Basic Psychosocial Needs

A nurse has migrated to a different country and started working there. Which factor is important for effective functioning?

cultural habituation

A client who underwent cardiac surgery 2 days ago is recovering well. The client's spouse, who is assisting with care, says, "My spouse is doing too much. I want to help, but they won't let me." The nurse says to the spouse, "It sounds like you need to feel you can be more helpful." In order to make the nonverbal behavior complement the words, what should the nurse do?

Direct the body and eyes at the spouse and client.

Which statement about religion and spirituality is most accurate?

Religion is an organized system of spiritual beliefs.

When a nurse reflects on questions such as "Why am I here?" the nurse is attempting to

develop a philosophical base for clearer thinking.

The nurse is in the process of assessing a non-English-speaking client, communicating through an interpreter. To facilitate communication, what should the nurse do first?

Ask client how the client wishes to be addressed.

A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss?

concerns regarding the cancer and how the surgery will affect the client

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

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

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?

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

A client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that they will have to wait to have their medication refilled. Which response by the nurse is most appropriate?

"I won't continue to talk with you if you curse."

A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?

"I would like to sit with you and talk about your child."

A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?

"It sounds like that offers you a sense of security."

An adolescent client has undergone an examination and had evidence collected after being sexually assaulted. The parent is overheard yelling to the child, "You're going to tell me who did this to you. What's their name?" Which is the nurse's best response?

"Please come with me. I need some important information."

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?

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

A client gives birth to a neonate at 30 weeks' gestation. The neonate is stable on minimal ventilator settings. The client's previous infant, who was born at 24 weeks' gestation, did not survive. The family is Roman Catholic and requests that the neonate be baptized as soon as possible. What response by the nurse is most appropriate?

"What would you like me to do to help arrange the baptism?"

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

"You appear upset about these questions. Is this true?"

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be most therapeutic?

"You sound concerned about what's happening."

When the nurse is assessing a client's cultural adaptation, which statement is least sensitive to the client's needs?

"Your eyes look dark; is this normal for you?"

A woman is brought to the emergency department by her husband, who reports that she accidentally fell down basement stairs and broke her arm. The client is quiet, withdrawn, and not making eye contact. During the examination, inspection reveals numerous bruises at different stages of healing over the client's legs, arms, and abdomen. Which nursing response(s) would be most appropriate to gather additional information? Select all that apply.

-"Do you wish to tell me anything more about how you fell down the stairs?" -"I've noticed several bruises on your body. Can you tell me how they happened?"

A nurse is surprised to see that a young adult client who is deaf has indicated a friend as their main source of support instead of a family member. Which is the best response from the nurse after learning this information?

Accept the client's answer.

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

Acceptance

The nurse is preparing to assess a client who is scheduled for a surgical procedure and notes they are communicating in sign language with another individual in the room. Which action by the nurse is most appropriate when this individual is reluctant to leave the room?

Ask the client if it is okay for the individual to stay.

The nurse is developing a discharge plan with a client who has had an abdominal hysterectomy. Before implementing the plan, the nurse should perform which action first?

Assess the client's available social support system.

The nurse notices some new electrical equipment has been brought to the operating suite. Which action should the nurse prioritize when preparing to use this new equipment?

Check that a safety label has been applied.

A client with an infected abdominal wound must be placed on contact precautions for 10 days. What should the nurse do to help meet the client's emotional needs?

Describe why the client is on contact precautions and what will occur there, and reassure the client.

An unconscious adult client has been brought to the emergency department by emergency medical services for care following a motor vehicle crash. The client has a laceration to the left leg, resulting in blood loss. Which action should the nurse prioritize after noting that 2 units of plasma have been ordered?

Determine if the client has an advance directive forbidding blood or blood products.

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?

Encourage parents to be present during the treatment.

The nurse is providing care for a toddler and notes the parents come at separate times and do not interact, but if they do come at the same time, they begin to fight and yell at each other. Each parent insists that the nurse should only listen to their requests and not the other parent's. The nurse then learns the couple is going through a divorce and fighting each other for full custody of the toddler. Which response should the nurse prioritize?

Ensure appropriate security measures are in place to protect the toddler.

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What action should the nurse take?

Explore their own feelings about the issues of anencephaly and organ donation.

What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness?

How is your condition affecting your family members and their usual roles?

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?

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.

A client expresses a desire to discuss spiritual and religious beliefs with someone. What is the best nursing intervention at this point?

Interview the client further to gather more details.

The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply.

Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body.

The nurse has been assisting a client who has been making progress in changing from a sedentary to a more active lifestyle, but the client also often reverts to their former habits. Which action should the nurse prioritize to deal with the frustration of the client not always following the care plan?

Remain nonthreatening and nonjudgmental when interacting with the client.

A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. What should the nurse do next?

Reschedule the infant's appointment for later in the week.

The nurse notes that the client seems anxious. Which strategy should the nurse use to enhance communication?

Sit down to talk with the client.

An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt.

The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket?

The client is at risk for injury from fighting the restraints.

An adult client is brought to the emergency department by a family member after being found incoherent and slurring their speech. The nurse notes the medical record indicates this has happened in the past; however, the client has repeatedly refused help with determining what is causing these symptoms. Which action by the nurse would be most appropriate as the nurse meets with this client for the first time?

Work to develop rapport with the client.

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

acceptance

A client is having trouble adjusting to a colostomy surgically created 4 days ago. The nurse prioritizes which nursing diagnosis?

altered body image

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

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

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?

fear of the unknown

A client who is a single parent of three teenage-aged children has metastatic breast cancer, and the health care provider has recommended another high-dose chemotherapy. The client's older adult parents live a 10-hour drive away and have only been able to visit twice since the initial diagnosis 14 months ago. The client is concerned about their children's welfare during the treatment. Which potential problem should the nurse help the client solve first?

finding support systems

Which activity would be most appropriate to include in a playroom that will be used by children age 13 months to 6 years?

free play with adult supervision

A client scheduled to have a surgery for a hernia the next day is anxious about the procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skill is the nurse demonstrating?

interpersonal skills

The client is Asian and non-English speaking. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom?

pain

The nurse cares for a client who was raped. Which intervention is most important for the nurse to implement?

periodically reminding the client that they did not deserve to be raped and did not cause the rape

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

previous coping skills

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

providing the client with support and realistic information on the colostomy

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

self-disclosure.

A client is admitted with glomerulonephritis. Which psychosocial problems could likely affect this client?

anxiety related to poorly functioning kidneys and body image disturbance

The health care provider (HCP) recommends that a client have a partial bowel resection and an ileostomy. Later, the client says to the nurse, "That doctor of mine surely likes to play big. I will bet the more the doctor can cut, the better they like it." Which reply by the nurse is most therapeutic?

"What do you mean by that statement?"

The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply.

-discussion of pertinent information -the client's agreement to the plan of care -freedom from coercion

A nurse is updating the care plan for a client to integrate spirituality into the client's care. What assessment question would the nurse use in an effort to update the care plan accordingly?

"Are there any spiritual practices that are important to you?"

Which factor is a priority when evaluating discharge plans for an older adult after a lower left lobectomy for lung cancer?

support available for assisting the client at home

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

telling the client about a community arthritis support group

Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy?

the cause of death can be discovered

The nurse educates staff on common legal issues. In which situation can a client's confidentiality legally be breached?

when a client near discharge is threatening to harm an ex-partner

A nurse is caring for a spiritually distressed client. Which are the factors affecting spiritual distress? Select all that apply.

-self-alienation -chronic illness -sociocultural deprivation

A client who is at the end of life tells the nurse about experiencing "spiritual distress." What should the nurse do first?

Determine what spiritual distress means to the client.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which intervention is the nursing priority?

Explain procedures and unit routines to the client, as well as checking orientation.

The nurse manager on the urology unit has employed three nurses from a culture that is different from that of most of the nurses and patients on this unit. Which strategy would help the newly employed nurses socialize into the team and promote the cultural competence of all of the nurses?

Hold a culture-sharing session at monthly meetings.

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

The nurse may hold values that could influence the care of the client.

A nurse is administering a prescribed dose of an injection to a middle-aged client with Bell's palsy. What are the sources of fulfillment in the middle-years of an adult client's life?

productive activity

The nurse on a mental health unit cares for a client who asks the nurse for a date. What action should the nurse take in this situation?

Explain the limits of the nurse-client relationship.

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which is a characteristic of rituals?

common and observable expressions of culture

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

"It's good that you can talk about your concerns. Try calling a friend when you want to smoke."

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

"There is nothing physically wrong with you. You need to stop breathing so rapidly."

A client being admitted to hospital is asked to sign a statement confirming that the client understands the rights to communicate information related to life support and resuscitation. The client asks the nurse why signing such a statement is necessary. What is the best response by the nurse?

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."

The nurse is assessing an adult client who is being admitted for pneumonia. A family member refuses to leave the client when the nurse asks them to so they can complete the assessment. Which action by the nurse would be most appropriate?

Ask the family member why they do not want to leave.

A client is grieving following a spontaneous abortion (miscarriage). She unexpectedly becomes pregnant again very quickly after the miscarriage, and is quickly able to move through her grief and become excited and happy about this pregnancy. Which type of grief did the client likely experience for her miscarriage?

Abbreviated grief

The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client.

An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease?

Utilize a peer with type 2 diabetes to role model lifestyle changes.

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

contact information for the breast cancer support group

The home health nurse is conducting a regular visit with an older adult client and their new caregiver. The nurse has been noticing subtle changes in the client over the past couple of months since the family caregiver has changed. Which finding(s) should the nurse further assess for possible intervention? Select all that apply.

anxiety mood changes low self-esteem

A nurse is caring for multiple grieving clients. Which client is most likely to experience disenfranchised grief?

A 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident

A nurse is providing care for a client who experienced a miscarriage at 28 weeks' gestation. What is the nurse's priority intervention to initially support the client's grieving process?

Be available to talk with the client about their loss.

The nurse is providing care to an adolescent who was sexually abused after being kidnapped. Which action(s) should the nurse perform when interacting with this client when they appear frightened and become combative? Select all that apply.

-Respect the client's personal space. -Remain calm and nonjudgmental. -Be aware of their own facial expressions, gestures, and movements. -Allow time for the client to make decisions.

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

"Your son can make an electronic history to facilitate his care if he gets sick away from home."

A client who comes to the crisis center in a very distressed state tells the nurse, "I just can't get over being fired last week. I've asked for help. I've talked to friends. I've tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use?

emotion management

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?

Maintain eye contact while talking.

On the first postpartum day, the nurse is caring for a primiparous client who speaks very little English. The nurse observes that the client has been bottle-feeding their neonate on occasion, but most of the neonatal care is being performed by the client's parent-in-law. Which action would be most appropriate?

Determine whether this is a cultural practice for the client and their family.

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

Dysfunctional

Which would be most helpful when coaching a client to stop smoking?

Establish the client's daily smoking pattern.

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

Explain the use of an advance directive to express the client's wishes.

The nurse manager is following up on an incident that occurred in the emergency department involving the care given to an intoxicated client. The client attacked and injured two staff members and an accompanying police officer after one of the nurses attempted to draw blood from the client to measure their blood alcohol content. Which action should the nurse manager ensure is included in this process?

Facilitate needed counseling and stress debriefing for the staff.

A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure?

The nurse should contact the person identified as the healthcare power of attorney.

Which interaction is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client?

Equal sharing of time for discussion of problems so there is mutuality in the relationship

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcohol use disorder. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources?

social worker

A client is admitted for an acute exacerbation of multiple sclerosis and says, "What is the point of all of this? I will never have a meaningful life." What is the nurse's best response?

"You sound very discouraged. Can you share with me your feelings about how this illness affects you?"

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?

"You're very concerned when you think about how this will change your life."

Which factors should be the primary factor in a nurse's decision whether to pray with a client?

the client's openness to being prayed for

When the client tells the nurse that they believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing

theism

A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. Which question would be appropriate for the nurse to ask to assist the client?

"What have you done so far to try to solve this problem?"

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse?

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

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

-Take a seat next to the client and sit quietly to reflect on what was said. -Say to the client, "You're feeling upset about the news you got about the transplant."

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

to reduce the risk of postoperative complications

A 17-year-old unmarried primigravida at 10 weeks' gestation tells the nurse that their family does not have much money and their parent just got laid off from work. What action should the nurse take?

Refer the client to a social worker for enrollment in a food assistance program.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. What best protects the client's right to self-determination?

respecting the client's desire to have the uncle make choices on her behalf

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

spiritual alienation

Which description best matches the role of a parish nurse?

A nurse who works to reintegrate the healing tradition into the life of a faith community.

A nurse is assessing available support systems for a client in the community mental health clinic. The client is divorced, has no siblings, and both parents died last year. The client has contact with once-supportive former in-laws; however, the client describes a strained relationship since the divorce. With regard to the relationship with the in-laws, what knowledge does the nurse use to plan care?

Low-quality support relationships often negatively affect coping in a crisis.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time?

Attend the funeral.

The nurse is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It's so horrible, and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client?

"It's okay to be scared. What is it about cancer that you are afraid of?"

The nurse observes an unlicensed assistive personnel (UAP) sharing extensive stories of their own parent's death with a dying client's spouse. Which statement demonstrates appropriate feedback for the nurse to offer to the UAP?

"It's probably best to avoid talking about your personal experience very much; keep communication client centered."

The healthcare provider has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family?

Accommodate their grieving, explain what is happening, and encourage involvement in the care.

The nurse is caring for a client with heart failure who is a veteran. The client has been readmitted to the acute care unit several times in the past few years. The nurse notes that the client does not have visitors. The client states that they do not know anyone in the area. What is the best way for the nurse to assist the client with finding social support after discharge?

Look online for veteran groups in the area.

A medical-surgical nurse is caring for a client with end-stage kidney disease. The client asks the nurse, "Will I die soon?" What would be the most appropriate response(s) by the nurse? Select all that apply.

-"You're in the final stage of illness, so you may have little time remaining." -"Do you want to talk about how you are feeling about your prognosis?"

A mastectomy is recommended for a 68-year-old client diagnosed with breast cancer a week ago. When approached about giving consent for the mastectomy, the client says, "What's the use in trying to get rid of the cancer? It will just come back! I can't handle another thing—having diabetes is enough. Besides, I'm getting old. It would be different if I were younger and had more energy." What action should the nurse take?

Explore with the client their feelings about their health problems and the proposed surgery.

A nurse is counseling a client who experienced a miscarriage at 18 weeks' gestation. The client states, "I don't know how to feel about my baby's death." What response by the nurse is most appropriate?

"There is no right or wrong way to feel about losing your baby."

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient?

Readiness for Enhanced Spiritual Well-Being

A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling?

the nurse's comfort and knowledge level related to the process of spiritual counselling