Passpoint - Stress and Coping

Which symptom reported by an adolescent's parents suggests that the adolescent may be abusing amphetamines? Select all that apply.

- restlessness - excessive perspiration - talkativeness

When assessing a 17-year-old client with depression for suicide risk, which question would be best?

Are you thinking about killing yourself?

Which goal is the priority for a client with a fractured femur who is in traction?

Prevent effects of immobility while in traction

The nurse is caring for a client with a panic attack. Which nursing intervention is most helpful for this client?

Stay with the client and remaining calm, confident, and reassuring

A home care nurse is visiting a family with a chronically ill 9-year-old child. What is a priority of client care when working with a family caring for their chronically ill child at home?

caregiver role strain

During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?

caregiver role strain

A client is informed by his healthcare provider that a tumor has been found. When the nurse sees the client later, the client states that no one knows what is wrong with him. The nurse determines that the client is experiencing which of the following?

could be in denial

A nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of the client's own physical features, the nurse should:

encourage the client to talk about fears and stressful life situations

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest?

take stress-management classes

A nurse is admitting a client with symptoms of posttraumatic stress disorder (PTSD). Which of the following findings should the nurse anticipate? Select all that apply.

- recurring thoughts of the crisis - difficulty falling asleep - outbursts of irritability or anger - inability to remember aspects of the event

A 54-year-old client with generalized anxiety disorder is admitted to the facility. Which therapeutic modalities are typically used to treat this disorder? Select all that apply.

- biofeedback - buspirone therapy - relaxation techniques

A physician prescribes clomipramine for a client with obsessive-compulsive disorder (OCD). What instructions should the nurse include when teaching the client about this medication? Select all that apply.

- avoid hazardous activities that require alertness or good coordination until adverse central nervous system effects are known - avoid alcohol and other depressants - use saliva substitutes or sugarless candy or gum to relieve dry mouth

A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of Anxiety. A short-term goal is established as follows: "The client will identify physical, emotional, and behavioral responses to anxiety." Which nursing interventions will help the client achieve this goal? Select all that apply.

- observe the client for overt signs of anxiety - help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses - introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise

When interacting with the mother of a child who has Duchenne muscular dystrophy, the nurse observes behavior indicating that the mother may feel guilty about her child's condition. The nurse interprets this behavior as guilt stemming from which factor?

the genetic mode of transmission

A client reports that before he leaves home to go anywhere, he counts the money in his wallet as many as 12 times. The nurse judges this behavior to indicate which client need?

the need to channel emotions unacceptable to him with an acceptable activity

A client on an inpatient psychiatric unit has had several episodes of auditory hallucinations. Currently, the client is not having hallucinations and is interacting appropriately. Which nursing assessment is a priority?

Client anxiety levels throughout the day

A nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one intervention would be best for the nurse to suggest for this client?

a life and social skills group

An adolescent client comes to the community crisis clinic. The client has multiple superficial cuts on their bilateral wrists. The client is crying uncontrollably and states that a close friend has left recently and the client doesn't want to live without the friend. What would be the most therapeutic initial nursing response?

I can see that you are feeling anxious. I will stay with you until you feel better

A nurse is assessing military personnel who have experienced combat and are diagnosed with posttraumatic stress disorder. Which client statement requires immediate intervention?

I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it.

The nurse cares for a middle-aged client with a below-the-knee amputation. What statement indicates the need for further assessment of the client's body image?

I hop I can handle having a prosthesis, but I'm really wondering what my wife will think

A client diagnosed with agoraphobia who experiences panic attacks is talking with a nurse about the progress made in treatment. Which client statement indicates a positive response to treatment?

I went to the mall with my friend last Saturday

The nurse is preparing the family to see the client who just died. The family invites the nurse to pray with them. The nurse is not comfortable with this request due to a different belief system. What is the nurse's best response?

I will stay with you while you visit

During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client says, "I have been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just do not have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. What would be the nurse's best response?

It's not unusual for some mothers to feel depressed after the birth of a baby. I'm going to contact your health care provider

A preadolescent client diagnosed with oppositional defiant disorder is verbally lashing out at other clients and threatening violence. What intervention should the nurse include when planning the care for a child?

assist the client to find ways to deal with their anger

A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate?

place the isolette in a quiet area of the nursery

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially?

The client will discuss her feelings related to her losses.

A client is having a severe reaction to cocaine and seems to have lost touch with reality. He is very suspicious of his friends who came with him and does not want to talk to the nurse. Suddenly, he yells out, "I'll kill you before I let you take me." Which comment by the nurse would be most useful to help the client reestablish his self-control and orientation?

You're reacting to the cocaine you used. You're safe here in the hospital.

A client with a self-inflicted gunshot wound in his arm is brought to the inpatient psychiatric unit from the emergency department. With his arm bandaged and in a sling, he is escorted to the unit by emergency department staff. A staff member states to the nurse, "He only hurt his arm, so he probably did it for attention." Which response by the nurse to the staff member would be most appropriate?

all suicide attempts or acts of self-harm are very serious and indicate a cry for help

A client is in the third trimester of pregnancy, and the spouse tells the nurse about worries for the client's increasing physical discomfort and overall health and safety. Which response from the nurse to the spouse is most appropriate?

can you help me understand what aspect of her health and safety concerns you most?

The nurse is conducting a home visit with a school-age child with a physical disability. What behaviors by the child alert the nurse to overprotective parenting?

dependency, fearfulness, and lack of outside interests

When caring for a client who has just had a total laryngectomy, the nurse should plan to

develop an alternative communication method

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client?

discuss secondary gains that are unconsciously driving the client's behavior

When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, what intervention would be most helpful in facilitating parent-infant bonding?

encouraging the parents to hold their infant

A client diagnosed with bulimia tells the nurse she only eats excessively when upset with her best friend, and then she vomits to avoid gaining a lot of weight. What should the nurse do next?

enroll the client in a coping skills group

A client's admitting diagnosis is schizophrenia with an episodic delusional disorder. The nurse applies what intervention strategy while working with the client in this pronounced delusional state?

focus on the client's underlying feelings, and redirect inappropriate responses

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

i can participate in sexual activity, but might not experience orgasm

A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. How will the nurse best describe biofeedback to the client?

it is a way to concentrate on the body's response during a stress situation

A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?

notify the physician that the partner has been waiting to discuss the mother's condition

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?

offering encouragement and support

In assessing an adolescent client at an outpatient clinic, the nurse is able to recognize that depression in adolescents is often what?

often masked by aggressive behaviors

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness?

over protection

Arrangements are made for a member of the colostomy support group to meet with a client before bowel surgery. What is accomplished by having a representative from the group meet the client preoperatively?

providing the client with support and realistic information on the colostomy

A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. The client admits drinking excessively over the previous 48 hours. This behavior is an example of:

situational crisis

A nurse is preparing a client for discharge after a prolonged hospitalization in which the client had a colostomy created because of colon cancer. The client's family has concerns about managing the client's care at home. Which factor plays the most important role in successful home care?

support from friends and family

A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles (1,200 km) away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about which potential problem?

support systems and coping strategies

A client with obsessive-compulsive disorder (OCD) reports having intrusive thoughts about a naked person performing sexual acts. The client realizes the thoughts are not based on a real occurrence but is not able to stop them from recurring. What would the nurse need to include in the teaching for this client?

teach the client how to explore the meaning and purpose for the obsessions and compulsions

A 56-year-old woman is admitted for a modified radical mastectomy. The client appears anxious and asks many questions. How should the nurse respond to this client

tell the client as much as she wants to know and is able to understand

Which action, displayed by a grieving partner over a dying spouse, should cause the nurse to suggest counseling?

the partner blames his spouse's family for the client's current health problems

A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may be caused by which factor?

uncertainty and an underlying fear of recurrence

A client is admitted for a surgical biopsy of a suspicious lump in the right breast. At the time the nurse arrives to take the client to surgery, the client is finishing a letter to the client's children. The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes wrong in the surgery." Which nursing response will be most therapeutic

what are you concerned about right now?

An adult client on a psychiatric unit is pacing and yelling. Which is the best response by the nurse?

when did these feelings begin?

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

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?

you must wait at least 1 year before becoming pregnant again

A young client is diagnosed with enuresis. Tests revealed there is no medical cause attributed to the client's bed wetting. The client's mother is upset and is blaming the client's father, from whom she has recently separated, for the problem. "It is all his father's fault!" the client's mother declares to the nurse. What would be the nurse's best response?

you seem really upset by this situation

Which adolescent would the nurse determine needs further evaluation?

a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class