Health & Illness Final Exam (second half of review questions)

which of the following interventions should be prioritized in the care of a suicidal client? a. remove all potentially harmful items from the clients room b. allow the client to express feelings of hopelessness c. note the clients capabilities to increase self-esteem d. set a "no suicide" contract with the client

- a. remove all potentially harmful items from the clients room

a client with multiple sclerosis plans to begin an exercise program. in addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which... a. increase the heart rate b. lead to dehydration c. are considered aerobic d. may be competitive

- b. lead to dehydration - rationale -> the client must take in adequate fluids before and during exercise periods

what are the appropriate interventions for caring for a client in alcohol withdrawal? (select all that apply) a. monitor vital signs b. provide stimulation in the environment c. maintain NPO status d. provide reality orientation as appropriate e. address hallucinations therapeutically

- a. monitor vital signs - d. provide reality orientation as appropriate - e. address hallucinations therapeutically - rationale -> when the client is experiencing the withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. the nurse would monitor vital signs closely and report abnormal findings. the nurse would reorient the client to reality frequently and would address hallucinations therapeutically

David is preoccupied with numerous bodily complaints even after a careful diagnostic workup reveals no physiologic problems. which nursing intervention would be therapeutic for him? a. acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems b. challenge the physical complaints by confronting the client with the normal diagnostic findings c. ignore the client's complaints, but request that the client keeps a list of all symptoms d. listen to the client's complaints carefully, and question him about specific symptoms

- a. acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems - rationale -> after physical factors are ruled out, somatic complaints are thought to be expressions of anxiety. the complaints are real to the client, but the nurse should not focus on them. prompting the client about other concerns will encourage the expression of anxiety and dependency needs. the nurse must help the client establish a daily routine that includes improved health behaviors. provide accommodation for the client and make them more comfortable (ie., pillows, temperature, positioning, etc.). this can help the client feel accepted and develop rapport and trust. this can allow the client to feel more comfortable and express their feelings and emotions more readily to the healthcare team

a client tells the nurse that psychotropic medicines are dangerous and refuses to take them. which intervention should the nurse use first? a. ask the client about any previous problems with psychotropic medications b. ask the client if an injection is preferable c. insist that the client takes the medication as prescribed d. withhold the medication until the client is less suspicious

- a. ask the client about any previous problems with psychotropic medications - rationale -> the nurse needs to clarify the client's previous experience with psychotropic medication in order to understand the meaning of the client's statement. attempt to understand the significance of these beliefs to the client at the time of their presentation. important clues to underlying fears and issues can be found in the client's seemingly illogical fantasies. explain the procedures and try to be sure the client understands the procedures before carrying them out. when the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff

using cognitive-behavioral therapy, which treatment would be appropriate for a client with depression? a. challenging negative thinking b. encouraging analysis of dreams c. prescribing antidepressant medications d. using ultraviolet light therapy

- a. challenging negative thinking - rationale -> cognitive-behavioral therapy includes identifying and challenging a client's negative cognitions. the belief is that these negative thoughts influence the feelings and behaviors of depression. cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior and emotions

Nurse Marge teaches the family of a client with major depressive disorder. which of the following information should be included in the teaching? (select all that apply) a. depression is characterized by sadness, feelings of hopelessness, and decreased self-worth​ b. it is common for a pressed individual to have thoughts of suicide c. attempts to cheer up a person with depression are often helpful​ d. talk therapy, along with antidepressant medications, is usually the treatment e. someone with depression may be preoccupied with spending money and too busy to sleep f. encourage a person with depression to keep a regular routine of activity and rest

- a. depression is characterized by sadness, feelings of hopelessness, and decreased self-worth​ - b. it is common for a pressed individual to have thoughts of suicide - d. talk therapy, along with antidepressant medications, is usually the treatment - f. encourage a person with depression to keep a regular routine of activity and rest - rationale -> these statements about major depressive disorders provide correct information and will be helpful to the client's family. depression exists on a continuum of severity, ranging from relatively mild, transient states of low mood to severe, long term symptoms that have a major impact on a person's quality of life. when a person's symptoms have reached the chronic end of the spectrum and require professional treatment, it's typically referred to as clinical depression

the nurse is reviewing the record of a female client with Crohn's disease. which stool characteristic should the nurse expect to note documented in the clients record? a. diarrhea b. chronic constipation c. constipation alternating with diarrhea d. stools constantly oozing from the rectums

- a. diarrhea - rationale -> Crohn's disease is characterized by non-bloody diarrhea of usually not more than four to five stools daily. over time, the diarrhea episodes increase in frequency, duration, and severity

the community nurse is following up on Mrs. Jenner who was hospitalized at Nurseslabs Medical Center due to depressive disorder, not otherwise specified, following the death of her spouse. in reviewing the client's chart, the nurse notes that Mrs. Jenner has an Axis II diagnosis of dependent personality disorder. which behavior would the nurse anticipate in this client? a. difficulty making decisions, lack of self-confidence b. grandiose thinking, attention-seeking behaviors c. odd mannerisms, speech, and behaviors d. unstable moods and impulsive behaviors

- a. difficulty making decisions, lack of self-confidence - rationale -> the client with a dependent personality disorder typically demonstrates anxious and fearful behavior and is reluctant to make decisions. lack of self-confidence is reflective of chronic low self-esteem. it involves fear of being alone and often causes those who have the disorder to do things to try to get other people to take care of them

it would be most helpful for the nurse to deal with a client with severe anxiety by... a. give specific instructions speaking in concise statements b. ask the client to identify the cause of her anxiety c. explain in detail the plan of care developed d. urge the client to focus on what the nurse is saying

- a. give specific instructions speaking in concise statements - rationale -> the client has narrowed the perceptual field. lengthy explanations cannot be followed by the client. maintain a calm, non-threatening manner while working with the client. anxiety is contagious and may be transferred from health care provider to client or vice versa. the client develops a feeling of security in presence of a calm staff person

the nurse is evaluating a female child with acute post streptococcal glomerulonephritis for signs of improvement. which finding typically is the earliest sign of improvement? a. increases urine output b. increased appetite c. increased energy level d. decreased diarrhea

- a. increased urine output - rationale -> increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post-streptococcal glomerulonephritis (APSGN) is improving

Latrice was invited by her friend Sharon to her birthday party at a disco ball. Sharon noticed that Latrice is avoiding interaction with the other guests and is seen leaving the party early. she asked her what seems to be the problem. she replied that "I might say something stupid". based on these observations, Latrice is experiencing... a. social phobia b. situational phobia c. claustrophobia d. agoraphobia

- a. social phobia - rationale -> social phobia is characterized by avoidance of social situations in which there is a fear of getting scrutinized by others that include talking in groups, eating in public, starting conversations, or public speaking

which of the following would best indicate to the nurse that a depressed client is improving? a. reduced levels of anxiety b. changes in vegetative signs c. compliance with medications d. requests to talk to the nurse

- b. changes in vegetative signs - rationale -> vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation, diminished libido, and poor concentration are biological responses to depression. improvement in these signs indicates a lifting of the depression. give step-by-step reminders such as "brush the teeth, clean the outer surfaces of your upper teeth, then your lower teeth. . .". encourage the client to get up and dress and to stay out of bed during the day. minimizing sleep during the day increases the likelihood of sleep at night. encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss is noted

a client with schizophrenia is referred for psychosocial rehabilitation. which of the following are typical of this type of program? (select all that apply) a. analyzing family issues and past problems b. developing social skills and supports c. learning how to live independently in a community d. learning job skills for employment e. treating family members affected by the illness f. participating in in-depth psychoanalytical counseling

- b. developing social skills and supports - c. learning how to live independently in a community - d. learning job skills for employment - rationale -> the goal of psychosocial rehabilitation as a treatment method is to help the client develop the skills and supports necessary for successful living, learning, and working in the community. analysis of family issues and past problems and treatment of family members are not commonly part of this type of program. the emphasis of psychosocial rehabilitation is on the client's development of skills in the here and now; consequently, psychoanalytic counseling is not part of the approach

the following are the different types of fractures except... a. open fracture b. diagonal fracture c. closed fracture d. comminuted fracture

- b. diagonal fracture

nurse Winona educates the family about symptom management for when the schizophrenic client becomes upset or anxious. which of the following would nurse Winona state to be helpful? a. call the therapist to request a medication change b. encourage the use of learned relaxation techniques c. request that the client be hospitalized until the crisis is over d. wait before the anxiety worsens before interviewing

- b. encourage the use of learned relaxation techniques - rationale -> the client with schizophrenia can learn relaxation techniques, which help reduce anxiety. the family can be supportive and helpful by encouraging the client to use these techniques. when client is ready, introduce strategies that can minimize anxiety and lower voices and "worrying" thoughts, teach client to do the following: focus on meaningful activities; learn to replace negative thoughts with constructive thoughts; perform deep breathing exercise; use a calming visualization or listen to music; or seek support from staff, family, or other supportive people

the psychiatric nurse uses cognitive-behavioral techniques when working with a client who experiences panic attacks. which of the following techniques are common to this theoretical framework? (select all that apply) a. administering anti-anxiety medication as prescribed b. encouraging the client to restructure thoughts c. helping the client to use controlled relaxation breathing d. helping the client examine evidence of stressors​ e. questioning the client about early childhood relationships f. teaching the client about anxiety and panic

- b. encouraging the client to restructure thoughts - c. helping the client to use controlled relaxation breathing - d. helping the client examine evidence of stressors​ - f. teaching the client about anxiety and panic - rationale -> these are all appropriate techniques based on the framework of cognitive-behavioral therapy. the main approaches to the treatment of panic disorder include both psychological and pharmacological interventions. psychological interventions consist of cognitive-behavioral therapy. as an added benefit in patients with a panic disorder that also has concomitant comorbid medical conditions, there are components of their therapeutic regimens which may also secondarily improve their respective medical illnesses

which of the following communication guidelines should the nurse use when talking with a client experiencing mania? a. address the client in a light and joking manner b. focus and redirect the conversation as necessary c. allow the client to talk about several different topics d. ask only open-ended questions to facilitate conversations

- b. focus and redirect the conversation as necessary - rationale -> to decrease stimulation, the nurse should attempt to redirect and focus the client's communication, not allow the client to talk about different topics. maintain a consistent approach, employ consistent expectations, and provide a structured environment. clear and consistent limits and expectations minimize potential for client's manipulation of staff. use a calm and firm approach. provides structure and control for a client who is out of control

which nursing diagnosis takes highest priority for a client with Parkinson's crisis? a. imbalanced nutrition (less than body requirements) b. ineffective airway clearance c. impaired urinary elimination d. risk for injury

- b. ineffective airway clearance - rationale -> in Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. a client confined to bed during such a crisis is at risk for aspiration and pneumonia. also, excessive drooling increases the risk of airway obstruction. because of these concerns, the nursing diagnosis of ineffective airway clearance takes highest priority. although the other options also are appropriate, they aren't immediately life-threatening

the classic signs and symptoms of rheumatoid arthritis include which of the following? a. pain on weight bearing, rash, and low-grade fever b. joint swelling, joint stiffness in the morning, and bilateral joint movement c. crepitus, development of Herberden's nodes, and anemia d. fatigue, leucopenia, and joint pain

- b. joint swelling, joint stiffness in the morning, and bilateral joint movement

which of the following conditions most commonly causes acute glomerulonephritis? a. a congenital condition leading to renal dysfunction b. prior infection with group A Streptococcus within the past 10-14 days c. viral infection of the glomeruli d. nephrotic syndrome

- b. prior infection with group A Streptococcus within the past 10-14 days - rationale -> acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of bodily fluid. preorbital edema and hypertension are common signs at diagnosis

when teaching the family of a client with schizophrenia, the nurse should provide which information? a. relapse can be prevented if the client takes the medication b. support is available to help family members meet their own needs c. improvement should occur if the client has a stimulating environment d. stressful family situations can precipitate a relapse in the client

- b. support is available to help family members meet their own needs - rationale -> because family members of a client with schizophrenia face difficult situations and great stress, the nurse should inform them of support services that can help them cope with such problems. provide information on client and family community resources for the client and family after discharge: day hospitals, support groups, organizations, psychoeducational programs, community respite centers (small homes), etc. schizophrenia is an overwhelming disease for both the client and the family. groups, support groups, and psychoeducational centers can help

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. which action would be the most therapeutic response? a. confront the delusional material directly by telling Gio that this simply is not so b. tell Gio that this must seem frightening to him but that you believe he is safe here c. tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions d. isolate Gio when he begins to talk about these beliefs

- b. tell Gio that this must seem frightening to him but that you believe he is safe here - rationale -> the nurse must realize that these perceptions are very real to the client. acknowledging the client's feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation. recognize the client's delusions as the client's perception of the environment. recognizing the client's perception can help you understand the feelings he or she is experiencing

a male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) PO twice daily for 10 days. which finding best demonstrates that the client has followed the prescribed regimen? a. urine output increases to 2,000 mL/day b. flank and abdominal discomfort decreases c. bacteria are absent on urine culture d. the res blood cell (RBC) count is normal

- c. bacteria are absent on urine culture - rationale -> co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. therefore, the absence of bacteria on urine culture indicates that the drug has achieved its desired effect

Rendell is admitted in an acute psychiatric unit at Nurseslabs Medical Center. he suddenly tells Nurse Matt about his plans for suicide. the nurse's priority is to... a. allow the client time alone for reflection b. encourage the client to use problem solving c. follow agency protocol for suicide precautions d. stimulate the clients interest in activities

- c. follow agency protocol for suicide precautions - rationale -> the nurse must act to safeguard the client from danger, including self-harm implementing the specific agency protocol for suicidal precautions would best protect the client. follow unit protocol for suicide regarding creating a safe environment (taking away potential weapons- belts, sharp objects, items, and so on)

the nurse is aware that the following lab value supports a diagnosis of pyelonephritis? a. myoglobinuria b. ketonuria c. pyuria d. low white blood cell (WBC) count

- c. pyuria - rationale -> pyelonephritis is diagnosed by the presence of leukocytes, hematuria, pyuria, and bacteriuria

the nurse is caring for a hospitalized female patient with a diagnosis of ulcerative colitis. which finding, if noted on assessment of the patient, would the nurse report to the physician? a. hypotension b. bloody diarrhea c. rebound tenderness d. a hemoglobin level of 12 mg/dL

- c. rebound tenderness - rationale -> rebound tenderness may indicate peritonitis

situation: a 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech, headache, and an inability to focus on what the doctor was saying. the nurse assesses the level of anxiety as... a. mild b. moderate c. severe d. panic

- c. severe - rationale -> the client's manifestations indicate severe anxiety. severe anxiety is intensely debilitating, and symptoms of severe anxiety meet key diagnostic criteria for clinically-significant anxiety disorders. people with severe anxiety typically score higher on scales of distress and lower on functioning. severe anxiety symptoms also frequently co-occur with major depression, which can contribute to greater disability

the nurse asks a client to roll up his sleeves so she can take his blood pressure. the client replies, "if you want I can go naked for you". the most therapeutic response by the nurse is... a. "you're attractive, but I'm not interested" b. "you wouldn't be the first that I will see naked" c. "I will report you to the guard if you don't control yourself" d. "I only need access to your arm. putting up your sleeve is fine"

- d. "I only need access to your arm. putting up your sleeve is fine" - rationale -> the nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. stay calm and be patient. gently but firmly tell the person that the behavior is inappropriate

situation: a widow age 28, whose husband died one (1) year ago due to AIDS, has just been told that she has AIDS. Panky says to the nurse, "why me? how could God do this to me?". the nurse's therapeutic response is... a. "I will refer you to a clergy who can help you understand what is happening to you" b. "it isn't fair that an innocent woman like you will suffer from AIDS" c. "that is a negative attitude" d. "it must really be frustrating for you. how can I help you best?"

- d. "it must really be frustrating for you. how can I help you best?" - rationale -> this response reflects the pain due to loss. a helping relationship can be forged by showing empathy and concern. communicate therapeutically with patient and family members and allow them to verbalize feelings. sharing feelings with a healthcare provider may help the patient find significance in the experience of loss

Mr. MC Princeton who is diagnosed with rheumatoid arthritis (RA) complains about joints that always hurt, saying "I just feel like staying in bed all day". which discharge instruction would be aimed at maintaining as much function as possible? a. "refrain from exercise because it only aggravates the disease process" b. "apply elastic bandages to all joints to increase the pain threshold" c. "maintain a supine position most of the day to prevent the stress of weight bearing" d. "promote aquatic (water) exercises to enhance joint mobility"

- d. "promote aquatic (water) exercises to enhance joint mobility" - rationale -> water exercises are excellent because water promotes buoyancy, which eases joint movement

after receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? a. a 23 year old with a migraine headache who is complaining of severe nausea associated with retching b. a 45 year old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching c. a 59 year old with Parkinson's disease who will need a swallowing assessment before breakfast d. a 63 year old with multiple sclerosis who has an oral temperature of 101.80 degrees F and flank pain

- d. a 63 year old with multiple sclerosis who has an oral temperature of 101.80 degrees F and flank pain - rationale -> urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. the elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. the physician should be notified immediately so that antibiotic therapy can be started quickly

the nurse closely observes the client who has been displaying aggressive behavior. the nurse observes that the clients anger is escalating. which approach is least helpful for the client at this time? a. acknowledging the clients behavior b. maintain a safe distance from the client c. assist the client to an area that is quiet d. initiate confinement measures

- d. initiate confinement measures - rationale -> the proper procedure for dealing with harmful behavior is to first try to calm the patient verbally. when verbal and psychopharmacologic interventions are not adequate to handle aggressiveness, seclusion or restraints may be applicable. alert staff if a potential for seclusion appears imminent. usual priority of interventions would be firmly setting limits; chemical restraints (tranquilizers); and seclusions

jaime has a diagnosis of schizophrenia with negative symptoms. in planning care for the client, Nurse Brienne would anticipate a problem with... a. auditory hallucinations b. bizarre behaviors c. ideas of reference d. motivation for activities

- d. motivation for activities - rationale -> in a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of motivation for activities, is a common problem. these "negative" symptoms are so-called because they are an absence as much as a presence: inexpressive faces, blank looks, monotone, and monosyllabic speech, few gestures, seeming lack of interest in the world and other people, inability to feel pleasure or act

the patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. what is your priority nursing diagnosis at this time? a. fatigue related to disease state b. activity intolerance due to generalized weakness c. impaired physical mobility related to neuromuscular impairment d. self-care deficit related to fatigue and neuromuscular weakness

- d. self-care deficit related to fatigue and neuromuscular weakness - rationale -> at this time, based on the patients statement, the priority is self-care deficit related to fatigue after physical therapy