover for your fear.' 'Does it help to joke about your illness?' 'The person who laughs on the outside cries on the inside.'

The response 'Does it help to joke about your illness?' is a nonjudgmental way to point out the client's behavior. The response 'Why are you always laughing?' is too confrontational; the client may not be able to answer the question. The response 'Your laughter is a cover for your fear' is too confrontational and an assumption by the nurse. The response 'The person who laughs on the outside cries on the inside' is too judgmental, an assumption, and a stereotypical response.

After signing a legal consent for hip replacement surgery and within hours before the surgery, the client states, "I decided not to go through with the surgery." Which response would the nurse use initially? "Then you shouldn't have signed the consent." "I can understand why you changed your mind." "Tell me why you decided to refuse the operation." "Let's talk about your concerns regarding the procedure."

The response, "Let's talk about your concerns regarding the procedure," attempts to explore why the client is refusing the procedure and promotes communication. The response, "Then you shouldn't have signed the consent," is accusatory; the client has the right to withdraw consent at any time. The response, "I can understand why you changed your mind," draws a conclusion without adequate data; also, the statement may increase the client's anxiety level. The response, "Tell me why you decided to refuse the operation," may be too direct and authoritative; also the statement may put the client on the defensive.

Which assessment finding for a client who is anxious indicates sympathetic nervous system stimulation? Dry skin Skin pallor Pupil constriction Bradycardia

The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor. The sympathetic system stimulates, rather than inhibits, secretion by the sweat glands. Constriction of pupils is not under sympathetic control; the parasympathetic system constricts the pupils. The parasympathetic system (vagus nerve) slows the pulse, and the sympathetic system increases it.

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. Which approach would the nurse take when interacting with this client? Explain why there is a need to increase activity. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

The withdrawal provides time for the client to assimilate what has occurred and to integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

Which role is most important for the nurse to assume when providing therapeutic crisis intervention? Passive listener Participant observer Active participant Friendly advisor

To intervene in a crisis, the nurse must assume a direct, active role because the client's ability to cope is decreased and help is needed to solve problems. Being a passive listener or a participant observer is insufficient. Being a friendly advisor can blur the boundaries between a professional and a social relationship.

Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management? Gentle massage of the abdomen Biofeedback-assisted relaxation techniques Application of a heat pack to the lower back Selecting a focal point and beginning breathing techniques

Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? Making huge efforts to avoid 'any kind of bug or spider' Experiencing flashbacks to an event that involved a sexual attack Spending hours each day worrying about something 'bad happening' Becoming suddenly tachycardic and diaphoretic for no apparent reason

Using worrying as a coping mechanism is a behavior characteristic of GAD. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of post-traumatic stress disorder (PTSD). Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack.

Which action would the nurse take when the client still has moderate to severe anxiety after the health care provider has explained the scheduled head and neck surgery? Attempt to discover the client's concerns. Elaborate on what the health care provider has already said about the surgery. Teach the client to use the suction equipment. Plan for the client's postoperative communication with a tracheostomy in place.

Various aspects of hospitalization and diagnosis may cause the client to become anxious. The nurse would identify what concerns the client the most. Anxiety interferes with learning, and it is the health care provider's responsibility to explain the surgery. Teaching the client to use the suction equipment preoperatively may cause the client unnecessary anxiety. A tracheostomy may not be performed; it depends on the type of surgery.

Which is the correct order of phases a client experiences in the event of a change in body image? 1. Shock 2. Withdrawal 3. Rehabilitation 4. Acknowledgement 5. Acceptance

When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgment phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use the prosthesis or change lifestyles or goals.

Children with special needs have the same needs as other children, although their means of satisfying these needs may be limited. Which effect would the nurse expect that these limitations will frequently cause? Frustration Overcompensation Feelings of rejection Emotional dysfunction

When one's effort toward meeting a goal is blocked or thwarted, frustration results. The child with special needs may be repeatedly thwarted when trying to meet developmental needs, especially in an environment where certain achievements beyond the child's ability are expected. Overcompensation does not occur, because the child is not cognitively and/or physically able. Feelings of rejection are an external factor that has little to do with the child's ability to cope with limitations. Emotional dysfunction is not a frequent occurrence.

Which reason may explain irregular menses in an adolescent whose mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image? Bulimia Anorexia Orthorexia Binge disorder

Which reason may explain irregular menses in an adolescent whose mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image? Bulimia Anorexia Orthorexia Binge disorder

Which action would the nurse identify as a potential contributor to staff post-traumatic stress disorder (PTSD) during a mass casualty assessment? Working less than 12 hours Encouraging and motivating team members Working continuously without any breaks Discussing feelings with the team members

Working continuously without any breaks will result in increased stress. Working less than 12 hours may reduce stress. By motivating team members, PTSD can be prevented. By discussing feelings with team members or nurse managers, stress can be reduced.

Which physical or behavioral signs of substance abuse would a nurse observe for in the adolescent population? Select all that apply. One, some, or all responses may be correct. Worrying about being addicted Showing a high performance in social activities Experiencing an overdose or withdrawal symptoms Worrying about a friend or family member who is addicted Manifesting bizarre behavior or confusion

Worrying about being addicted, experiencing overdose or withdrawal symptoms, and manifesting bizarre behavior may be the earliest signs of substance abuse. Showing high performance in social activities and worrying about a friend or family member's substance abuse are not with a manifestation of substance abuse.