Psychosocial Integrity

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

C. Establish the client's daily smoking pattern.

A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate? A. "We are mean to hurt you that way." B. "It's okay to cry when something hurts." C. "You were very good not to cry with the needle." D. "That really didn't hurt, did it?"

B. "It's okay to cry when something hurts."

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. when making decisions about her care B. to allow her mother to continue in her role as a mother C. alone and not in combination with other defense mechanisms D. to permit her mother to seek unconventional treatments

B. to allow her mother to continue in her role as a mother

The nurse is caring for a 15-year-old adolescent mother after birth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in client teaching? A. dependence on parents after birth B. potential rejection by the boyfriend C. increased stress for new mothers D. inability to achieve educational goals

C. increased stress for new mothers

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication? A. lithium carbonate B. thiothixene C. lorazepam D. clozapine

C. lorazepam

In working with a rape victim, which intervention is most important? A. telling the client that the rapist will eventually be caught, put on trial, and jailed B. recommending that the client resume sexual relations with her partner as soon as possible C. periodically reminding the client that she did not deserve and did not cause the rape D. continuing to encourage the client to report the rape to the legal authorities

C. periodically reminding the client that she did not deserve and did not cause the rape

In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is A. reflection B. clarification C. self-disclosure D. restating

C. self-disclosure

A client concerned about being diagnosed with type 2 diabetes tells a nurse, "My parent suffered with diabetes for many years and finally died of kidney failure in spite of treatment. Why should I try if I'm going to go through the same thing?" What is the nurse's most appropriate response? A. "There are no guarantees about how diabetes will progress." B. "It sounds like your parent's diabetes wasn't under very good control." C. "Your parent didn't get the proper treatment." D. "Are you worried that you'll have the same experience as your parent?"

D. "Are you worried that you'll have the same experience as your parent?"

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay? A. "What are the worst challenges that you have faced?" B. "What could you have done to prevent this illness?" C. "How can we take away your worries while you are in the hospital?" D. "How is this illness impacting you and your family?"

D. "How is this illness impacting you and your family?"

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness? A. denial B. introjection C. regression D. repression

D. repression

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief? A. anger B. bargaining C. denial D. shock

D. shock

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. A. Offer to stay with the grieving parents. B. Remind the parents that there must have been something wrong with the baby. C. The nurse should control emotions so as to not upset the parents. D. Provide an early opportunity for the couple to see the child if desired. E. Answer the parents' questions accurately.

A. Offer to stay with the grieving parents. D. Provide an early opportunity for the couple to see the child if desired. E. Answer the parents' questions accurately.

When assessing a client with post-traumatic stress disorder secondary to being adopted as a child, the nurse would expect which findings? Select all that apply. A. difficulty communicating feelings B. excessive repetitive movements C. sleep pattern disturbances D. outgoing personality E. lack of impulse control

A. difficulty communicating feelings C. sleep pattern disturbances E. lack of impulse control

While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience? A. fear of the unknown B. fear of the effects of anesthesia C. fear of changes in body image D. fear of being in pain

A. fear of the unknown

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern? A. suicide potential B. avoidance behavior C. alcohol abuse D. explosive outbursts

A. suicide potential

The nurse is caring for a client who is a recent immigrant from China. Through the hospital interpreter, the client expresses an unwillingness to eat the fried fish that was on the meal tray, describing it as "too hot." What is the nurse's best action? A. Ask the interpreter to ask the client to leave the food in the fridge for a few minutes before starting eating. B. Ask the interpreter to ask the client about the specific meaning of the description of "hot." C. Ask the interpreter to ask the client's family to bring a favorite food from home. D. Ask the interpreter to suggest culturally appropriate foods for the client.

B. Ask the interpreter to ask the client about the specific meaning of the description of "hot."

An adolescent client is admitted for treatment of anorexia nervosa with a body mass index (BMI) of 13. What is the nurse's priority in planning the care? A. Meet daily with the client to discuss manipulation and countertransference. B. Monitor the client's urine output and vital signs. C. Keep the client on bed rest until the goal weight is achieved. D. Encourage the client to perform muscle-building exercises.

B. Monitor the client's urine output and vital signs.

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? A. health promotion and maintenance B. psychosocial integrity C. physiologic adaptation D. reduction of risk potential

B. psychosocial integrity

When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the A. priestess B. spiritual healer C. rabbi D. preacher

B. spiritual healer

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? A. "You sound discouraged. Chemotherapy commonly makes people feel worse." B. "Can you tell me what side effects of the chemotherapy are most troubling for you?" C. "Can you tell me more about how you are feeling right now about your treatment?" D. "It can be discouraging to feel worse after treatment. How can I help you feel better?"

C. "Can you tell me more about how you are feeling right now about your treatment?"

The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." How should the nurse respond? A. "Tell me who do you mean when you say 'everyone' wants to kills you." B. "Why do you think someone wants to kill you?" C. "Don't worry, we'll protect you. No one can come here to harm you." D. "You're frightened. This is a hospital and these people are staff members. You're safe here."

D. "You're frightened. This is a hospital and these people are staff members. You're safe here."

The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, "Bastard," under his breath. Which nursing action is most appropriate? A. Ignore the client because he appears to be hallucinating. B. Remind the client that vulgar language is not appropriate in the hospital. C. Suggest the client spend some time in his room. D. Approach the client to interrupt the hallucinations.

D. Approach the client to interrupt the hallucinations.

The nurse is preparing to take a meal tray to the client. The nurse understands that the client follows a kosher diet. Which foods noted on the tray would be of a concern to the nurse? A. salmon and broccoli B. cream cheese and bagels C. sardines and wheat crackers D. turkey and cheese sandwich

D. turkey and cheese sandwich

A nursing student and a charge nurse of a psychiatric unit are discussing the outcomes of clients with depression. Which if stated by the student, indicates that the student understands depression outcomes? A. "All people are at risk of depression. Nine out of 10 people will have depression in their lives." B. "When an individual has depression, they will experience the problem all of their life." C. "There are patterns with this illness. If a person has one depressive episode, they have a 60% chance of experiencing another." D. "Depression is situational. As long as the cause does not happen again, the depression should never happen again."

C. "There are patterns with this illness. If a person has one depressive episode, they have a 60% chance of experiencing another."

When working with a client who has a mental illness and the client's family, which approach will be most effective? A. Advise each family member on how to deal with the client. B. Form an alliance with the client. C. Convey warmth and acceptance to each family member. D. Help the client to conform to the family's wishes.

C. Convey warmth and acceptance to each family member.

A laboring client at 28 weeks gestation is in preterm labor. Her partner gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse? A. "You seem really stressed. Do you have any one to talk to about this?" B. "Your partner seems to be coping just fine. She has managed very well today." C. "You and your partner have been through a lot with this pregnancy. Let's talk about this further." D. "I know you are upset. However you need to put this in perspective for the sake of your partner and infant."

C. "You and your partner have been through a lot with this pregnancy. Let's talk about this further."

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? A. Obtain a PRN prescription for lorazepam to reduce binge eating urges. B. Schedule daily family therapy sessions. C. Enroll the client in a coping skills group. D. Work with the client to limit her purging.

C. Enroll the client in a coping skills group.

While doing the shift assessment on a 5-year-old boy, a nurse notices several bruises on his back and arms. The bruises are different colors and sizes. When she asks the child how he got them, he states, "I fell off of my bike." What should the nurse do next? A. Continue to ask the child how he received the injuries. B. Contact the physician and tell him to call the police. C. Talk with the child's parents when they arrive. D. Contact Child Protective Services to report the injuries.

C. Talk with the child's parents when they arrive.

A client has been diagnosed with invasive testicular cancer and asks if it is necessary to undergo further treatment after the surgery. What would be an appropriate initial response by the nurse? A. Arrange a meeting for the client with the health care provider and oncologist to discuss concerns. B. Ask the client if he would like to discuss his concerns with the social worker. C. Explore what the client thinks will help make a decision. D. Ask the client if he would like to talk to the hospital chaplain.

C. Explore what the client thinks will help make a decision.

A 19-year-old male with cystic fibrosis (CF) is hospitalized for a serious lung infection and is in need of a lung transplant. However, he has a rare blood type that complicates the process of obtaining a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence with medication and therapy. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request? A. It is a signal of the depressive side of his bipolar disorder, and he should be checked for suicidal thoughts/plans. B. It is a signal of delirium as a result of the many medications the client is taking and requires further assessment by the pharmacist or health care provider (HCP). C. It is a signal of an exacerbation of the client's CF and warrants further assessment by his lung specialist. D. It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff.

D. It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff.

A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby is coming!" To help the client remain calm and cooperative during the imminent birth, which response by the nurse is most appropriate? A. "I'll explain what is happening to guide you as we go along." B. "Please do not push because you will tear your cervix." C. "You're right, the baby is coming, so just relax." D. "Your health care provider will be here as soon as possible."

A. "I'll explain what is happening to guide you as we go along."

The nurse is caring for an 8-year-old girl with frequent urinary tract infections who is withdrawn and quiet. The nurse learns the child is left with a male caregiver while the mother is at work. The child states, "It hurts down there." What is the best response to the child? A. "Are there other times you have hurt down there?" B. "Is the babysitter touching you down there?" C. "The hurt is from the urinary tract infection." D. "The medications will help your hurt soon."

A. "Are there other times you have hurt down there?"

When assessing a 17-year-old client with depression for suicide risk, which question would be best? A. "Are you thinking about killing yourself?" B. "What movies about death have you watched lately?" C. "Has anyone in your family ever committed suicide?" D. "Can you tell me what you think about suicide?"

A. "Are you thinking about killing yourself?"

Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my spouse." How should the nurse respond? A. "Can you tell me more about what your goals for a sexual relationship with your spouse are?" B. "There are really good reconstructions that can be performed once your surgical site is healed." C. "I hear you are concerned. I can arrange to speak with you and your spouse about your sexual relationship." D. "I am sure your spouse loves you very much and will still find you attractive."

A. "Can you tell me more about what your goals for a sexual relationship with your spouse are?"

A client diagnosed with antisocial personality disorder asks the nurse for an additional smoke break because of anxiety. Which response by the nurse is best? A. "Clients are permitted to smoke at designated times. You have to follow the rules." B. "Smoking is harmful to your health. I don't want to contribute to your bad habits." C. "I'm sorry but I can't take you. I'm busy." D. "I have a few minutes. I'll take you."

A. "Clients are permitted to smoke at designated times. You have to follow the rules."

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? A. "I hope I can handle having a prosthesis, but I'm really wondering what my wife will think." B. "I hope to get skilled enough at using my prosthesis to help others like me adjust." C. "Whenever I start to feel sorry for myself, I remember that my buddy died in that accident." D. "When I get my prosthesis, I want to learn to walk so I can participate in walk-a-thons."

A. "I hope I can handle having a prosthesis, but I'm really wondering what my wife will think."

The nurse accompanies the physician when a client is told that they have colon cancer and will require surgery. When the physician informs the client of the diagnosis, the client states, "There is no way that this is true, I am not even sick!" Which is the nurse's best response? A. "I understand how difficult this must be to accept." B. "Other people have done very well with this surgery." C. "You will come to accept this diagnosis and work through it." D. "Maybe it's not as bad as you think it will be."

A. "I understand how difficult this must be to accept."

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. What should the nurse tell the husband? A. Ignore the vulgarity and distract her. B. Say nothing and leave the room. C. Tell her to stop swearing immediately. D. Tell her that she is very rude.

A. Ignore the vulgarity and distract her.

Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? A. absence of crying during the examination B. clinging to the parent during the examination C. playing with toys on the examination room floor D. talking easily with the nurse

A. absence of crying during the examination

The parent of a school-age child with autism asks the nurse how she should tell her son that he has autism. Which response by the nurse is most therapeutic? A. "You should let the health care professionals tell your son about his diagnosis of autism." B. "Explain the definition of autism and emphasize your child's strengths as well as his areas of challenge." C. "Tell your son that he is different from other kids his age and that you will always be there to support him." D. "Explain to your son that he has a developmental disorder that makes him different from other children his age."

B. "Explain the definition of autism and emphasize your child's strengths as well as his areas of challenge."

An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply. A. "Our child doesn't understand how this affects the family." B. "Our child is just trying to get attention." C. "Our child would not do this again." D. "Our child needs to learn new coping skills." E. "Our child will be fine in a couple of days."

B. "Our child is just trying to get attention." C. "Our child would not do this again." E. "Our child will be fine in a couple of days."

While interviewing a preschool-age girl who has been sexually abused about the event, which approach would be most effective? A. Draw a picture and explain what it means. B. "Play out" the event using anatomically correct dolls. C. Name the perpetrator. D. Describe what happened during the abusive act.

B. "Play out" the event using anatomically correct dolls.

The health care provider is preparing a plan of care for a client with borderline personality disorder. Which medication would the nurse anticipate for this client? A. Antipsychotics, along with an antidepressant, will treat illusions, ideas of reference, paranoid thinking, anxiety, and hostility in clients. B. Selective serotonin reuptake inhibitors (SSRIs), along with an atypical antipsychotic, are used to treat mood instability and impulsivity. C. Monoamine oxidase inhibitors (MAOIs) work best because the effects are felt very quickly. D. Anxiolytics will reduce the anxiety and cognitive distortions that frequently occur in these clients.

B. Selective serotonin reuptake inhibitors (SSRIs), along with an atypical antipsychotic, are used to treat mood instability and impulsivity

The nurse is preparing to administer oral medication to an 8-year-old child who is resistant to taking the medication. Which is the most effective statement made by the nurse that would encourage the child to take the medication? A. "I will leave this medication with you on your table so that you can take it later." B. "Would you like to take your medication now?" C. "I have your medication. Swallow these please." D. "If you don't take this medication, I will get the physician to order a shot."

C. "I have your medication. Swallow these please."

An 18-month-old child is admitted to the pediatric unit. Which of the following can the nurse do to reduce the stress on the client during this hospitalization? A. Encourage play times with other children on the unit B. Allow the child to explore the environment C. Encourage the client's caregivers to be with the client as much as possible D. Minimize needle sticks to the client

C. Encourage the client's caregivers to be with the client as much as possible

During family teaching, the daughter of a client with dementia mentions to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? A. "I tell her reality, such as, 'That noise is the wind in the trees.'" B. "I turn off the radio when we're in another room." C. "I understand the misperceptions are part of the disease." D. "I tell her she's wrong, and then I tell her what's right."

D. "I tell her she's wrong, and then I tell her what's right."

A nurse is caring for a veteran with a history of explosive anger, unemployment, and depression since being discharged from the service. The client reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response? A. "You can change your behavior if you're motivated to do so." B. "Weak people don't want to make changes in their lives." C. "It isn't too late for you to make changes in your life." D. "Many people who've been in your situation experience similar emotions and behaviors."

D. "Many people who've been in your situation experience similar emotions and behaviors."

A postpartum client tells the nurse that she and her partner had an argument about continuing breastfeeding before the partner left for work in the morning. THe partner was up all night, not able to sleep with the baby crying, and wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? A. "I know an excellent support group for breastfeeding." B. "I will come back in a few days and talk to your husband." C. "Have you considered offering breast milk and formula?" D. "What are your feelings about breastfeeding?"

D. "What are your feelings about breastfeeding?"

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: A. allowing parents and siblings to visit frequently. B. arranging for tutoring in school work. C. emphasizing the need to follow the facility regimen. D. encouraging peer visitation.

D. encouraging peer visitation.

A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does not experience further confusion. Which measure if suggested by the family would the nurse discourage? A. keeping lights dimmed during daylight hours B. posting a calendar in the room C. providing for uninterrupted sleep D. bringing familiar objects from home for the room

A. keeping lights dimmed during daylight hours

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care? A. helping the client identify and verbalize their feelings about the incident B. helping the client identify any stressors or psychological conflicts C. exploring personal relationships that may be related to the paralysis D. teaching the client to deal with any limitations of the paralysis

A. helping the client identify and verbalize their feelings about the incident

A nurse works in a suicide crisis clinic. The clients that represent the highest risk for suicide are those who state: A. "I'm thinking of driving my car into a tree on the way home." B. "If my life doesn't get better, I might take matters into my own hands." C. "I'm always thinking about dying." D. "I gave my clothes away because I'm depressed and think about death a lot."

A. "I'm thinking of driving my car into a tree on the way home."

A client ashamedly tells the nurse that he hit his wife while intoxicated and asks the nurse if his wife will ever forgive him. What is the nurse's most appropriate response? A. "You seem to have some feelings about hitting your wife." B. "It would depend on how much she really cares for you." C. "Perhaps you could ask her and find out." D. "That is something you can explore in family therapy."

A. "You seem to have some feelings about hitting your wife."

An adolescent is a heavy user of marijuana and alcohol. When the nurse confronts the client about his drug and alcohol use, he admits previous heavy use in order to feel more comfortable around peers and achieve social acceptance. He says he has been trying to stay clean since his parents found out and had him seek treatment. When the nurse develops a plan of care with the client, what should be the highest priority to help him maintain sobriety? A. peer recognition that does not involve substance use B. the threat of legal charges if caught drinking or smoking marijuana C. a strict no-drug policy at his high school D. support and guidance from his parents

A. peer recognition that does not involve substance use

The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? A. safety B. manipulation C. splitting D. empathy

A. safety

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first? A. Reassure the client that her feelings are typical reactions to serious trauma. B. Reassure the client that her symptoms are temporary. C. Acknowledge the unfairness of the client's situation. D. Explain the effects of stress on the mind and body.

B. Reassure the client that her symptoms are temporary.

An emergency department nurse is conducting an assessment interview with an elderly client. The client states, "I was so frightened when I fell while crossing the street." Which statement would be the best response? A. "You will feel less frightened tomorrow." B. "That must have been frightening for you." C. "Why were you afraid on the street?" D. "Were you afraid because you were alone?"

B. "That must have been frightening for you."

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first? A. Administer an anticholinergic medication. B. Assess the physical problems. C. Call the healthcare provider. D. Encourage the client to discuss the delusions.

B. Assess the physical problems.

While preparing a client for surgery, a nurse discovers that the client's view about spirituality is entirely different from the nurse's. What is the most appropriate action by the nurse? A. Suggest the client meet with a chaplain for spiritual support. B. Respect the privacy of the client's spiritual beliefs and rituals. C. Request a nurse who shares the client's belief to continue care. D. Tell the client that their illness is due to spiritual views.

B. Respect the privacy of the client's spiritual beliefs and rituals.

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? A. Delay discussing the client's questions with her until the convalescent phase of her care. B. Delay discussing the client's questions with her until her apprehension subsides. C. Tell the client as much as she wants to know and is able to understand. D. Explain to the client that she should discuss her questions with her health care provider (HCP).

C. Tell the client as much as she wants to know and is able to understand.

A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating which stage of separation anxiety? A. despair B. detachment C. regression D. protest

D. protest

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client? A. problem solving B. medication management C. insight oriented D. reality orientation

D. reality orientation

A nurse is caring for a client with chronic pain. In planning care, what will the nurse focus on as part of incorporating spiritual health into the client's plan for pain control? A. the client's willingness to ask others to pray for the relief of the client's pain B. the client's belief about the effects of positive spiritual thoughts on pain levels C. the client's sense of meaning and purpose as it relates to quality of life and pain D. spiritually linked actions that the client has used to manage pain in the past

D. spiritually linked actions that the client has used to manage pain in the past

A nurse is admitting a client to the palliative unit and discussing advanced directives. Which statement made by the client leads the nurse to believe the client requires clarification around advanced directives? A. "I can let my family know what treatment I want in the future." B. "This will allow me to identify who my power of attorney will be." C. "This will stop my daughter-in-law from putting me in a home." D. "It is good to do this now before I am unable to make the decisions."

C. "This will stop my daughter-in-law from putting me in a home."

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? A. The client will explore her strengths. B. The client will prioritize problems. C. The client will identify two positive qualities. D. The client will discuss her feelings related to her losses.

D. The client will discuss her feelings related to her losses.

A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, "You're going to tell me who did this to you. What's his name?" Which is the nurse's best response? A. "Please come with me, sir. I need some important information." B. "If you don't stop yelling, I'll have to call Security." C. "Stop yelling. You're being inappropriate." D. "Please be quiet. You're not helping your daughter this way."

A. "Please come with me, sir. I need some important information."

The wife of a client with alcohol dependency tells the nurse, "I'm tired of making excuses for him to his boss and coworkers when he can't make it into work. I believe him every time he says he's going to quit." The nurse recognizes the wife's statement as indicating which behavior? A. enabling B. helpfulness C. self-defeat D. masochism

A. enabling

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling? A. "My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids." B. "My son got worried because I made this silly comment about wanting to be with my husband in heaven." C. "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." D. "My primary care provider just put me on an antidepressant, and I'll be fine in a week or so."

C. "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died."

The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse? A. Speak to family members to ascertain whether the client is suicidal B. Ask a direct question such as, "Do you ever think about killing yourself?" C. Arrange for the client to be placed on immediate suicidal precautions D. Talk to the client to determine whether the client is an attention seeker

B. Ask a direct question such as, "Do you ever think about killing yourself?"

A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate: A. withdrawal B. aggression C. tearfulness D. apathy

B. aggression

A client scans the adult inpatient unit on arrival at the hospital. The client is neatly dressed and clutches a leather briefcase. The client refuses to let the nurse touch the briefcase to check it for valuables or contraband. Which action by the nurse would be best? A. Obtain help to take the briefcase away from the client. B. Inspect the briefcase when the client is temporarily out of the room. C. Tell the client that he must follow hospital policy if he wishes to stay. D. Ask the client to open the briefcase and describe its contents.

D. Ask the client to open the briefcase and describe its contents.

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. What is the nurse's role in this situation? A. Encourage the client to pray for clarity on the matter and offer support. B. Provide examples of ways clients handle spiritual and care planning conflicts. C. Inform the client's healthcare provider of the client's concerns. D. Assist the client in obtaining information to make an informed decision.

D. Assist the client in obtaining information to make an informed decision.

To decrease a female client's anxiety about being placed in the lithotomy position for surgery, what should the nurse do? A. Pad the stirrups for comfort. B. Reassure the client that an all-female surgical team will be present. C. Explain in detail what will occur in the operating room. D. Determine what the client is concerned about.

D. Determine what the client is concerned about.

In the hospital setting, the child of a client who is dying tells the nurse, "It is hard to just sit here for hours and not say or do anything." As the nurse responds to the child's statement, what issue is most important for the nurse to focus on during their discussion? A. Provide background music of familiar songs. B. Think about ways to complete unfinished business. C. Perform actions that facilitate comfort measures. D. Know that being present with the person is important.

D. Know that being present with the person is important.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? A. Assess the nature of the commands by asking what the voices are saying. B. Provide reassurance that the client is safe and promise the staff will protect the client. C. Provide reassurance that the client is safe and the voices are not real. D. Administer a neuroleptic medication before speaking with the client.

A. Assess the nature of the commands by asking what the voices are saying.

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? A. slurring of words when excited B. visual hallucinations C. an exaggerated sense of well-being D. inappropriate laughter

C. an exaggerated sense of well-being

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior? A. tangential B. perserveration C. avolition D. word salad

C. avolition

A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all medications. What is appropriate for the nurse to say to the client? A. "Taking several medications can be difficult. Tell me about the difficulties you're having." B. "Why aren't you taking your medications? Don't you want to get better?" C. "Don't you realize that resistance can develop if you don't take your medications properly?" D. "You must take your medication as instructed. Do you need supervision?"

A. "Taking several medications can be difficult. Tell me about the difficulties you're having."

A school-age child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, "It's that school nurse again. She's done nothing but try to make trouble for our family since my son started school. And now you're in on it." What is the nurse's most appropriate response? A. "You sound pretty angry with the school nurse. Tell me what's happened." B. "The school nurse is concerned about your son and is only doing her job." C. "Let me tell you why your son was referred, and then you can tell me about your concerns." D. "You don't need to feel singled out. We see a number of children who go to your son's school."

A. "You sound pretty angry with the school nurse. Tell me what's happened."

A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. The client gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate? A. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. B. Ask the client to describe what the voices are saying. C. Encourage the client to go to the client's room to experience fewer distractions. D. Approach and touch the client to get the client's attention.

A. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I don't know why she didn't keep the doors locked like I told her. I can't believe she's had sex with another man now." How should the nurse respond? A. "Let's talk about how you feel. Maybe it would help to talk to other men who have been through this." B. "It wasn't consensual sex. Let's see if your wife was physically injured." C. "Your wife needs your support right now, not your criticism." D. "Maybe the doors were locked, but the man broke in anyway."

A. "Let's talk about how you feel. Maybe it would help to talk to other men who have been through this."

The nurse leading a group session for parents of children diagnosed with oppositional defiant disorder. The nurse should give which recommendation for discipline? A. Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration. B. Use time-out as the primary means of punishment for the child regardless of what the child has done. C. Avoid limiting the child's use of the television and computer for punishment. D. Use primarily positive reinforcement for good behavior while ignoring any demonstrated bad behavior.

A. Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration.

A client is voluntarily admitted to a substance use disorder unit. The client admits to drinking at least 1 qt (1 L) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings will the nurse document as evidence of alcohol withdrawal? A. vomiting, watery frequent diarrhea, and pulse below 80 beats/minute B. pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness C. dehydration, temperature above 101°F (38.3°C), and pruritus D. blood pressure of 90/50 mmHg, decreased appetite, and somnolence

B. pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness

The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife asked him for a divorce. Which intervention is most appropriate? A. allowing the client to talk about the HCPs he has seen and the medications he has taken B. informing the client about a different medication for his nausea C. directing the client to describe his feelings about his impending divorce D. asking the client to describe his problem with nausea

C. directing the client to describe his feelings about his impending divorce

A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. The client can swallow without difficulty. While caring for the client, the nurse discovers that the weight loss is related to the client's refusal to eat. The client states to the nurse that they would rather die than remain alive with this disease. How should the nurse intervene? A. Support the client's decision because they have a fatal disease. B. Report this finding to the client's family, and suggest they talk with the physician about having a feeding tube placed. C. Ask the physician to consult a psychiatrist because the client is exhibiting suicidal behavior. D. Explore the client's feelings about dealing with ALS using open-ended questions.

D. Explore the client's feelings about dealing with ALS using open-ended questions.

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. Sit at the other corner of the room. B. Do not ask very personal questions. C. Do not probe into emotional issues. D. Maintain eye contact while talking.

D. Maintain eye contact while talking.

An adolescent presents to the emergency department after a motor vehicle accident. Police inform the parent that the client was thrown from the vehicle, was not wearing a seatbelt, and they believe the client was driving while under the influence of alcohol. The health care provider updates the parent that the adolescent has a cervical spine fracture and may be paralyzed. The parent becomes upset and agitated with the police officer and health care provider, and says "You are both wrong! My Johnny is a good boy! He would never do that - he plays basketball and is on the honor roll!" In which stage of the grief process is the parent? A. anger B. bargaining C. acceptance D. denial

D. denial

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? A. role-playing B. reporting the abuse to a prosecutor C. giving the child's drawings to the abuser D. engaging in play therapy

D. engaging in play therapy

Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which intervention should the nurse expect to implement to accomplish this goal? A. explaining the preoperative and postoperative procedures to the mother B. allowing the infant to play with surgical equipment C. making sure the infant's favorite toy is available D. having the mother stay with the infant

D. having the mother stay with the infant

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have? A. difficulties with speech B. unable to recognize objects by touch C. sleep disturbance D. impulsive acts of aggression

D. impulsive acts of aggression

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: A. is ready to be discharged from treatment. B. is responding appropriately to the antipsychotic. C. is experiencing a split personality. D. may be experiencing increased energy and is at increased risk for suicide.

D. may be experiencing increased energy and is at increased risk for suicide.

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the mother and partner to do? A. Bottle-feed the twins to prevent exhaustion and fatigue. B. Plan for each parent to spend equal amounts of time with each twin. C. Avoid assistance from other family members until attachment occurs. D. Relate to each twin individually to enhance the attachment process.

D. Relate to each twin individually to enhance the attachment process.

An intensive care nurse is caring for a client diagnosed with persistant vegatative state that has an order for terminal weaning. The nurse personally believes that life is sacred and that everything should be done to preserve life. What should the nurse do? Select all that apply. A. Tell the family that it is unethical to unplug the respirator and let the client die. B. Offer an opinion about the sanctity of life and suggest doing everything to preserve it. C. Excuse oneself from the area when the healthcare team unplugs the respirator. D. Assist with the terminal weaning as ordered and provide support to the family. E. Ask the charge nurse to approve a change in the nurse's current client assignment.

D. Assist with the terminal weaning as ordered and provide support to the family. E. Ask the charge nurse to approve a change in the nurse's current client assignment.

An older adult experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the client most likely has which problem? A. delayed grieving related to her Alzheimer's disease B. trouble adjusting to living alone without her husband C. the onset of Alzheimer's disease D. delirium and a urinary tract infection (UTI)

D. delirium and a urinary tract infection (UTI)

A young Middle Eastern woman's father and brother arrive at the hospital to learn that the physician arrived early and discussed the results of the client's skin biopsy directly with her. They become agitated and begin yelling. The best action for the nurse to take is to: A. ask the the father and brother if they would like the physician to meet with the family. B. call security to escort these men out of the hospital. C. offer to review the information given the client with them. D. activate the psychiatric emergency team for support.

A. ask the the father and brother if they would like the physician to meet with the family.

A client was admitted to the inpatient unit 3 days ago with a flat affect, psychomotor deficits, anorexia, hopelessness, and suicidal ideation. The health care provider prescribed 75 mg of venlafaxine extended release to be given every morning. The client interacted minimally with the staff and spent most of the day in his room. At the beginning of the shift, the nurse observes that the client is smiling and cheerful and appears to be relaxed. What should the nurse interpret as the most likely cause of the client's behavior? A. The client's sudden improvement calls for close observation by the staff B. The venlafaxine is helping the client's symptoms of depression significantly. C. The staff can decrease their observation of the client. D. The client is nearing discharge due to the improvement of his symptoms.

A. The client's sudden improvement calls for close observation by the staff

When a client with croup is admitted to the facility, a physician orders treatment with a mist tent. As the caregiver attempts to put the client in the crib, the client cries and clings to the caregiver. What should the nurse do to gain the client's cooperation with the treatment? A. Encourage the caregiver to stand next to the crib and stay with the client. B. Let the client sit on the caregiver's lap next to the mist tent. C. Turn off the mist so the noise doesn't frighten the client. D. Put the side rail down so the client can get into and out of the crib unaided.

A. Encourage the caregiver to stand next to the crib and stay with the client.

An elderly client with primary degenerative dementia is slow in following simple directions and is indecisive selecting clothes to be worn for the day. What is the best approach for the nurse to take? A. Give the client the opportunity to select from two outfits and cue follow-through instructions. B. Allow the client to select from the outfits and minimize other distractions in the environment. C. Time limit the indecision and let the client know that activities of daily living need to be completed faster. D. Pick an outfit and assist with dressing because the client is too distracted to complete this activity without help.

A. Give the client the opportunity to select from two outfits and cue follow-through instructions.

A middle-age adult has been identified as being in the stagnation stage of developmental conflict. What evidence would support this assessment? Select all that apply. A. increased nap and sleeping hours B. bought a new sports car C. recently became engaged D. withdrawn from family obligations E. started classes at the community college

A. increased nap and sleeping hours D. withdrawn from family obligations

A client with acute mania exhibits euphoria, pressured speech, and flight of ideas. The client has been talking to the nurse nonstop for 5 minutes and lunch has arrived on the unit. What should the nurse do next? A. Walk away, and approach the client in a few minutes before the food gets cold. B. Do not interrupt the client, but wait for him to finish talking. C. Excuse oneself while telling the client to come to the dining room for lunch. D. Tell the client he needs to stop talking because it is time to eat lunch.

C. Excuse oneself while telling the client to come to the dining room for lunch.

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? A. "What has your neighbor been doing that bothers you?" B. "What exactly are these terrible voices saying to you?" C. "How long have you been hearing these terrible voices?" D. "We won't let your neighbor visit, so you'll be safe."

B. "What exactly are these terrible voices saying to you?"

A client diagnosed with major depression and substance dependence is being admitted to the concurrent disorder treatment unit. In explaining the focus of this program, the nurse should tell what information to the client? A. The depression with be treated first, then the addiction. B. There will be simultaneous treatment of the addiction and depression. C. As the addiction is treated, the depression will clear up on its own. D. The addiction will be treated first, then the depression.

B. There will be simultaneous treatment of the addiction and depression.

Which activity by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip? A. helping the child play with some toys B. holding and cuddling the child C. staying at the bedside and holding the child's hand D. reading some of the child's favorite stories

B. holding and cuddling the child

A family has moved from Spain to a primarily Spanish-speaking neighborhood near a large English-speaking metropolitan area in North America. The nurse caring for this family recognizes that which family member will likely require the greatest amount of time to learn the English language? A. the 58-year-old father in the family who works in a nearby factory B. the 12-year-old son in the family who attends public school C. the 18-year-old daughter in the family who works at a restaurant in a neighboring town D. the 45-year-old mother in the family who does not work outside the home

D. the 45-year-old mother in the family who does not work outside the home

A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. When discussing the potential impact of this procedure on the client's sexuality, how should the nurse respond to the client? A. "When can I schedule an appointment with you and your partner to discuss any issues either of you may have regarding sexuality?" B. "Do you anticipate any problems with sex related to your scheduled hysterectomy?" C. "All women experience sexual problems with this surgical procedure. Do you have any questions?" D. "Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

D. "Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

A hospitalized client is experiencing "fight versus flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for which symptom? A. decreased mental acuity B. increased urinary output C. increased blood glucose D. decreased arterial blood pressure

C. increased blood glucose

A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The most therapeutic nursing intervention would be to A. continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. B. immediately call the chaplain because you realize symptoms may resolve with spiritual counseling. C. ask a chaplain to meet with you and the client on the unit so you can monitor the exchange. D. tell the client you are not allowed to call the chaplain when a client is this disturbed.

A. continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis.

What information should the nurse plan to include when teaching the client and family about a substance abuse problem? A. the family's responsibility for the client B. the physical, physiologic, and psychological effects of substances C. the reasons that could have led the client to use the substance D. the role of the family in perpetuating the problem

B. the physical, physiologic, and psychological effects of substances

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? A. "Can you tell me more about your spiritual beliefs and practices?" B. "Faith can be a wonderful support after such a devastating event." C. "Is there anyone else I can call to support you at this time?" D. "I respect your choice not to seek spiritual support at this time."

C. "Is there anyone else I can call to support you at this time?"

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped? A. "Do you think taking several slow, deep breaths would help?" B. "Have you tried walking to ease your anxiety?" C. "What are you thinking about before you start to prepare supper?" D. "What do you do when you're anxious to help yourself feel better?"

C. "What are you thinking about before you start to prepare supper?"

Which questions should the nurse include in a cultural assessment? Select all that apply. A. "What do you think about religions other than yours?" B. "Do you have a particular name for this illness?" C. "What do you do to promote good health?" D. "What do you think is causing your illness?" E. "To what religion do you belong?"

C. "What do you do to promote good health?" D. "What do you think is causing your illness?" E. "To what religion do you belong?" B. "Do you have a particular name for this illness?"

A client's spouse has arrived prior to surgery. When the client is transferred to the operating room, what would be appropriate for the nurse to tell the spouse? A. Encourage the spouse to go to work and come back later in the evening when the anesthetic effects are gone. B. Take this opportunity to discuss the concerns the client expressed regarding the implications this surgery has for the client's family. C. Inform the spouse that the spouse can see the client immediately after surgery. D. Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back.

D. Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back.