Psychosocial Integrity (11)

The nurse is collecting the health history of a client admitted to the medical-surgical unit. The client states "At midnight, I am supposed to be observing my monthly fast for my religion." Which statement should the nurse make?

"Can you describe to me what occurs during your fast?" Rationale: The nurse should assess and plan interventions that meet the client's religious needs. For a client who reports the need to participate in a monthly fast, the nurse should gather more information related to the process, including specific restrictions and timeframe. There is no indication that the client requires IV fluids. Telling the client to refuse meal trays or moving the fast to another day does not address the client's needs.

The hospice nurse is caring for a client who is actively dying. The client's adult child states "I don't think I can stay and watch." Which response would be appropriate for the nurse to make?

"Can you describe to me your concerns?" Rationale: The nurse should recognize when the family of a client who is actively dying requires support. Encouraging the family members to discuss their concerns will also support the client. During the dying process, the nurse should encourage the client's family to be present. However, if a family member voices concerns, the nurse should provide the family member with support and have them explore their feelings.

The nurse is assessing a client's spirituality during the hospital admission process. Which statement should the nurse make?

"Can you describe what gives you meaning in life?" Rationale: Religion and spirituality are important aspects of a client that can influence their healthcare. When assessing a client's spirituality, the nurse should not make assumptions regarding the client's needs. The nurse should explore the client's personal belief system to identify how to meet the client's spiritual needs during the hospital admission.

The nurse is caring for a client who has been diagnosed with terminal cancer and is quietly crying. Which response by the nurse would be most appropriate?

"I am going to sit here next to you." Rationale: When observing non-verbal behavior, such as crying, the nurse should demonstrate empathy by being present with the client. The nurse should sit with the client, allowing the client the opportunity to express their feelings. Sympathy, such as expressing a personal opinion, and assuming how the client feels are not therapeutic communication techniques. Telling the client to call their family puts the burden on the client to solve the issue by themselves.

The nurse is caring for a client who is Asian and is post-operative 24 hours from an appendectomy. The client is hesitant to get out of bed. Which response would be the most appropriate for the nurse to make?

"Can you describe what you are feeling when you try to move?" Rationale: The client who is hesitant to move and get out of bed may be expecting pain. Clients who are Asian tend to control their emotions and expressions of physical discomfort in front of strangers. Telling the client to get up and walk to prevent complications is important, however, the nurse needs to assess why the client is hesitating to get up. Leaving the client or waiting for the family does not address the reason why the client is hesitant to get up.

The nurse is reviewing the health history of a client during an annual wellness visit. The nurse notes that the client is not up to date with vaccinations. Which statement should the nurse make?

"Can you describe your personal beliefs about vaccinations?" Rationale: During the health history, the nurse should use culturally congruent statements that explore the client's beliefs and values. The choice to receive vaccinations is often based on personal beliefs and values. The nurse should explore the client's beliefs before asking for consent to receive vaccinations. Asking about previous vaccinations or the reason for the incomplete record can be accusatory to the client.

The nurse is providing care to a client with borderline personality disorder who has a history of manipulative behavior. The client gives the nurse a painted rock and states "This is a gift for you because you are the best nurse." Which statement by the nurse would be appropriate?

"I am unable to accept, but I am wondering what this gift means to you." Rationale: Clients with borderline personality disorder will use manipulative behaviors to control caregivers. Giving gifts and praising others is a common manipulative technique used by individuals with BPD. When provided with a gift and verbal praise, the nurse should respond by putting the focus back on the client by asking the importance of the object. Keeping the object, complimenting the client for the praise, or justifying why they cannot keep the object validates the behavior.

The nurse is providing end-of-life care for a client with terminal cancer. Which statement by the client would indicate to the nurse the client is coping with the care?

"I am writing down my memories in a journal." Rationale: Clients who are experiencing end-of-life care will go through the stages of grief and loss. A client who is coping with end-of-life care will exhibit behaviors of accepting the diagnosis, such as discussing with family and reflecting on one's life. Clients who speak of a speedy death or cry easily may not be coping with end-of-life care and will require additional support.

A nurse is caring for a client with stage IV cervical cancer who is receiving prescribed chemotherapy. The client states, "I don't want any more chemotherapy, but my children insist I keep going." Which statement should the nurse make?

"I can discuss the process with you to stop treatment." Rationale: A client has the right to make decisions about their care. The role of the nurse is to support the client in these decisions and provide the client with appropriate information.

The clinic nurse is interviewing a client who is being evaluated for psychiatric care. Which statement by the client would support a diagnosis of a manic episode of bipolar disorder?

"I plan on quitting my job so I can devote more time to social media." Rationale: Bipolar disorder is a group of disorders that has cycles of depression and irritable or erratic moods. When a client is experiencing a manic episode of bipolar disorder, the client will have an intense mood, where the client may make irrational choices, such as quitting a job. The client may have grandiose ideas of becoming famous. A client who reports sleeping more often, increasing eating, or skipping routine activities may be experiencing depression.

The nurse observes a client who is newly diagnosed with cancer crying. Which statement by the nurse most demonstrates a caring practice?

"Let me close the door, and I can pull up a chair so we can talk." Rationale: A nurse who demonstrates caring practice will listen to the client, taking time to be present. Closing the door, sitting next to the client, and allowing the client to express feelings are caring actions. The nurse should not try to distract the client from their feelings or place the burden on the client.

The clinic nurse is reviewing the dietary history of an adolescent female client. The client states "I have been counting my calories; I do not want to gain weight." Which statement by the nurse would be appropriate?

"Let's talk about the types of foods you eat during the day." Rationale: Adolescence is a period of rapid physical, emotional, social, and sexual maturation in which the rate of growth can vary among individuals. Nutrient needs for adolescence are increased during this period of growth. Weight consciousness is often an issue among adolescents, especially female clients. When assessing the dietary history of an adolescent female client who reports counting calories, the nurse should explore the types of foods the client eats. Clients who are at risk for developing eating disorders may express concern about gaining weight. The nurse should assess the types and amounts of food the client is eating.

The nurse is caring for a client who is Hispanic and is newly diagnosed with depression. Which statement by the client would indicate to the nurse a cultural issue that impacts the client's understanding of the diagnosis?

"My family will help me figure out how to deal with this." Rationale: In some cultures, the diagnosis of mental health is considered a stigma. For clients who are Hispanic, mental health issues are dealt with in the family and not to be discussed with strangers. This could impact the client's ability to receive treatment.

The nurse is assessing the safety of an adolescent client. Which statement by the client would require the nurse to intervene?

"My friends at school think I dress weird." Rationale: Adolescents are at increased risk for suicide when faced with feelings of decreased self-worth and hopelessness. The nurse should assess for factors that can impact an adolescent client's ability to cope or handle stressful situations. An adolescent who reports a lack of social support may be a victim of bullying, which will require the nurse to intervene. An adolescent who looks forward to new things, such as a pet, or seeks help from others, such as a tutor, is demonstrating appropriate coping skills. Family involvement demonstrates a support system.

The nurse is teaching a client who is newly diagnosed with diabetes type I about needle disposal. Which statement should the nurse include in the teaching?

"Put used sharps in a strong, plastic container that has a lid." Rationale: Clients should be taught to put used sharps in a strong, plastic container. When the container is 3/4 full, put the lid on, seal it with tape, and label "do not recycle." It is then acceptable to put the container in the household trash or bring it to a drop-off location such as a hospital, pharmacy, health department, or police or fire station. Sharps that retract after use should be disposed of like all other sharps.

The nurse is teaching a client who just had a leg cast removed about ways to strength the calf muscle to reduce the stress due to inactivity. Which of the following statements by a client indicates a need for further teaching?

"The faster I move through the exercises, the sooner my muscle strength will return." Rationale: Isometric exercises are used for strengthening muscles without moving the joint. These can be used for maintaining strength in immobilized muscles in casts or traction. It is recommended that clients should do the exercises consistently two or three times a week to build strength. The nurse should instruct the client to perform the eight to 12 repetitions of each exercise for one to three sets. Clients should move slowly through each exercise to help build muscle strength. Moving too quickly can increase stress and damage the muscle.

The nurse is providing room orientation to a client who is newly admitted. When instructing the client how to alert the staff, which statement should the nurse make?

"Use the call light device when you need assistance." Rationale: The best communication tool for clients to use is the call light. The hospital operator directs calls to the correct unit or provides announcements regarding emergencies. Hourly rounding is when staff visually observes clients and provides basic care, such as bathroom visits. Clients should still alert staff if needed and not wait for the rounding schedule. Calling the client care station may delay in alerting the staff.

During a family assessment, which statement by the nurse would assess the family functioning?

"What holidays does the family celebrate?" Rationale: A family assessment focuses on collecting data about the family structure, developmental assessment, and family functioning. Family structure focuses on who are considered members of the family, including those that do not live in the home. Developmental assessment focus on how families adapt during changes and difficult times, such as if someone is having a problem or recent changes within the family. Family functioning identifies how each person behaves in the family and what the family does as a unit, such as celebrate holidays.

The emergency nurse is caring for a client who has a visitor requesting to see the client. Which statement is most appropriate for the nurse to make?

"What is your relationship to the client?" Rationale: Family units are comprised of different people with different roles. The traditional framework of families has shifted to include non-genetic related family members such as friends. When assessing a client's family, the nurse should focus on the relationship the individual has with the client.

The nurse is caring for a client who was newly diagnosed with cancer. The client states "Am I going to die?" Which response would be most appropriate for the nurse?

"Would like to talk about how you feel?" Rationale: When communicating with clients, the nurse should understand that verbal communication is a social interaction requiring effective skills to promote a therapeutic relationship. The nurse should be truthful, open-minded, and knowledgeable in communicating with clients. The nurse should avoid providing personal opinions, dismissing the client's concerns, or attempting to adjust the client's perception of the situation. The nurse should encourage the client to explore feelings and further communicate needs.

The nurse is preparing to complete a health history for a newly admitted client. The nurse observes the client squeezing and twisting their hands together and notes rapid breathing. The client states they are feeling sick to their stomach. Which statement should the nurse make?

"You seem uncomfortable, we can wait to finish this." Rationale: Moderate to severe anxiety causes a person to have one focus. The client is not ready to participate in a health history, and it should be rescheduled for a later time. The nurse should stay with the client to offer assistance if needed but should never tell them to relax.

The home health nurse is conducting a health history interview with a client who does not speak English. Which action should the nurse take when communicating with the client?

Access the telecommunication interpreter Rationale: When speaking with a client that does not speak English, the nurse should access the telecommunication interpreter. If an interpreter is unavailable, the nurse can speak in simple terms while using actions. The nurse should maintain a moderate, low tone of voice and avoid shouting or talking loudly. The nurse should avoid using medical terms, and the client may not be able to read English or use family members to translate. When asking questions, the nurse should discuss one topic at a time and avoid conjunctions.

The nurse is participating in the planning of a facility's annual disaster drills. Which of the following indicates correct understanding of disaster planning?

An internal disaster plan requires a strategy for evacuation and relocation of clients. Rationale: Facilities require annual drills for both internal and external disasters. Internal disaster plans always require a strategy for safely evacuating and relocating clients. A mass casualty event differs from a multi-casualty event in that it is broader in scope and typically overwhelms local medical capabilities, requiring collaboration with numerous healthcare facilities and possibly state, regional, and federal assistance. Facilities are required to plan drills for natural disasters but may choose disasters that are prevalent in their region, such as avalanches near mountains or hurricanes near the ocean. All facilities should plan active shooter drills, regardless of geographic location or prevalence of gun violence in the surrounding community

While performing hygiene care for a pediatric infant, the nurse notes a soiled string of yarn around the infant's neck. Which action should the nurse take?

Ask the parent the purpose of the string Rationale: The culturally competent nurse would ask the parent the meaning of the string. Washing the string with soap and water does not address the purpose of the string or safety. The nurse should not just remove the string and tie it to the clothes or just remove the string without first assessing the purpose. The nurse should involve the parent in the decision-making.

The nurse working with an unlicensed personal assistant (UAP) to care for a client who has soft, bilateral wrist restraints placed. Which task should the nurse delegate to the UAP?

Assist the client during mealtimes. Rationale: A client who is in soft wrist restraints will require an assessment of skin and circulation and maintain documentation on restraint criteria, which is the responsibility of the nurse. The nurse can delegate to the UAP assisting the client to the bathroom and with eating and drinking.

The nurse is caring for a client who is has been diagnosed with terminal cancer. The client states "If I can just see my adult child marry, I will be ok with dying." Which stages of dying should the nurse understand that the client is experiencing?

Bargaining Rationale: The five stages of dying is the process that a client will go through when grieving and accepting pending death. In the denial stage, the client will not acknowledge the death and pretend it is not occurring. In the bargaining stage, the client will try to negotiate or barter for more time. During the depression stage, the client will exhibit signs of grieving, such as crying. In the acceptance stage, the client has come to terms with the pending death and has peace with the outcome.

The nurse is caring for a client with constipation. The client believes in the philosophical concept of yin and yang and requests only cold food for treatment. Which food should the nurse remove from the client's meal tray?

Bran cereal Rationale: Clients who believe in the philosophical concept of yin and yang identify certain conditions that are hot and cold. If a condition is considered hot, such as constipation, the client will prefer to eat cold foods, such as chicken, dairy, fresh vegetables, fruits, and honey. Cold conditions, such as cancer or pneumonia, are treated with hot foods, such as cereals or eggs.

The nurse is caring for a client who is actively dying and is experiencing delirium. Which of the following is an appropriate action by the nurse?

Decrease environmental stimuli Rationale: A client who is experiencing delirium, which is a state of confusion, disorientation, restlessness, and anxiety. The nurse should provide the client with a quiet, well-lit room. The nurse should calm the client by staying close and using a calm voice, and slow strokes of the skin. The nurse should administer pain medication to a client who is actively dying. Restraints should be avoided by clients who are actively dying.

The graduate nurse is researching how to implement culturally congruent care into practice. Which action should the graduate nurse take first?

Explore personal beliefs and values Rationale: Culturally congruent care focuses on providing a case based on the client's cultural beliefs, practices, and values. Before a nurse can implement culturally congruent care, the nurse should explore personal beliefs and values. Understanding one's personal beliefs and values provide a foundation to then understand another person's culture. Once the nurse has explored their beliefs, then reading current literature, attending a conference, and interviewing other nurses will further expand the nurse's understanding.

The nurse is planning care for a group of assigned clients. Which action by the nurse would require the use of sterile gloves?

Insertion of an indwelling urinary catheter Rationale: Surgical asepsis is used for procedures that require sterile technique. Sterile technique is required for procedures that could introduce infectious agents to the client, such as placement of an indwelling urinary catheter, wound dressing change, or preparing injectable medications. Medical asepsis or clean technique is used for procedures such as placement of a peripheral IV, administering a rectal medication, or performing hygiene care.

The nurse is preparing to administer prescribed medication to a client who is Native American. The nurse enters the room and observes a Shaman performing a healing ritual for the client. Which action should the nurse take?

Leave the room and return when the healing ritual is finished Rationale: Shamans are tribal leaders or medicine men that are used in the Native American culture to relieve illness. The culturally competent nurse should allow privacy for the healing ritual and return when it is completed. The culturally competent nurse should incorporate the client's beliefs into the client's care as long as the health belief and practice are safe.

The hospice nurse is assessing a client who is actively dying. Which finding should nurse understand as a final sign of impending death?

Loss of hearing Rationale: The physical manifestations at end of life include glazing of the eyes, decreased blood pressure, and increased respiratory rate. The loss of hearing is the last sense to disappear indicating the final stages of the end of life.

The nurse is caring for a client with lower extremity paralysis who uses a wheelchair and is non-weight bearing. Which of the following actions will promote a safe transfer to the wheelchair?

Obtain a mechanical lift Rationale: The Occupational Safety and Health Administration recommends a no-lift policy for all health care facilities. They advise using patient handling aids and mechanical lifting equipment for patients who are unable to assist in their transfer. The use of mechanical lifts and other patient handling devices reduces the risk of injury to nurses and clients. Patients who are unable to bear partial weight or full weight or who are uncooperative should be transferred using a full-body sling lift with two caregivers. This client is non-weight bearing and therefore, is a candidate for a lift and not for stand and pivot or any other means.

The nurse is implementing culturally congruent care into practice. Which action by the nurse demonstrates cultural knowledge?

Participate in a monthly education session Rationale: Cultural competency theory focuses on five interrelated concepts of awareness, knowledge, skill, encounter, and desire. A nurse who demonstrates cultural knowledge will seek out education related to culture, such as participating in a monthly education session. Cultural awareness is the process of self-examination, which can be demonstrated by creating a blog about personal reflections. Cultural skill is the ability to conduct a cultural assessment, which can be demonstrated by developing a data collection tool. Cultural encounter is the process of directly engaging with culturally diverse clients, such as when volunteering with a community group.

A nurse is performing a bladder scan on a female client with history of a hysterectomy. Which action by the nurse indicates correct use of the ultrasound bladder scanner?

Points the directional icon on the scanner head toward the client's head Rationale: The directional icon on the scanner head should be pointing toward the client's head to mimic the client's anatomical placement and obtain an accurate measurement. The nurse should select 'male' as the biological sex with clients who have a history of a hysterectomy due to the absence of the uterus. Ultrasound gel should be placed above the pubic symphysis, at the level of the bladder. The scanner head should be pointed down towards the coccyx to obtain an accurate read.

A nurse is caring for a client with bipolar disorder. The nurse reads in the client's medical record that the client was awake the previous night experiencing an acute manic episode. Which of the following interventions should the nurse include when planning care for this client?

Provide frequent rest periods during the daytime Rationale: A client who is experiencing an acute manic episode will exhibit restlessness, going from activity to activity with heightened emotional response. A client who was awake all night from a manic episode will need rest periods throughout the day. Encouraging stimulating activities can exacerbate the manic episode. While a warm shower before bed could be relaxing, it will not prevent the client from experiencing insomnia from the manic episode. Limiting visitors could decrease simulation but does not impact the effects of the manic episode.

The nurse is teaching a client about protective measures to reduce the risk of electrical shock while using medical devices. Which of the following statements by the client indicates the need for further teaching?

Rationale: It indicates the need for further teaching if the client states they will repair frayed or damaged electrical cords with electrical tape. Devices that indicate damage should not be used and should be evaluated and repaired by an electrician. It indicates a correct understanding of the use of protective equipment to reduce electrical shock by placing protective covers on electrical outlets around children, to use only grounded outlets, and to avoid overloading outlets with too many appliances.

The nurse is assessing a client who has a history of anxiety. The client states, "I always think I leave the stove on; I must have obsessive-compulsive disorder." Which statement would be appropriate for the nurse to make?

Rationale: Obsessive-compulsive disorder is a neurological disorder where the client experiences intrusive thoughts (obsessions) and ritualistic behaviors (compulsive). The client will report having a recurring thought, such as leaving the stove on. The thought is persistent, and the client cannot focus on anything else. The nurse should ask the client to describe how they feel when experiencing the intrusive thought. With OCD, there is no distinct trigger to the intrusive thought. Asking if the client worries about other things does not assess how the thought is processed by the client. Often with OCD, the intrusive thoughts are ongoing, without any time constraints.

The nurse is caring for a client who is receiving a continuous infusion of norepinephrine. The infusion pump battery is not charging even though the pump is plugged in. Which of the following actions is appropriate?

Replace it with another pump that has been charging properly. Rationale: The client is on a vasopressor to support hemodynamic stability. If the power were to fail or the client would need to leave the room, the pump would not continue to function and the client would not receive a life sustaining treatment. The pump should be replaced now while the situation isn't critical. The nurse should not attempt to troubleshoot software or mechanical failures.

A nurse is implementing fall precaution strategies for a client who is visually impaired. Which action would be an appropriate action for the nurse to take?

Replace the call light with a touch pad call switch Rationale: Clients who are visually impaired are unable to see all of the buttons on the call light. Replacing the call light with a touchpad call switch enables the client to easily call for assistance. Placing the bed in the lowest position is a fall prevention strategy. However, this intervention benefits all clients regardless of impairment. Applying non-slip socks on the client will prevent a fall while ambulating. The nurse should perform actions specific to the client's impairment. Activating the position-sensitive bed alarm is a fall prevention strategy. However, bed alarms are beneficial for clients who have cognitive impairments and cannot understand instructions.

The charge nurse observes the staff nurse collecting the health history of a client whose primary language is Spanish. Which action by the nurse would require the charge nurse to intervene?

Requests the client's adolescent child to answer questions Rationale: When caring for a client who does not speak English, the nurse should first utilize a certified interpreter. If a certified interpreter is unavailable, the nurse should then use the telephonic interpreting system or a bilingual staff member. The nurse should never use family members to interpret.

The charge nurse overhears two new graduate nurses talking in the breakroom. One graduate nurse state "I hate getting reports from the older nurses; they are just too slow." The charge nurse should understand that the nurse is demonstrating which of the following?

Stereotyping Rationale: Stereotyping is an assumed belief about a group of people, such as believing that older people are slow. Discrimination would be refusing to receive a report from an older nurse based on age. Oppression is policies that would provide a disadvantage to older nurses, such as creating schedules that do not allow time off between shifts. Acculturation is the assimilation into a culture.

The nurse is assessing a client who reports experiencing an increase in environmental stressors. Which finding would indicate to the nurse that the client has long-term physiological effects of the stress?

Tachycardia with rest Rationale: Clients who report experiencing environmental stressors will have an increase in the flight or fight response. The signal of stress triggers the hypothalamus, which activates the autonomic nervous system. Clients will exhibit physiological symptoms of stress. Long-term effects include weight gain, hypertension, tachycardia with rest, and hyperglycemia.

A nurse has administered 5 ml of intravenous hydralazine to a client. As the multi-dose medication vial is discarded, the nurse notes the prescription was to administer 2 ml. Which action does the nurse perform first?

Take the client's blood pressure Rationale: Hydralazine is a vasodilator used in the treatment of hypertension. Upon noticing the dosage error, the nurse should immediately assess the client's condition by taking vital signs. Hydralazine decreases blood pressure. Informing the charge nurse and notifying the healthcare provider are important actions to manage the client's condition after the error. However, assessing the client is the priority. Checking the client's respirations will not evaluate the effects of hydralazine.

The nurse is discharging a newborn from the hospital. Upon inspection of the car, which of the following is the correct use of the infant car seat?

The car seat is rear facing in the center of the back seat. Rationale: The safest place for a car seat is the middle of the rear seat. Rear-facing seats are used for infants less than 20 lbs. Infants should never be placed in the front seat. Infant carriers are not the same as car seats.

When conducting an environmental risk assessment for a family using an ecomap. Which finding would indicate a social risk for the family?

The children are homeschooled. Rationale: When assessing the environmental health of a family, the nurse will gather information about relationships and connections to social units. Families that have contact outside the core family, such as attending church services, visits with relatives, and working indicate a support network. Children who are homeschooled may be at risk due to a decrease in social connections.

The nurse is caring for a client who was newly diagnosed with cancer. The client states, "I am doing ok today." Which nonverbal body language observed by the nurse would require the nurse to follow up?

The client is looking down and avoiding eye contact. Rationale: Nonverbal communication can provide the nurse with subtle information about the client. Nonverbal communication, exhibited in body language, can also indicate if the client is being honest about answering questions. A client who looks away, avoiding eye contact while reporting feeling fine, might not be answering truthfully about their feelings. Nonverbal communication such as nodding and smiling would indicate that the client is comfortable.

The emergency department (ED) nurse is caring for assigned clients. The culturally competent nurse is aware that which client is at the greatest risk for cultural disparity?

The client who recently immigrated from Mexico who fell from a ladder Rationale: Clients who are from different cultures that are newly exposed to new cultures, such as a client who recently immigrated, are at risk of healthcare disparities. The client who recently immigrated has not experienced the culture of the healthcare system and could experience challenges receiving culturally competent care. The other clients have assimilated into the culture.

The nurse is caring for a family who recently experienced a house fire. Which actions by the family indicates to the nurse resiliency?

The family has been attending group therapy. Rationale: Resiliency is the ability to respond to stressful events in a healthy way. A family who experienced a traumatic event, such as fire, will demonstrate resiliency through coping strategies that promote moving forward, such as accepting help from outside sources. Actions, such as reliving the events, focusing on the cause, or not moving forward may not be coping with the event.

A nurse is inspecting equipment in a client's restroom for safety. Which finding requires intervention by the nurse?

The nurse call pull cord is wrapped around the handrail. Rationale: Nurse-call pull cords in the shower should be hanging low enough for the client to pull in case of a fall. The nurse should unwrap the cord from the handrail. A commode chair provides support to a client with a physical disability or weakness while taking a shower. The pan is not necessary in the shower. A raised seat with armrests on the toilet provides support and decreases the risk of falls. A rubber mat prevents the client from slipping and falling on wet surfaces.

The nurse is reviewing the medical record for a client who is a Jehovah's Witness. Which prescription should the nurse clarify with the healthcare provider?

Type and cross for blood transfusion Rationale: Jehovah's Witnesses are prohibited from taking blood or blood products. The nurse should clarify the prescription for type and cross for blood transfusion with the healthcare provider. Clients who are Muslim may require meals after sunset during holy days. Clients who are Christian Scientists may refuse conventional treatments, such as pain medication or vaccinations.

The nurse is caring for a client who is terminally ill and recently immigrated to the United States. The nurse understands that to provide quality end-of-life care for the client, which action by the nurse should be a priority?

Understand the client's personal and cultural views regarding death and dying Rationale: Differences in beliefs, values, and traditional health care practices are relevant when planning end-of-life care. It is the nurse's responsibility to become familiar with the client's personal and cultural views to provide the most effective and appropriate end-of-life care. It may not be practical to arrange for care to be provided by the staff familiar with the client's culture.

The nurse is admitting a client to the hospital. The client states "Hospitals make me anxious ever since my last visit." Which of the following would be the most appropriate response by the nurse?

"Can you tell me more about that experience?" Rationale: Using therapeutic communication, the nurse should encourage the client to explore their feelings and express any concerns. Asking direct questions can make a client defensive, which could lead to further anxiety or fear.

The nurse is caring for a client with a lower extremity fracture who is on bed rest. The client states, "I need to go home so I can take care of my family." Which response by the nurse demonstrates the therapeutic communication technique of focusing?

"Can you tell me more about your concerns for your family?" Rationale: Focusing communication technique centers the conversation on specific factors or concepts, such as concern about family. Clarifying restates the client's statement to ensure correct understanding. Empathy is verbalizing an understanding of the client's feelings. Sharing observations is when the nurse comments on what was observed.

The nurse is collecting the health history of a client who was admitted from the emergency department. The client states "I already told the other nurse all of this information." Which is the most appropriate response by the nurse?

"Confirming what you have reported is to ensure we provide safe care." Rationale: The nurse is responsible for collecting and validating subjective data from clients. When taking care of a client following a transfer or admission, the nurse should review with the client the history collected. The nurse should explain to the client that reviewing and validating the client's history is to promote safe care and avoid any errors. The nurse can review information in the medical record, but it still needs to be validated with the client. Collecting the health history is best completed before the physical assessment.

The nurse is collecting the demographic data of a client. Which statement by the nurse demonstrates inclusive therapeutic communication?

"Do you have a partner?" Rationale: When interviewing clients, the nurse should be aware of heterosexist biases. Inclusive communication should focus on asking questions that provide information about the client without judging, isolating, or omitting a client's choices or beliefs. When collecting demographic data, the nurse should ask questions that are open to anyone, such as using "partner" instead of "spouse," "wife," or "husband." The nurse should avoid direct questions that imply the client is heterosexual or require the client to declare an identity.

The community health nurse is discussing concerns with a client during a family assessment. The client states "How do we ensure our adolescent will not experiment with drugs?" Which is the best statement for the nurse to make?

"Engage in family activities several times a week." Rationale: Substance use and abuse is a major stress and issue with families. To decrease the risk for substance abuse and use in children, families should be encouraged to engage in activities together, build close relationships with the family, and model behavior by family members. Strict boundaries, discussing the risks, and monitoring social media are not preventive measures.

The nurse is completing a health history for a middle-aged client. The client states, "I just got divorced last month." Which statement by the nurse would be most appropriate?

"How has the divorce impacted your health?" Rationale: When communicating with clients, the nurse should listen to the client and provide support or encouragement. The nurse should avoid interpretation of the client's words or discuss personal opinions. The nurse should be truthful, focusing on the client's concerns and feelings. The nurse should ask questions that encourage the client to discuss openly their feelings.

The hospice nurse is providing care to a client with terminal cancer. The client states, "This pain is getting unbearable; I just want you to end it all." Which response by the nurse would be most appropriate?

"I can only imagine how hard this is for you." Rationale: Clients who have terminal disease will often voice feelings of helplessness or despair. A client who is also experiencing pain may express frustration and state that they want to die. This can be challenging for the nurse. The nurse should respond with empathy, validating the client's feelings. The nurse should avoid comments that dismiss the client's feelings, such as referring back to family or stating that the client does not mean it. While assisted suicide is illegal, stating that does not create a therapeutic relationship with the client.

The nurse is reviewing the health history of a client who is Native American. Which statement made by the client would be the priority for the nurse to follow up?

"I drink alcohol occasionally, but all of my family members do." Rationale: When collecting health history, the nurse should assess for cultural physiological variations that could impact the client's health. Common health problems specific to the client who is Native American are related to alcohol consumption, such as cirrhosis of the liver and fetal alcohol syndrome. The nurse should educate the client on the risks associated with alcohol intake. It is common among Native Americans to use herbal medication, which the nurse would further assess the type and use but is not the priority. Meditation is a non-pharmacological stress reduction technique. Dietary intake is important to assess when preventing heart disease and diabetes but is not the priority.

The nurse is caring for a client with terminal cancer. When discussing the plan of care with the daughter, which statement would indicate the daughter is experiencing anticipatory grief?

"I have been in touch with our church to plan my mother's services." Rationale: Anticipatory grief is the experience of the client or family members that prolongs or predicts the impending loss. During anticipatory grief, the client or family member may engage in activities that prepare or complete tasks related to the actual loss, such as planning funeral services.

The nurse is assisting a client to ambulate for the first time following hip surgery. Which statement by the client would indicate the client is exhibiting positive intrapersonal communication?

"I know this will be difficult, but I can handle the challenge." Rationale: Intrapersonal communication refers to the communication within one's self, which is positive affirmation. Positive intrapersonal communication includes statements that are encouraging and supportive, such as stating the ability to tackle challenges. Negative intrapersonal communication includes statements that indicate defeat or making fun of themselves.

The home health nurse is visiting with an older adult client who recently moved in with their adult child. Which statement by the client would indicate to the nurse the client might be experiencing mistreatment?

"I recently added my daughter on to my bank account." Rationale: Older adults are at risk for mistreatment, which is the intentional acts or lack of care by a caregiver towards the client. Mistreatment can be neglect, which would be a failure to provide social interactions and basic food, water, and physical aids, such as eyeglasses. Financial abuse refers to denying the client access to their personal resources, stealing money, or coercing the client to sign contracts.

The nurse is teaching a client newly diagnosed with HIV about virus transmission. Which statement by the client would indicate to the nurse the need for further teaching?

"I should avoid cooking for my family." Rationale: HIV is transmitted through direct contact with bodily fluids, such as unprotected sex or sharing of used needles. HIV is not transmitted through casual contact, such as preparing food or using shared gym equipment. Clients who are newly diagnosed with HIV should be instructed to contact previous sexual partners.

The nurse is speaking with the spouse of a client who has terminal cancer. Which statement made by the client's spouse indicates appropriate coping?

"I try to set aside a few minutes to myself each day." Rationale: The nurse will need to assess the need for psychological support for the family of clients with a terminal disease. The family who has difficulty sleeping or is overwhelmed with caring for the client will require psychosocial support.

The nurse is preparing to administer prescribed medication to a client with paranoid schizophrenia. The client states, "I can't take that; you are trying to poison me." Which statement should the nurse make?

"I understand that fear; would you like to see the packaging?" Rationale: When communicating with a client with paranoid schizophrenia, the nurse should speak indirectly to the client, identify with the client's feelings, avoid rationalizing but share in the mistrust, and provide the client with options. Offering to show the client the packaging addresses their fears of being poisoned. Telling the client about the medication does not address the delusion of the medication being tampered with. Asking about refusing the medication or trying to rationalize the thought will increase the client's paranoia.

A hospice nurse is caring for a client with terminal pancreatic cancer who is receiving end-of-life care. The client states, "I do not want to eat or be fed." Which statement should the nurse make?

"I understand your choice and will inform the healthcare provider." Rationale: The client has the right to make decisions about their end-of-life care. If the client decides to not receive care, such as eating, the nurse should respect the client's rights and report to the healthcare provider. The other options do not respect the client's decision.

The nurse is caring for a client who uses oxygen at home. Which of the following statements by the client warrants additional assessment by the nurse?

"I wear my oxygen when I'm preparing our dinner." Rationale: Clients should always maintain at least two meters (approx. 6 feet) between a fire and a portable oxygen concentrator and accessories. This includes gas stovetops. Clients may need to wear oxygen when showering or bathing, but it is important the concentrator itself does not get wet. Extension tubing can be used to facilitate this. Clients will have spare tanks at home in case of power failure. They should be stored in a secure location away from open flame and heat.

The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which statement by the client would require the nurse to assess the family dynamics?

"I will try to make myself useful when I move into their home." Rationale: Older adult clients are often faced with moving from their homes into a skilled nursing facility or with family. The loss of their home and possessions can be challenging for the adult client. However, a loss of self-concept and freedom, along with the feeling of being a burden, is a concern. Families can also experience caregiver strain. The nurse should assess the family dynamics to ensure a healthy outcome.

The nurse has provided strategies to a client about infection prevention. Which of the following statements by the client indicates the need for further teaching?

"I will use antimicrobial soap and hot water to wash my hands." Rationale: Antimicrobial soap is not needed for routine handwashing and can lead to resistant organisms. Raw fruits and vegetables can carry infectious organisms and should be washed before eating. Fingernails should be cut and clean to prevent harboring of organisms. The nurse should instruct the client to avoid sharing personal grooming items, such as toothbrushes.

The home health nurse is visiting with a client who experienced the loss of a spouse. The client states, "I can't believe this has happened; what will I do?" What statement by the nurse would be appropriate?

"Tell me more about what you are feeling." Rationale: Listening attentively to the client and encouraging the client to talk are appropriate responses by the nurse for the client who is experiencing bargaining, according to Kubler-Ross's stages of grieving.

The charge nurse overhears a staff nurse and unlicensed assistive personal (UAP) discussing the care of a client who is Hispanic and had abdominal surgery. The UAP reports to the nurse "The client states the pain medication is not working." Which statement by the staff nurse would require the charge nurse to intervene?

"Was the client just sitting up in bed?" Rationale: Cultural bias can cause nurses to make quick judgments and assessments of a situation. The bias is often based on nurses' backgrounds and personal experiences. Often, these biases are unconscious, or not realizing they have these views. A nurse whose first response is to ask if the client is sitting up in bed when reporting pain is demonstrating a cultural bias. This implies that the client is not really in pain if they are just sitting up in bed. Checking the pain, gathering more information about the client's pain, or reporting the pain to the healthcare provider are appropriate actions for the nurse to take.

The hospice nurse is reviewing the medical record for a client who is receiving palliative care. Which prescriptions should the nurse expect? [Select all that apply.]

-Provide skin moister barrier cream -Apply artificial tear eyedrops -Perform mouth care every hour -Administer oxygen 2 L/min via nasal cannula Rationale: Palliative care focuses on interventions that promote comfort at end of life. Applying moisture barrier cream, administering artificial tear eye drops, mouth care, and administering oxygen provides comfort. Obtaining vital signs does not provide comfort and does not provide benefits to the client.

Which actions by the nurse demonstrate caring practices? [Select all that apply.]

-Sitting with a client who is crying -Holding a client's hand during a procedure -Asking the client about their hobbies -Involving the client's family Rationale: A nurse demonstrates caring in practice by knowing the client, using therapeutic touch, listening, and involving the family. Offering advice is not a caring act; the nurse provides education and information but does not express personal opinions to clients.

An emergency department (ED) charge nurse is receiving training on providing assignments to unit nurses who are floated to the ED during a disaster activation. Which assignment is appropriate for a nurse from an orthopedic unit?

A client with a femur fracture who is placed in skin traction Rationale: The charge nurse should assign a client that closely matches the nurses' competencies. A client on skin traction is an appropriate client to assign to an orthopedic nurse. Skin traction is applied to clients who have fractures. A client who requires cardiac monitoring is not an appropriate client to assign to an orthopedic nurse. Cardiac monitoring requires telemetry training. Taking care of a client on hemodialysis requires specialized training. Providing care to a client on mechanical ventilation is an advanced competency for critical care nurses.

During a disaster activation, a nurse is tasked with recommending the most stable client for discharge within the hour. Which client should the nurse recommend?

A client with an ankle fracture who uses crutches for ambulation Rationale: A client with an ankle fracture who requires crutches is the most stable client for discharge. The client can ambulate with an assistive device. A client who needs medication assistance for a newly diagnosed disease is not appropriate for discharge. The client requires a case management consult. A client who has had major surgery is not the most appropriate client for discharge. A new colostomy requires extensive client education. A client on negative pressure wound therapy (NPWT) is not an appropriate client for discharge within an hour. Arrangements for home use of NPWT is a lengthy approval process.

A nurse is preparing to obtain a blood specimen from a client. Which action should the nurse take?

Asks the client to state their name and date of birth Rationale: The nurse should identify the client by asking them to state their name and date of birth. Ensuring client identification prevents the nurse from mistakenly obtaining blood from the incorrect client. The tube should not be labeled until after the blood specimen is collected. Writing the information directly on the tube can smudge and does not ensure proper identification of the specimen. Placing a client label on the biohazard bag does not ensure proper identification if the specimen is separated from the bag upon analysis.

During a client interview, which action by the nurse demonstrates the orientation phase of the helping relationship?

Prioritize the health concerns identified by the client Rationale: The phases of a healthy relationship provide structure to the client-nurse relationship. The preinteraction phase focuses on reviewing data, including the client's electronic medical record. During the orientation phase, the nurse will begin to observe the client, assess the client's health status, and prioritize health concerns. The nurse will encourage the client to express feelings, provide information, and take actions to meet goals during the working phase.

The nurse is planning care for a client with bipolar who is experiencing an acute manic episode. Which action is a priority for the nurse to implement?

Rationale: When caring for a client with bipolar who is experiencing an acute episode, the priority actions for the nurse are to keep the client safe and prevent injury. During an acute manic episode, the client will have extreme restlessness and physical activity may be difficult to control. The nurse should implement actions to keep the client hydrated, rested, and safe. The client in the acute manic episode will not have the cognitive focus to attend group therapy, perform hygiene care, and report changes in condition.

The nurse is caring for a client who is experiencing an acute phase of schizophrenia and is exhibiting positive symptoms. Which finding should the nurse expect to observe?

The client reports that the call bell is a tracking device. Rationale: The symptoms of schizophrenia are categorized as positive, negative, cognitive, and mood. Positive symptoms refer to symptoms that add to a client's personality, such as delusions, hallucinations, and perceptions that are not based in reality. Negative symptoms refer to symptoms that take away from the client's personality, such as loss of motivation, inability to experience pleasure, and feeling of emptiness. Cognitive symptoms refer to the client's inability to process information, inability to focus or pay attention, and difficulty with memory. Mood symptoms refer to when the client is depressed, anxious, or suicidal.