NUR 221 PrepU: Basic Psychosocial Needs.

Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for chemotherapy. When the nurse enters the client's room, the client is sobbing and states, "I thought the chemotherapy would help, but now I feel worse." Which response by the nurse is most appropriate?

"Can you tell me more about how you are feeling right now about your treatment?" Rationale: In asking the client how they are feeling about treatment, the nurse is engaging in active listening by focusing on the actual information offered by the client. This promotes interactions focused on the client's feelings and concerns. Addressing the client's feelings validates the client as a person and helps establish trust. Focusing only on side effects of chemotherapy is an assumption by the nurse and narrows the client's ability to respond. Simply making statements about how the feelings are common will not facilitate exploration of the client's feelings. Asking the client to say how the nurse can help does not encourage more discussion about how the client feels.

The son of an older adult client who has cognitive impairments approaches the nurse and says, "I'm so upset. The health care provider says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment?

"I want the social worker to make this decision so Dad won't blame me." Rationale: Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

"I will begin with inpatient treatment and participate in an aftercare program." Rationale: Inpatient treatment and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they do not address the client's need for long-term treatment.

A nurse performs a spiritual and religious assessment for a client. The client identifies as an atheist. Which statement made by the nurse ensures therapeutic communication?

"Is there anything you would like me to include in the spirituality part of your assessment?" Rationale: An atheist believes that God does not exist. The nurse shows support and provides therapeutic communication by giving the client the option to put down something else in this section of the assessment related to spirituality. The other statements compare the client's beliefs to others or border on proselytizing, which is a breach of the nurse-client relationship boundary and a breach of trust.

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The client has not smoked a cigarette for 3 weeks and tells the nurse about fears of starting smoking again because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?

"It is good that you can talk about your concerns. Try calling a friend when you want to smoke." Rationale: It is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support.Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client to anticipate failure.Telling the client to exercise more self-control does not provide support.Taking a vacation to avoid job pressures does not address the issue of how to manage the desire to smoke when in a stressful situation.

The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which statement by the nurse provides appropriate interpretation of the impact of stressors on the client's health?

"These life stressors place you at moderate risk for illness." Rationale: Holmes and Rahe's theory of stress response suggests that all life events, whether positive or negative, cause stress. The Holmes and Rahe stress scale ranks life events according to how much stress they cause. Scores are interpreted based on points accumulated. Clients who accumulate points totaling up to 150 are considered to have a low risk of developing illness in the near future. Those with points between 150 and 299 are considered to be in the moderate- to high-risk category. Clients with scores 300 and higher are at the greatest risk of stress-related illness.

A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply. A. Discuss the RN's concerns with another nurse on the unit to see what they think. B. Continue to document the behaviors, but wait until something happens to report. C. Report the behaviors to the unit manager for further investigation. D. Do nothing as the RN does not have proof of controlled substance abuse. E. Talk compassionately to the LPN/VN and discuss the RN's concerns and observations.

C. Report the behaviors to the unit manager for further investigation. E. Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. Rationale: ANA Code of Ethics for Nurses provision 3 states that nurses have a duty to protect the patient, the public, and the integrity of the nursing profession when they observe physical or mental impairment in a nurse or other healthcare professional. Substance abuse is treatable and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; she is still liable for her actions. The nurse should talk to the suspected nurse and report to management. It should not be discussed with others on the unit. It is not appropriate to wait until something happens.

A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress? A. Spiritual guilt. B. Spiritual anger. C. Spiritual alienation. D. Spiritual loss.

C. Spiritual alienation. Rationale: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used when? A. To permit her mother to seek unconventional treatments. B. Alone and not in combination with other defense mechanisms. C. When making decisions about her care. D. To allow her mother to continue in her role as a mother.

D. To allow her mother to continue in her role as a mother. Rationale: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation.

A nurse is caring for a client with advanced cancer. Based on the accompanying nursing progress notes, what should be the nurse's next intervention?

Explain the use of an advance directive to express the client's wishes. Rationale: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate their own wishes. This document can include a living will, which instructs the healthcare provider to administer no life-sustaining treatment, and a durable power of attorney for health care, which names another person to act on the client's behalf for medical decisions if the client cannot act for self. By explaining the use of an advanced directive to the client at this time, the client has the opportunity to document future wishes. The document on client rights does not specifically address the client's wishes regarding future care. Calling the spouse is a breach of the client's right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge of the resources available in the community through hospice and home care agencies in collaboration with the client's healthcare provider.

To approach a deaf client, what should the nurse do first?

Get the client's attention. Rationale: The nurse should avoid startling the client who is deaf and should obtain the attention of the client before speaking. The client who is deaf cannot hear knocking on the door or talking. Opening the blinds is not a helpful way to get the client's attention.

A client suspects the end of life is near. However, others talk about only pleasant matters and maintain a persistently cheerful facade. The nurse plans care for this client by recognizing that these behaviors will most likely cause the client to experience which feeling?

Isolation. Rationale: Clients tend to experience isolation and loneliness when those around them are trying to hide or mask the truth. They are then left to face the realities of death alone. Clients do not experience relief or hopefulness when others are falsely cheerful. Independence is promoted by offering realistic choices about care at the end of life.

Family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the patient's bedside to perform Anointing of the Sick. The nurse who is providing care for the client should recognize that the family is likely

Roman Catholic. Rationale: Among the sacraments of the Roman Catholic Church is the Anointing of the Sick. This specific rite is not a component of Jehovah's Witness, Christian Scientist, or Jewish religious belief.

A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. Which response by the nurse will be most effective?

Telling the client about her community's arthritis support group. Rationale: The client should be encouraged to join the community arthritis support group so that she can share her feelings with others who are facing similar experiences with this chronic illness and can identify with her concerns. A hobby will not help her resolve her feelings of being alone. Seeking counseling or discussing her feelings with a minister may be helpful, but these activities will not necessarily help the client to understand that there are many individuals who must adjust their lifestyles because of arthritis and that she is not alone.

Which statement best explains why the nurse should acknowledge differences between the nurse's culture and the client's culture?

The nurse may hold values that could influence the care of the client. Rationale: To avoid ethnocentric behavior toward the client, it is important that nurses understand their own cultural beliefs. Only by acknowledging their own beliefs can they be careful not to impose them on the clients they care for, thereby influencing the quality of care.It is stereotypical for nurses to assume that they can determine which cultural groups will be noncompliant.It is stereotypical for nurses to anticipate the client's response to care based on the client's culture.Nurses need to be aware of their beliefs, but not in order to alter them to match the client's culture.

A client who recently had a colostomy expresses concerns about the sexual relationship with the client's spouse. Which statement made by the nurse is appropriate?

"I can refer you to a support group so that you can speak with others with similar problems." Rationale: Having this client speak with someone who has had a similar surgery and concerns would be beneficial. Discussing the client's concerns with the spouse does not address the client's needs. The client is coping normally and does not need professional help. In fact, the client may feel that the nurse violated confidentiality.

When performing client education, the nurse knows that which client statement is a safe, cost-saving choice?

"I do cost comparisons between different pharmacies and different manufacturers, and ask my health care provider to prescribe a different brand of medication to save money." Rationale: Performing cost comparisons by calling different pharmacies or comparing the costs of the same medication by different manufacturers can identify opportunities for the client to get the needed medication for less money, and asking the health care provider to prescribe a different brand or manufacturer is a safe choice. Splitting medications in half unless instructed to do so can be dangerous, causing it to be toxic or ineffective. Choosing not to take a medication can be unsafe, and failing to tell the health care prescriber about not taking a medication is even more dangerous, causing the provider to make decisions based on false information. Clients failing to finish a full course of antibiotics can lead to antibiotic resistance.

The nurse is caring for a client with a terminal illness who is awaiting transfer to hospice. The client states, "It is all out of my hands now." How should the nurse respond?

"I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" Rationale: The client has a complex situation involving both a transfer to a new area of care and facing a terminal illness. While the nurse may have the focus of preparing the client for transfer to a new care area, this may not be the client's primary concern. Assuming the client's comment is related to the transfer could impede exploration of the client's actual reason for the comment. The priority is to clarify the comment's meaning before offering to explore coping strategies or how the nurse can help.

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. How would the nurse respond?

"Is there anyone else I can call to support you at this time?" Rationale: The clients are displaying evidence of spiritual pain and distress. The nurse acknowledges that this can be a normal part of the grieving process and does not pressure the clients to access spiritual supports if they have been refused. However, the nurse does not just accept this refusal and not explore other methods of support. Instead, the nurse should offer to call someone the clients may want to have with them as a support at this time. At this time of acute grief and spiritual pain, the nurse should not attempt to explore the client's spiritual beliefs. This can be explored later in the grieving process when the clients demonstrate readiness for this exploration.

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly." Rationale: In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

A nurse is assessing a client's spiritual needs when the client becomes angry and defensive about the questions being asked. What would the nurse say to make the client comfortable?

"You appear upset about these questions. Is this true?" Rationale: The nurse should first clarify if the client's appearance as angry or defensive is actually related to the spirituality-related questions before making assumptions. Some clients are relieved to know that the spiritual aspect of their being is worthy of the nurse's concern. However, the nurse should not sound vague and judgmental by saying something like, "We ask because having a spiritual connection can really help you during this time." Saying something like, "Many clients get uncomfortable when asked about their spiritual beliefs" takes the focus away from this client. Just telling the client everyone is asked these questions does not explore the reaction.

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client?

"You may want to have an abortion if you find out you are pregnant." Rationale: This statement hinders the therapeutic relationship because it advises the client to make a personal choice that may be against the client's values and beliefs. This statement would block further communication about the options that are available to the client. The other statements appropriately respond to feelings a victim may have following sexual assault or violent attack and provide reassurance that the victim acted as rationally and appropriately as anyone could in a life-threatening situation and let the client know that the nurse understands the emotions one commonly feels following a violent attack.

The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he won't get the right care if he gets sick at college." What is the nurse's best response?

"Your son can make an electronic history to facilitate his care if he gets sick away from home." Rationale: Access to a well-constructed electronic history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary, and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern.

The nurse is caring for a client with a terminal illness who is awaiting transfer to hospice. The client states, "It is all out of my hands now." How should the nurse respond? A. "I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" B. "I hear you saying you do not feel in control. What coping technique do you usually use when feeling this way?" C. "Are you feeling like you do not have control? Would you like to discuss the planned transfer to hospice?" D. "Change and transition can be challenging. We are here to support you. What can I do now to help?"

A. "I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" Rationale: The client has a complex situation involving both a transfer to a new area of care and facing a terminal illness. While the nurse may have the focus of preparing the client for transfer to a new care area, this may not be the client's primary concern. Assuming the client's comment is related to the transfer could impede exploration of the client's actual reason for the comment. The priority is to clarify the comment's meaning before offering to explore coping strategies or how the nurse can help.

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

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

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: A. "You seem upset this morning." B. "You've had your light on for 20 minutes?" C. "My name is Mary, and I'm your nurse for today." D. "I'm sorry. I was busy with another client."

A. "You seem upset this morning." Rationale: To be therapeutic, the nurse should respond to the content of the client's statements. This client is obviously angry. A restatement or summary of what the nurse heard the client say is appropriate. By making an introduction or apologizing, the nurse would ignore the client's expressed feelings. Repeating the client's statement as a question indicates either skepticism about the client's statement or ignorance of the client's needs and would likely fuel the client's anger.

Which would be most helpful when coaching a client to stop smoking? A. Establish the client's daily smoking pattern. B. Review the negative effects of smoking on the body. C. Explain how smoking worsens high blood pressure. D. Discuss the effects of passive smoking on environmental pollution.

A. Establish the client's daily smoking pattern. Rationale: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply. A. Explore the possibility of a female nurse being willing to swap clients. B. Report to the charge nurse to make them aware of the situation. C. Explain that it is discriminatory to not accept male nursing care. D. Explain that the unit is made up of mostly male nurses so it may not be possible. E. Notify the facility patient-advocate to make them aware of the situation.

A. Explore the possibility of a female nurse being willing to swap clients. B. Report to the charge nurse to make them aware of the situation. E. Notify the facility patient-advocate to make them aware of the situation. Rationale: The nurse should do whatever is necessary to ensure the client's health and well-being, as well as respect the integrity of all of the participants involved per the ANA Code of Ethics for Nurses. Best practice would be to talk with the charge nurse or unit manager about the situation and see if there is a possibility of a female nurse that could swap client assignments. Telling them that it is discriminatory or making excuses for providing male nurses will not ensure the nurse's obligation to provide culturally competent care to this client.

A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply. A. Exploring factors that are creating conflict with client's beliefs. B. Identifying current or past spiritual supports. C. Reading aloud Bible passages that relate to the client's needs. D. Offering to pray with the client to help resolve the conflict. E. Asking the client about original spiritual beliefs.

A. Exploring factors that are creating conflict with client's beliefs. B. Identifying current or past spiritual supports. E. Asking the client about original spiritual beliefs. Rationale: The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonable for the nurse to explore the client's faith origins as well as what the usual sources of spiritual support were or are. Commonly, a hospitalized client is separated from those of common faith practices so this should be explored. The nurse can also carefully explore what is contributing the challenges to faith the client is expressing. The scenario does not state that the client is Christian so reading from the Bible is an assumption by the reader, first. Second, the nurse would not take the step of reading to the client from a religious text unless this was a direct request by the client. Nurses should also not offer to pray with the client but should only engage in this if directly asked and if this is something the nurse is comfortable with.

The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse? A. Seek input from all groups and strive for consensus on what would benefit most or all of these people. B. Make decisions based on findings from the community assessment. C. Support the implementation of the ideas of the majority. D. Seek to promote homogeneity and common views rather than focus on differences.

A. Seek input from all groups and strive for consensus on what would benefit most or all of these people. Rationale: The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.

What short-term goal for a client hospitalized with a stress related disorder is most realistic? A. The client will write a list of strengths and needs. B. The client will practice assertiveness skills in confronting his mother. C. The client will describe plans for how to get back into school. D. The client will demonstrate a positive self-image.

A. The client will write a list of strengths and needs. Rationale: Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self-assessment.

A nurse is caring for a middle-aged client who has undergone hemicolectomy for colon cancer. The client has two children. Which concepts about family would the nurse apply when providing care for this client? Select all that apply. A. The effects of an illness on a family depend on the stage of the family's life cycle. B. Families become stronger when one member is ill. C. Changes in sleeping and eating patterns may be signs of stress in a family. D. A family member may have more than one role at a time in the family. E. Children respond more positively when they know what is going on. F. Illness in one family member can affect all family members.

A. The effects of an illness on a family depend on the stage of the family's life cycle. C. Changes in sleeping and eating patterns may be signs of stress in a family. D. A family member may have more than one role at a time in the family. F. Illness in one family member can affect all family members. Rationale: Illness in one family member can affect all family members, even children. Families do not necessarily become stronger when one family member is ill. Illnesses can create stressful family environments, which may put a lot of pressure on family members. When one family member cannot fulfill a role because of illness, the roles of the other family members are affected. While age-appropriate information is provided to the child, children are still impacted by the change in living situation and stress in the environment. And being informed may not always be the best thing for children. Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family depends on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress.

A 30-year-old client shares with the nurse that he or she has had a really hard time since the divorce 1 year ago, struggling with depression and anxiety. The client had a makeover and will be going on vacation with a best friend next month. The client has started thinking about dating again. The nurse understands that this client is in which stage of the grief process?

Acceptance. Rationale: The client is in the acceptance stage of grief regarding the divorce. The client has come to terms with the new reality, accepted the new reality, and is focusing on the positives and living life to the fullest. The bargaining stage of grief is characterized by making deals or promises of doing things differently if only there could be a different outcome. Depression would appear as intense sadness, feelings of hopelessness and often crying, and the client has most likely already worked through this stage, as the client reported struggling with depression over the last year since the divorce. Ongoing is not one of the stages of grief, and this client appears to be dealing with the grief well at this point.

The nurse is preparing a client who has pancreatic cancer for surgery, during which the client will have a Whipple procedure. The client says they are Catholic but never really goes to church or prays much. The client is crying and very frightened. What is the most appropriate action the nurse can do for the client before the surgery?

Ask the client if they would like to see a priest. Rationale: Even when daily prayers or other religious practices are not a routine part of a client's life, they often assume importance during life transitions, such as loss of a loved one, accident, or serious illness. It would not be appropriate to leave the client to reflect on their life. Contacting the physician for prn medication or something for anxiety for the client would not be the most appropriate action the nurse can take at this time.

The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket? A. The client states that the restraints are tight and uncomfortable. B. The client is at risk for injury from fighting the restraints. C. The staff want extra protection for themselves. D. Staff assessment reveals that the client will feel more secure under the blanket.

B. The client is at risk for injury from fighting the restraints. Rationale: A full-length restraint blanket is added when the client is at risk for injury from fighting the restraints. The increased degree of restriction is justified only when the risk of client injury increases. Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate protection for the staff.

A client is 36 weeks' gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse? A. "Do you belong to any community groups that may be able to support you?" B. "Tell me more about how you are feeling." C. "It appears that you are concerned about where your friends and family are living right now." D. "Would you like to speak to the hospital social worker?"

B. "Tell me more about how you are feeling." Rationale: Recent immigrants may be separated from their friends, family, and support systems. There are many variations in how cultural and ethnic beliefs and practices impact how individuals respond to the experience of pregnancy and birth. This nurse's response further explores the client's feelings to assist in a culturally competent and sensitive manner. It would be inappropriate to assume that the client is concerned about the family's living arrangements. It would be inappropriate to ask the client about belonging to any support groups or to refer the client to a social worker at this time. It would be most beneficial at this time to explore the client's feelings to identify what the concerns are and how the client believes the nurse may be able to help.

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse? A. "You can always change your mind afterwards. Did you want to try to see how it feels first?" B. "You have a right to withdraw consent. Can you share more about your decision?" C. "You have the right to refuse treatment. I'll let the healthcare provider know." D. "I respect your right to make that choice. However, do you think you may just be scared?"

B. "You have a right to withdraw consent. Can you share more about your decision?" Rationale: The nurse understands that a client must give consent for a procedure and may withdraw that consent if the client chooses. This answer demonstrates that the client's change of decision is worth exploring. Indicating that the client can have the tube removed afterwards does not respect the current request. Leading the client by assigning the decision to fear is not as helpful as having an open-ended approach. Simply accepting the decision without exploration of the client's feelings is negligent communication by the nurse.

The nurse is caring for a client who recently lost an infant to sudden infant death syndrome (SIDS). The client talks about how going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate? A. Bargaining. B. Acceptance. C. Denial. D. Delusion.

B. Acceptance. Rationale: This client demonstrates acceptance of the new reality. The client shows both dealing with the grief and resuming a more normal life again, such as going back to work and planning another pregnancy. It is normal for the client to still experience times of happiness and sadness, but this shows the client has moved into the acceptance stage and is accepting the loss of the baby without trying to change it. Denial would be characterized by refusing to admit the loss of the baby was real, such as believing that the baby was not really dead. Delusion is not a stage of grief, but rather a false or irrational belief that a person holds strongly to despite proof to the contrary. Bargaining would be characterized by trying to make deals to change the outcome, such as "Take me instead and let my baby live."

Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what? A. Stereotyping. B. Cultural blindness. C. Cultural imposition. D. Cultural assimilation.

B. Cultural blindness. Rationale: Cultural blindness is characterized by ignoring cultural differences or considerations and proceeding as if they do not exist. This phenomenon may underlie the failure to incorporate cultural considerations into dietary choices. Stereotyping assumes homogeneity of members of other cultures while cultural assimilation involves the replacement of values with those of a dominant culture. Cultural imposition presumes that everyone should conform to a majority belief system.

The hospice nurse is caring for a client who has been diagnosed with terminal cancer. The client breaks down in tears and shares with the nurse "I should just end it now so my kids can start moving on with their lives. They will be better off without me. When they come to visit tomorrow, just tell them I'm not up for visitors." The nurse understands the client is in which stage of the grief process? A. Acceptance. B. Depression. C. Denial. D. Suicidal.

B. Depression. Rationale: The client is in the depression stage of the grief process, which is characterized by withdrawal from life and loved ones, feelings of intense sadness, and feeling like there is no reason to go on. The denial stage is characterized by feeling of shock and numbness, disbelief that this is real. Acceptance is accepting the new reality, focusing on what time is left and trying to make the most of it. This client may be suicidal; however, this is not one of the five stages of grief.

Which statement about religion and spirituality is most accurate? A. Religion and spirituality are synonymous. B. Religion is an organized system of spiritual beliefs. C. Spirituality is the behavioral manifestation of religious beliefs. D. Spirituality is a recently developed alternative to traditional religious belief.

B. Religion is an organized system of spiritual beliefs. Rationale: Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion nor is it a recent development.

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest? A. Spend more time with the family. B. Take stress-management classes. C. Leave work at work. D. Find ways to make work fun.

B. Take stress-management classes. Rationale: The nurse would suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach how to manage stress more effectively. The client may not be able to make the job fun. The information provided by the client does not indicate that spending too little time with the family and taking the job home contribute to the client's stress.

A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling? A. The family's wishes related to their involvement in the client's spiritual practices. B. The nurse's comfort and knowledge level related to the process of spiritual counselling. C. Whether the client is receiving palliative care measures or is approaching end of life. D. The degree of alignment between the client's spiritual beliefs and those held by the nurse.

B. The nurse's comfort and knowledge level related to the process of spiritual counselling. Rationale: A nurse who feels competent to counsel the client may assist the client in achieving spiritual goals through spiritual counselling. The level of ability of the nurse to perform in this role is not directly related to the level of congruence between the nurse's beliefs and that of the client; people of all faiths are permitted to counsel those of others. The nurse would consider the client's condition when offering counselling, but this is not the most important factor--the nurse's abilities are. Family involvement may be necessary, but this would be determined by the nurse asking the client's preference rather than being based on the family's preference.

A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse? A. "People with strong beliefs have better outcomes." B. "It's good to have something to believe in." C. "It sounds like that offers you a sense of security." D. "Think about your leader when you have moments of doubt."

C. "It sounds like that offers you a sense of security." Rationale: Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.

A nurse is working in the emergency department when a woman comes in reporting that she was notified that her husband was just admitted following an accident. The woman is pacing, tearful, and her attention span seems poor. The nurse recognizes that the woman is having moderate anxiety. What should be the nurse's first response? A. "Hi! I'm really glad you are here. I work on this unit and was here when your husband came in. He was in really bad shape." B. "Your husband had an X-ray, and he might have a fractured femur. His hemoglobin and hematocrit are stable. He is diaphoretic. He has had an analgesic while awaiting an orthopedic consultation." C. "Your husband is awake and stable right now. I'll take you to his room." D. "You seem really nervous about all of this. Maybe you should complete the admission paperwork before seeing your husband."

C. "Your husband is awake and stable right now. I'll take you to his room." Rationale: When people are experiencing moderate anxiety, their attention span is limited and they are only able to focus on immediate concerns, so being brief and concise with communication initially is best. Giving the client too many details, or using medical terms prior to her knowing the immediate condition of her husband, will just increase her anxiety. At this point she is also unable to focus on details such as paperwork as her immediate concern is her husband.

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? A. Drawing up a schedule and making certain that it is adhered to. B. Devising a bathing and dressing schedule for each morning. C. Assisting the client with bathing and dressing by giving clear, simple directions. D. Bathing and dressing the client each morning until the client is willing to perform self-care independently.

C. Assisting the client with bathing and dressing by giving clear, simple directions. Rationale: This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required.

A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss? A. How body image changes will affect the client's sexual activity. B. History of breast cancer in the family. C. Concerns regarding the cancer and how the surgery will affect the client. D. Impact of surgery on the family's coping abilities.

C. Concerns regarding the cancer and how the surgery will affect the client. Rationale: The primary concerns to address at this time are the effect on the client of the diagnosis of cancer and the impending mastectomy. The other choices are also appropriate to address but are not the priority at this time.

A woman employed full-time wants to request a leave of absence to care for her father who is being treated for colon cancer 300 miles (480 km) away. What should the nurse advise the client to do first? A. Find someone to do her work while she is away. B. Make a plan to see how long she can be out of work without financial concerns. C. Contact her employee resources department about policies guiding leaves of absence. D. Ask her father if he can afford a caregiver.

C. Contact her employee resources department about policies guiding leaves of absence. Rationale: The nurse should advise the client to check with her employer to determine the policies and legislation followed there regarding leaves of absence. While the client can consider the other options, the first step is to obtain information from her employer.

An older adult client shares with the nurse having never gotten over the grief of losing a parent 22 years ago. The client states that the parent completed suicide and the client found the parent and called for emergency assistance. The nurse assesses that the client is experiencing which type of grief? A. Uncomplicated. B. Anticipatory. C. Dysfunctional. D. Disenfranchised.

C. Dysfunctional. Rationale: Dysfunctional grief is intense grief that does not result in reconciliation of feelings, such as this client is experiencing. Anticipatory grieving is grief before the actual loss occurs. Uncomplicated grief is a grief reaction that normally follows a significant loss and proceeds normally. Disenfranchised grief is grief that is not openly acknowledged, socially sanctioned, or publicly shared.

A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client has decided to continue the pregnancy based on religious beliefs and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate? A. Advise the client that the prolonged neonatal death will be very painful for her. B. Contact the client's minister to discuss the client's options related to the pregnancy. C. Explore the nurse's own feelings about the issues of anencephaly and organ donation. D. Ask the client if her family agrees with her decision.

C. Explore the nurse's own feelings about the issues of anencephaly and organ donation. Rationale: Anencephaly is a neural tube defect that is not compatible with life, although some infants with anencephaly live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse may have a strong reaction to the client's decision, so to support taking a nonjudgmental stance, the nurse should explore his or her own feelings about the issue of anencephaly and organ donation. The nurse try to persuade the client to terminate the pregnancy or imply that this would be a better course. Contacting the client's minister to explore the client's options is not appropriate; the client may have already discussed the matter with her minister or may not be religious. Telling the client that the neonatal death will be prolonged and painful to her is not helpful and may also be inaccurate, as death may occur very soon after birth. Contacting the client's family members is not appropriate, as the client may wish not to discuss the matter with her family.

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient? A. Spiritual Distress. B. Impaired Religiosity. C. Readiness for Enhanced Spiritual Well-Being. D. Risk for Loneliness.

C. Readiness for Enhanced Spiritual Well-Being. Rationale: The most appropriate diagnosis for this patient is Readiness for Enhanced Spiritual Well-Being. The patient desires to experience and integrate meaning and purpose in life through connection with self, others, art, music, literature, nature, or a power greater than themself.

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response?

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

A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about breast prosthesis and wigs. After answering the questions directly, what additional information should the nurse provide?

Contact information for the breast cancer support group. Rationale: Giving the client a list of community resources that could provide support and guidance assists the client to maintain her self-image and independence. The support group will include other women who have undergone similar therapies and can offer suggestions for breast products and wigs. Because the client is asking about specific resources, she does not need a referral to a social worker, home health agency, or plastic surgeon.

The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." What should the nurse do next? A. Schedule a follow-up appointment in 48 hours. B. Inform the health care provider (HCP) of the client's statement. C. Ask the client whether a family member could help. D. Ask the social worker to find financial assistance for the client.

D. Ask the social worker to find financial assistance for the client. Rationale: The client needs to continue the medication without interruption to minimize the chance of decompensation. Because the client is in danger of noncompliance with the medication due to financial concerns, the nurse should contact the social worker to assist with locating resources for the client. Although the HCP is responsible for prescribing the client's medication, the HCP is not routinely involved in finding financial assistance for a client's medication needs. Scheduling a follow-up appointment in 48 hours does not address the client's immediate need for the medication; the client could stop the medication before being seen and become severely depressed. A family member's assistance may not be a sufficient, a permanent, or an appropriate means of financial help for this client.

When planning discharge instructions with a client who has had an abdominal hysterectomy, what should the nurse do first? A. Call the social worker to evaluate the client. B. Read the discharge instructions to the client. C. Have the client watch an educational video. D. Assess the client's available social supports.

D. Assess the client's available social supports. Rationale: Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate.

A child with a nut allergy presents with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." What should the nurse do first? A. Notify the health care provider (HCP). B. Refer the client to the dietician. C. Obtain a social service consult. D. Assess the parent's ability to read.

D. Assess the parent's ability to read. Rationale: Three severe reactions in 3 months indicate a serious problem with adhering to the prevention plan. The nurse should first determine if the parent can actually read the label. The underlying problem may be that the parent is visually impaired or unable to read. The parent's reading level determines what additional support is needed. Referrals to social service or dietary may be indicated, but the nurse does not yet have enough information about the problem. The nurse would communicate with the HCP after assessing the situation to recommend referrals.

A client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, "I'm so frustrated with my doctors. The wound care doctor tells me this won't heal and I need to have my toes amputated, and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, what should the nurse do? A. Remind the client of the responsibilities for health habits regarding diabetes. B. Review the HCPs' progress notes with the client. C. Assure the client that the health care providers (HCPs) know what they are doing. D. Contact the client's case manager to set up a care conference.

D. Contact the client's case manager to set up a care conference. Rationale: The nurse is ultimately responsible to coordinate the client's care while hospitalized; therefore, it is the nurse's responsibility to arrange a care conference to help get the client's questions, concerns, and frustrations addressed. Assuring the client that the HCPs know what they are doing does not address the client's concern or frustration with receiving conflicting information. While it is true that the client is ultimately responsible for health, asking the client to accept the consequences is a form of blaming the client. The HCPs' progress notes will not provide information that will address the client's concern or resolve the conflicting courses of action that the two HCPs are proposing.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He's doing too much. I told him to let me help, but he won't let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, what should the nurse do? A. Avoid direct eye contact with the client and wife. B. Direct the eyes at the client. C. Shift the eyes back and forth between the client and wife. D. Direct the body and eyes at the wife and client.

D. Direct the body and eyes at the wife and client. Rationale: Assuming cultural appropriateness of eye contact with the client and his wife, this body language would make the nurse's nonverbal message congruent with the nurse's verbal message and demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and wife conveys a lack of assurance about the nurse's focus and comments.

A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary healthcare facility with symptoms of fever, cough, and running nose. While interviewing the client, which points should the nurse keep in mind? A. Do not probe into emotional issues. B. Do not ask very personal questions. C. Sit at the other corner of the room. D. Maintain eye contact while talking.

D. Maintain eye contact while talking. Rationale: While interviewing a client of Anglo descent, the nurse should maintain eye contact because it indicates openness and sincerity. Such clients freely express positive and negative feelings; therefore, the nurse may probe into emotional issues. Anglo culture is an open culture and members of this culture don't mind providing personal information. Also, clients of Anglo descent are not threatened by closeness so the nurse does not have to sit in another corner of the room.

A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? A. Determine whether the client qualifies for local assistance programs. B. Instruct the client in methods for low-cost, highly nutritious meal preparation. C. Ask the client if she has a job and the amount of income earned. D. Refer the client to a social worker for enrollment in a food assistance program.

D. Refer the client to a social worker for enrollment in a food assistance program. Rationale: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program.Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's needs for additional funds for food.Determining whether the client qualifies for government assistance is part of the role of the social worker, not the nurse.Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.

The health care provider (HCP) recommends amputation of the left leg above the knee to the client and orders a surgical consult. After the HCP leaves, the client tells the nurse that "I would rather die, than lose my leg like my dad did. He never had any quality of life after his surgery." What should the nurse do? Select all that apply.

Document the client's comments, then notify the HCP of the client's wishes. Call the HCP and recommend the exploration of alternative treatments to amputation. Rationale: The nurse is responsible for advocating for the client and notifying the physician of the client's comments and desire to not have the amputation. The nurse could also have the primary care provider discuss other options with the client , It would be inappropriate to call the spouse for consent as the client is of sound mind. Telling the client to get a second opinion for alternate treatment plans is not a nursing responsibility. It would not benefit the client to do nothing and just wait for the surgeon to come to talk before initiating any further nursing action.

A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do?

Gather more information about the client's feelings about the childcare arrangements. Rationale: The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs.

A group of nursing students are reviewing current nursing codes of ethics. Such a code is important in the nursing profession because:

Nursing practice involves numerous interactions between laws and individual values. Rationale: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

In working with a rape victim, which intervention is most important?

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

The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client?

Plan and implement care in a way that is sensitive to the needs of the client. Rationale: Providing culturally competent nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations within society. To provide culturally competent care, the nurse does not need to ask the client to explain the reasons for the client's beliefs. Assuring the client that the client's cultural preferences will be respected is dismissive and presumes the behavior of others instead of actively creating culturally competent interventions in the plan of care. Introducing the client to other clients makes the assumption that clients of similar cultural backgrounds will share interests and a desire to interact with each other. Making such an assumption is not a culturally competent approach.

A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply.

Take a seat next to the client and sit quietly to reflect on what was said. Say to the client, "You're feeling upset about the news you got about the transplant." Rationale: Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain a conversation. By reflecting on the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse would not leave the client alone abruptly stopping therapeutic communication. Negotiating treatment frequency is not in the scope of practice of the nurse.