coping

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions?

Unconscious control of unacceptable feelings

A 6-year-old child is about to have an intravenous catheter inserted. What is the nurse's best response when the child starts to cry?

"Do you want the IV in your right or left arm?"

An older adult is admitted for evaluation of anemia and unsteady gait. While obtaining a health history, the nurse notes that the client seems to make up stories to fill in for memory lapses. How should the nurse document what the client is doing?

Confabulating

A client who underwent mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." What is the nurse's best response?

"losing power seems important to you"

A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond?

"Let's talk about how you're feeling about your child's diagnosis."

A client who had a panic attack yesterday says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." The most therapeutic response by the nurse is:

"What were you doing yesterday when you first noticed the feeling?"

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and nurse concludes that the relationship with the husband was probably:

Ambivalent

A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. What does the nurse determine is the reason for the steroids?

Compensate for sudden lack of these hormones following surgery

The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention?

Correct2 Providing the parents the opportunity to say goodbye to their newborn

A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, the nurse should consider that:

Crying releases tension and frees psychic energy for coping.

A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention?

Facilitating a discussion of the spouse's death

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention?

Focusing on the present

Children with special needs have the same needs as other children, although their means of satisfying these needs may be limited. What effect should the nurse expect that these limitations will frequently cause?

Frustration

An 8-year-old child who has been undergoing chemotherapy will soon return to school after a prolonged absence. Classmates are aware that the child is being treated for cancer. How should the school nurse prepare the class for the child's return to school?

Initiate a discussion with the students about cancer treatments and the side effects of chemotherapy.Unconscious control of unacceptable feelings

A 3-year-old child is hospitalized with nephrotic syndrome. The child has oliguria and generalized edema. What factor does the nurse identify that will have the greatest effect on the child's adjustment to hospitalization?

Lack of parental visits

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?

Projection

A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history?

Providing the client with a sense of security and safety

A nursing assistant is frequently late for work and often tells the nurse manager that although he leaves his apartment early he is delayed by heavy traffic. What defense mechanism is being used by the nursing assistant?

Rationalization

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to:

Relieve the client's discomfort.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is:

Repression

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis?

Spending hours each day worrying about something "bad happening"

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?

Strategies to handle stress

The spouse of a client who had a cerebrovascular accident (CVA, also known as "brain attack:) insists on doing everything for the client during visits. After these visits, the client seems to be depressed. The nurse understands that these visits probably have what effect on the client?

loss of indepence

A parent asks the nurse what to do when their toddler has temper tantrums. What play materials should the nurse suggest that the child be offered as another means of expressing anger?

pegs and pounding board