PN PASSPOINT: 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 would be most therapeutic? Select all that apply.

"I'll sit here with you for a while. Would it help you to talk about it?" "You're feeling worse since chemotherapy started?"

A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?

"I'll tell you what the monitors show."

The nurse is providing personal hygiene measures to a client who is morbidly obese and diabetic when the client states, "I've heard the nurses and others joking about me. Could you be my nurse tomorrow?" Which response by the nurse would be most appropriate?

"I'm going to report your concerns to my supervisor, and if I return I'll come see how you are."

The nurse is helping a client with a terminal illness understand advance directives. Which statement by the client demonstrates an understanding of these documents?

"They guide the client's treatment in certain health care situations."

A client on an inpatient psychiatric unit is pacing up and down the hallway. The client has a history of aggression. Which comment made by the nurse would be the most appropriate?

"You are pacing. Let's walk together and talk about it."

A client with terminal cancer tells a nurse, "I've given up. I have no hope left. I'm ready to die." Which response is most therapeutic?

"You've given up hope?"

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply.

Bring up the suspected physical abuse with a trusted authority figure. Report the suspicion to the local Adult Protective Services Agency within 24 hours.

A client in a senior center informs the nurse, "My spouse recently passed away, and a few weeks later two of my friends and a family member died." Which action should the nurse implement to assist this client?

Encourage the client to seek grief counseling.

A client who has discovered a breast lump is tearful and expresses concern regarding the situation. What is the best response by the nurse?

Encourage verbalization of fears.

The LVN/LPN is transporting a surgical client to the operating room when the client says, "I am not sure what they are going to do to me." What is the nurse's best action?

Notify the surgeon about the client's concern.

A client states, "I'd feel so much better if I could just sleep!" What method to promote sleep can the nurse reinforce to the client?

Resist napping during the day.

The nurse is caring for a client with dementia that has a tendency to wander into other client areas, posing a safety risk for the client and others. Which method would be most beneficial for this client to promote safety that is the least restrictive?

Use an electronic monitoring system.

The nurse should question the signed consent form for surgery for which of the following clients?

a 54-year-old client with a fractured femur committed to a mental health unit

A client becomes angry and belligerent toward a nurse after speaking on the phone with a parent. The nurse recognizes this behavior as reflecting which coping mechanism?

displacement

A client lives with a parent and the client's three children. Which type of family does this describe?

extended

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?

introducing new issues to the client

A nurse is concerned about a client's ability to retain information during education sessions. Which of the following techniques would enhance the retention of material in presentations?

using repetition

A nurse is talking to grieving parents whose child died from sudden infant death syndrome (SIDS). What should the nurse emphasize to the parents?

"The death couldn't have been prevented and isn't your fault."

An adolescent admitted with a fractured femur had an open reduction and internal fixation two days ago and is currently in traction and asks the nurse what would happen if a terrorist decided to bomb the hospital. What's the nurse's best response?

"What do you think might happen if terrorists attacked?"

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 mostappropriate response by the nurse?

"You have a right to withdraw consent. Can you share more about your decision?"

The nurse in charge is reviewing client care priorities on the unit. In which order, from highest priority to lowest, will the nurse recommend the listed cases for review by the hospital's ethics review board? All options must be used.

1) A client with terminal cancer is unable to consent to care and can no longer take food orally; immediate family disagrees about invasive measures. 2) A client with terminal cancer disagrees with the recommendations of the health care provider to discontinue aggressive therapy and be placed on palliative care. 3) A client with end-stage kidney disease has expressed wanting to discontinue hemodialysis treatments and does not wish to be considered for transplant. 4) A client with a referral for future total hip arthroplasty refuses to receive any blood products based on religious beliefs. 5)A client with type 2 diabetes does not adhere to the diet and medication recommendations as outlined by the health care provider.

A client with Alzheimer's-type dementia aggressively approaches a second client in the hallway. In what order, from first to last, should the nurse perform the listed actions to ensure safety? All options must be used.

1) Call for the assistance of an unlicensed assistive personnel (UAP). 2) Step in between the aggressive client and the second client. 3) Redirect the aggressive client using short verbal directions. 4) Request the UAP assist the other client away from the area. 5) Attempt to return the aggressive client back to the client's room.

A client with terminal cancer states, "I just wish this could all be over. This is no life." Which action(s) should the nurse take? Select all that apply.

1) Interview the client about any religious or spiritual beliefs that the client finds comforting. 2) Determine which symptoms the client finds to be the most distressing at this time. 3) Perform a depression screening assessment with the client and compare to past results. 4) Consult the pain and symptom management department with the client's consent.