Hurst Psychosocial Integrity
The adult child of a client diagnosed with bipolar disorder asks the nurse if they will one day be diagnosed with the same disorder. What is the nurse's best response? 1. "There is a familial tendency for developing this disorder; however, it doesn't mean you will definitely develop this disorder." 2. "You should not worry about developing this disorder. You are young and healthy." 3. "If you were going to develop this disorder, you would have it by now." 4. "You have not been exposed to anything that would contribute to the development of this disorder, so you will not develop this disorder."
1. Correct: Studies to determine if an illness is familial compare the percentages of family members with the illness to those in the general public or within a control group. Bipolar disorder is an example of a psychiatric illness with familial tendencies. Other psychiatric illnesses include schizophrenia, major depression, anorexia nervosa, panic disorder, somatization disorder, antisocial personality disorder, and alcoholism.
A schizophrenic client tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.
2. Correct: The correct answer is to present reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client. This delusion is called "thought withdrawal". It is the belief that thoughts have been removed from one's mind by an outside agency.
The nurse is teaching a family member of a client with a terminal illness the signs of impending death. Which statement by a family member indicates the need for further teaching? 1. "I will continue to talk in normal tones." 2. "Decrease in respirations may happen." 3. "Death is soon, if their shoulders are cool." 4. "They may prefer to sleep rather than talk."
3. "Death is soon, if their shoulders are cool." 3. Correct: The systems of the body will begin to function erratic and slower as death approaches. As the feedback of the circulatory system fails, the client will have fluctuating temperature control. As death process continues, the circulatory system in the extremities will fail. The arms and legs will become cooler. The family member will require further teaching regarding indicators of approaching death.
A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.
3., 4. & 5. Correct: Remove harmful objects from the client's access, such as sharp objects, straps, belts, ties, glass items, and alcohol. Close supervision is necessary during meals. Increased feelings of self-worth may be experienced when the client feels accepted unconditionally regardless of thoughts or behavior. Option 3 The suicidal client has a feeling of hopelessness. When the staff secures a promise that the client will seek out staff when feeling suicidal, this is an action that the client is being accepted unconditionally regardless of their thoughts. True.The client may experience a sense of feelings of self-worth by this action.
The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none in the past 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? 1. I am feeling better so I hope that I don't have to take the medication for long. 2. I can stop the medication after I have been out of the hospital for a year. 3. The medicine is good for me now; however, I don't want to take it forever. 4. The medication keeps me out of the hospital, and I don't want to hear voices again.
4. Correct: The client must take the medicine long-term. If the client makes the connection between the medicine and feeling better, adherence is more likely.
A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? "1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"
"Do you think people want to kill you with rays?" 1. Correct: By restating the client's primary idea this reinforces to the client that statement has been heard. This allows the client to clarify the statement or realize that the nurse has understood the comment. This is the therapeutic communication technique of restating.
A client had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I am worried that the pathology report will indicate cancer." Which response would the nurse initiate to assist the client in reducing their anxiety? 1. "You are anxious about the pathology report?" 2. "Would you like me to recommend a movie for you to watch?" 3. "I will notify your daughter that you are concerned about the pathology report." 4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"
1. "You are anxious about the pathology report?" 1. Correct: Utilizing the therapeutic communication technique of restating encourages the client to continue expressing their thoughts and feelings. This correct response by the nurse will also encourage the client to continue verbalizing or clarify their statement if needed. Restating is an effective communication technique to reduce the client's anxiety.
Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.
1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicates neglect or abuse by the parents or caregivers. 2. Incorrect: The child in a burned house would be reported only if the story were inconsistent as to how the house caught on fire, or if foul play is suspected. 3. Incorrect: A child fighting at school is inappropriate, but this doesn't mean there is family abuse/neglect at home. 4. Incorrect: A 16 month old who is sick may not take liquids, but the fact that the mother brought the child in means she is attentive and concerned. The nurse would determine why the 16 month old is not drinking liquids then rehydrate the child to prevent dehydration.
A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."
1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on options and does not have the nurse tell the client what to do. It is much more therapeutic to help the client make the decision for themselves, instead of the nurse. This prevents any biases from impacting the outcome.
The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now". Which response by the nurse is therapeutic? 1. "You are feeling all alone." 2. "Why do you say you are lonely?" 3. "Your feelings of loneliness will decrease." 4. "I know other people who lost someone feel this way."
1. Correct: The nurse is utilizing the therapeutic communication technique of restating. The central statement by the client is restated. The client is able to identify that their thoughts or feelings have been received correctly. This also allows the client to clarify their thoughts or feelings if needed.
An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.
1. Correct: The unexpected death of a spouse can elicit a wide variety of emotions due to the grief that is being experienced. Individuals who are grieving often find it difficult to seek help, even from close family members. Elderly clients tend to wish to retain their independence. They often do not want to be burdens to the family members, but may find themselves unable to cope effectively. In this case, the signs of ineffective coping is the lack of eye contact and the personal appearance of the client. The nurse should assess the client's ability to adapt and cope with the unexpected loss and work through the grief process.
The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.
1. Correct: Victims of abuse most often report causes of injuries that don't fit with the type of injury observed. For example, a victim may report that a bruised eye came from "running into" a door. The victim may feel the abuse is a personal incident or is afraid of the abuser.
The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.
1. Set verbal limits and have the client return to assigned room. 1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior.
A school-age child with Asperger's Syndrome has been receiving out-patient behavioral and cognition therapy to improve socialization skills. However, recent symptoms and a positive Covid test resulted in the child's hospitalization. The nurse is aware what important measures should be implemented to help this client cope with hospital admission? 1. Allow the client to arrange personal items in the room. 2. Have a parent stay with the child. 3. Maintain consistent daily nursing care routine for client. 4. Keep TV and lights on to distract client from hospital noise. 5. Describe simple details of treatments in advance with client.
1., 2., 3. & 5. Correct: Asperger's Syndrome is a disorder on the autism scale in which an individual has difficulty with socialization and behavioral skills. Additionally, any changes to a consistent, daily routine can result in extreme distress. The nurse must try to create a routine as similar as possible to that which the child follows at home. Since a predictable schedule is vital, allowing the child a small measure of control would help ease the trauma of hospitalization. The child could arrange personal items while the nurse schedules tasks at the same time, with the same personnel if possible, to help decrease anxiety. The scenario does not provide any facility-specific details regarding isolation protocols for Covid clients. However, because the client is young (school-age is 6-12), a parent or guardian is usually permitted to remain with the child at all times. In this age group, the presence of a parent would provide more support than a phone call.
A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.
1., 3., 4., & 6. Correct: Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as: "Are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. Incorrect: You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. 5. Incorrect: You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client.
A client is being admitted to the hospital for possible appendicitis. During the admission history and physical, the client reports having fatigue and trouble concentrating. What other client statement during the assessment would lead the nurse to suspect marijuana use? 1. "My eyes have looked bloodshot lately." 2. "I've noticed that my appetite has been decreasing." 3. "I sometimes feel that I am off balance." 4. "I have been losing weight lately." 5. "I don't have the desire to do the things I used to do." 6. "My heart seems to beat fast a lot of the time."
1., 3., 5., & 6 Correct: Red eyes are a classic sign of marijuana use. The red, bloodshot eyes that the client described may be the result of marijuana use, because it can cause vasodilation in the capillaries of the eye, resulting in increased blood flow. Tetrahydrocannabinol (THC), which is the active ingredient in marijuana, can attach to neuron receptors in the brain that disrupt various mental and physical functions. THC can affect pleasure, thinking, memory, concentration, movement, and coordination. That is why this client may feel "off balance" at times. In addition, sensory alterations and problems with time perception may be noted. The statement from the client about not having the desire to do the things that were formerly done may be a sign of marijuana use. Marijuana has been linked to decreasing motivation and diminishing the desire to engage in activities that were formerly rewarding or enjoyable. Another physical sign of marijuana use is increased heart rate, which would correlate with the client's statement about the sensation of the heart beating faster much of the time.
A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.
1.,2., & 4. Correct: Breathing through the mouth causes the mucous membranes and tongue in the mouth and lips to become dry. Oral care should be initiated every 2- 4 hours to increase oral integrity. As the client becomes progressively weaker the nurse should assist with oral hygiene. By creating a supportive environment, the dying client will experience less anxiety. Reducing the noise level and glare in the room will also create a supportive environment. Other ways to maintain a supportive environment are keeping the linen loose and clean. The client's eyes may become dry due to dehydration and less blinking of the eyelids. Optical lubricant should be applied to the eyes to decrease the burning and itching in the eyes.
The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? 1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now."
2. "You are worried that you may be responsible for your friend's condition?" 2. Correct: This type of therapeutic communication is called restating. By repeating the client's statement, the nurse expresses an understanding of what the client said. Restating also gives the client the chance to clarify or continue his thoughts.
How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.
2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.
The nurse is assessing a client who was admitted to the inpatient psychiatric unit five days ago for exacerbation of psychotic symptoms, as evidenced by delusions of grandeur. Which type of client remarks indicate continued delusions of grandeur? 1. Comments with fear as a theme. 2. Comments with a theme of being grand or powerful. 3. Comments related to missing body organs. 4. Comments related to being under someone else's control.
2. Correct: Delusions of grandeur include thoughts that the person has exaggerated power or importance. Clients experiencing these feeling believe they are a deity, have special powers, rare abilities or hidden talents. They often feel they should be praised and publicly recognized for these powers.
A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization
2. Correct: Hallucinations are false sensory perceptions not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 1. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality. Often the client will either feel all powerful or have extreme unrealistic fears. 3. Incorrect: Flashbacks are a spontaneous recurrence of the hallucinogenic state without ingestion of the drug. These can occur months after the drug has been taken. 4. Incorrect: Depersonalization can occur, but it is the observation of oneself having an experience. The client may report feelings of being an outside observer of their own thoughts or body with a sense of loss of control. This is sometimes described as an out-of-body experience for the client.
A client receiving electro-convulsive therapy (ECT) tells the nurse, "I don't know if I can take another treatment." What is the nurse's best response? 1. "Remember to focus on the fact that you will be fine after you complete all of your treatments." 2. "The therapy must be difficult for you at times. How do you feel about your progress at this point?" 3. "Hang in there. It's for your own good and times will get better." 4. "What makes you say that? You know it will make you well."
2. Correct: The correct answer allows the client to continue discussing feelings and redirects the client to thoughts of progress and effectiveness of the treatment. Acknowledge the client's feelings and then asking an open-ended question are both appropriate a therapeutic communication techniques.
A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."
2. Correct: The nurse is focusing on the 'here and now' by acknowledging the client's changed appearance without adding any personal comments. This response avoids typical communication blocks such as "you look great", which seems positive but is considered a judgment by the nurse. The nurse's broad statement shares an observation in an open-ended manner. 1. Incorrect: This remark provides false reassurance to the client by assuming change in visual appearance must be based on emotional improvement. This is very misleading and non-therapeutic for the client. 3. Incorrect: Questions can be positive communication tools if presented in an open-ended format. Asking about life changes in this manner could be answered yes or no, which indicates a closed-ended question. A sudden improvement in appearance may be one of the warning signs of suicidal ideations, but the nurse's inquiry would not provide the information needed. 4. Incorrect: The nurse is inferring the client needs a special occasion in order to be clean and well-kempt. Such a comment is presumptuous and judgmental.
A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not a reliable healthcare option.
2. Correct: This is the best course of action for the nurse. The health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best to incorporate all components into the care of the person. 1. Incorrect: Leaving will not allow the nurse to discuss care of the client with all members of the healthcare team and family. This is a good time to learn about the curandero, health beliefs, etc. 3. Incorrect: The client and family have requested the curandero. Asking him to leave would be insulting. The nurse would not develop a good rapport with the client this way. 4. Incorrect: This does not take into account the client's beliefs in health, wellness, and illness. The nurse should work to incorporate folk medicine from the curandero as long as it will not harm the client.
A client admitted to the psychiatric unit is diagnosed with depression. What is the nurse's best response? 1. I understand what you are feeling. I have been left by someone I loved before. 2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.
2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 2. Correct: Empathy is the ability to see beyond outward behavior and to understand the situation from the client's point of view. Therapeutic language is necessary for this client and this acknowledges the clients feelings, restates for clarification, and allows the clients expression of feelings in a trusting environment.
A distraught client arrives at a mental health crisis center following a house fire that also took the life of a young family member. The nurse knows what action is most important when initiating crisis intervention for this client? 1. Assist the client to verbalize feelings of grief. 2. Assess client for any suicidal behaviors. 3. Admit client to general mental health unit. 4. Assign client to a grief counseling group.
2.Assess client for any suicidal behaviors. Rationale: Client safety is always the nurse's priority concern where no other life threatening issues exist. A distraught client in crisis from such overwhelming events does not always think or act clearly. The loss of home combined with the death of a family member places the client at potential risk for suicide. Because the client has presented to the mental health crisis center, the nurse must assume the worst and assess for unexpected responses.
A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "But I only had just a few drinks". What is the most therapeutic statement the nurse could make to the client? 1. "If you only had a few drinks, how did you wreck?" 2. "What do you mean by 'just a few drinks'?" 3. "Tell me what you remember about the accident." 4. "You were driving when the accident happened."
3. "Tell me what you remember about the accident." 3. Correct: While providing care to this client, it is important for the nurse to remain professional and non-judgmental. Because no life-threatening injuries are indicated, the most therapeutic approach would be to allow the client to verbalize feelings at this time. Additionally, having the client recall any specifics about the incident may provide the nurse with additional data for a neuro assessment.
The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure
3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails, and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa. 1. Incorrect: Despite the fact that anorexic clients experience severe weight loss, they continue to view themselves as heavy and generally wear loose fitting clothing to hide what they perceive as an overweight body. 2. Incorrect: Because of skeletal muscle atrophy and poor nutritional intake, anorexic clients display sallow, dry skin with brittle nails and hair. Oily, non-elastic skin would not be noted in a client with anorexia nervosa. 4. Incorrect: Gingival infections and dental caries are typical of clients with bulimia, another eating disorder in which stomach acid from frequent vomiting causes gum infections or dental caries. This is not common in anorexics.
While completing the admission history on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."
3. Correct. The nurse recognizes that the client's spouse is emotionally distraught at this moment, and is most in need of the nurse's focus at this time. Major life events have affected this family unit, including the client's terminal diagnosis and separation to a new living environment. This spouse is understandably overwhelmed by the changes occurring and, while the nurse will need to complete the admission paperwork, family needs must be met. Focusing on the spouse's emotional needs and allowing time to verbalize feelings could positively affect the client's adaptation to the situation.
A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)? 1. Bradypnea 2. Bradycardia 3. Irregular respirations 4. Elevated systolic pressure
3. Correct: An early sign of increased ICP is irregular respirations. The increased ICP is precipitating neurological changes which results in a decrease in cerebral perfusion. This action results in irregular respirations due to the vasomotor center being stimulated 1. Incorrect: Bradypnea is a late sign of increased ICP. The normal breathing rate for an adult is 12 - 20 breaths per minute. Increased intracranial pressure will compromise the blood flow in the brain. The result of the decreased blood flow is bradypnea. 2. Incorrect: As the intracranial pressure increases and hypertension occurs the parasympathetic system is stimulated. The parasympathetic system stimulation results in bradycardia. Bradycardia is a pulse less than 60 beats per minute. Bradycardia is not an early sign of increased ICP. 4. Incorrect: The cerebral blood flow decreases as intracranial pressure elevates. The response is an increase in the systolic pressure as result of the arterial pressure increase. This is a later sign of increased ICP.
Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).
3. Correct: Avoiding eating meat on Fridays during Lent is a practice of those of the Catholic faith; this action demonstrates cultural sensitivity and spiritual support. 1. Incorrect: Kosher food is required in Judaism. Kosher diet is based on a section of Jewish law which identifies which foods can be eaten. 2. Incorrect: A priest, not the nurse would administer last rites of the sick. Only a priest has been trained to celebrate the Sacrament of Reconciliation and the Anointing of the sick (last rites). 4. Incorrect: Persons of the Muslim (Islam) faith who are dying want their body turned to Mecca (east). The body or the heels should be positioned to the Mecca (east).
During the hospital discharge instructions a client asks the nurse, "What do you think I should do about my husband's smoking?" Which statement by the nurse is appropriate? 1. "Why are you asking me for advice?" 2. "I think you should talk to your husband." 3. "What do you think you should do?" 4. "You need to support him through his addiction."
3. Correct: By using the therapeutic communication of reflecting, the nurse is referring the client back to their statements. The communication direction is returned to the client for their reflection on questions and feelings. 1. Incorrect: The nurse is asking a direct question back to the client. This is the nontherapeutic communication technique of requesting an explanation. The nurse is controlling the direction of the communication. The nurse needs to provide answers that the client requested not information that the nurse wants to address. 2. Incorrect: The nurse is sharing with the client their ideas of what the client should do. The nurse is utilizing nontherapeutic communication technique of giving advice. When the nurse is giving advice, the client is placed in a dependent role. 4. Incorrect: The nurse is focusing the communication to the needs of the husband and not the client. This nontherapeutic communication technique of defending the husband will act as a communication block with the client.
After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.
3. Correct: Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected. If an autopsy is performed, all body parts must be returned for burial.
The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"
3. Correct: The correct answer demonstrates the therapeutic communication technique of "restating". The main idea is to let the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary. 1. Incorrect: This response is disapproving and gives advice. It is not therapeutic. The nurse does not know the client is making excuses and should not assume. 2. Incorrect: This response is giving reassurance. This statement seems like the nurse is somewhat "blowing off" the client. It does not address this issue.4. Incorrect: This response is belittling. This statement does not address the client's problem. It also implies that the client should not have problems studying.
Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake
3. Correct: They can hold these items in their hand and eat while walking around.
A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."
3. Correct: This mother seems to be experiencing more than the baby blues that many new mothers experience. There are clues in the stem of this question that you should recognize as warning signs of something more significant than the baby blues. The mother states that she no longer is thinking clearly and expresses that she can no longer cope with the existing situation. This mother seems to be experiencing postpartum depression that can include more severe symptoms such as suicidal thoughts of thoughts of causing harm to the baby. Therefore, it is crucial that the nurse ask a very straightforward, direct question to the mother to assess if the mother has any thoughts of harming herself or the infant. Failure to do so could put the mother and/or infant's life at risk for harm.
A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."
3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm to themselves. 1. Incorrect: The client has a negative outlook about themselves. This statement indicates low self-esteem. The client is not exhibiting suicidal tendencies. 2. Incorrect: The client is having difficulty making choices. This statement indicates indecisiveness, which is a symptom of depression. Indecisiveness is not a risk for suicide or self-directed injury. 4. Incorrect: This statement indicates possible social isolation and low self-esteem. The client maybe physically separated from people or the perception of being isolated from others. The client does not exhibit a loss of hope that is connected with suicide.
A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.
3. Redirect the client to another activity.
A nurse is assessing a terminally ill client who is restless with an O2 saturation of 58 mm Hg. Which nursing intervention would the nurse implement? 1. Monitor the client's breathing pattern 2. Wipe the mouth with oral care sponge 3. Soothe the client by affirming your presence 4. Initiate oxygen via nasal cannula at 4 L/minute
3. Soothe the client by affirming your presence 3. Correct: As the oxygen saturation level decreases, the client becomes restless and anxious. The nurse should initiate calming interventions such as speaking to the client in a soothing voice tone and reassuring the client that there is someone present to support them.
The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.
3., & 4. Correct: When a person is confused and has dementia, we need to communicate in a simple manner. Provide simple directions or instructions, short sentences, and gestures. Use pictures. Do not give instructions on multiple things. Do not argue, criticize, or correct the client. This can increase anxiety, agitation, and anger. 1. Incorrect: Use a gentle touch rather than a firm touch with these clients. You do not want to be confrontational or evoke fear in the client. 2. Incorrect: Be flexible. If one approach does not work, try another. 5. Incorrect: Avoid questions or topics that require extensive thought, memory, or words. This can increase anxiety, frustration, and agitation. 6. Incorrect: Do not require or force participation in activities or events. This can increase anxiety, frustration, and agitation.
A client arrives at the emergency room with chest pain, dyspnea and diaphoresis, stating "I think I am going to die." What would be the most appropriate comment by the nurse? 1. "We will do everything we can for you." 2. "Would you like me to call your family?" 3. "What makes you think you are going to die?" 4. "Have you ever had these symptoms before?"
4. "Have you ever had these symptoms before?" 4. Correct: If you assume the worse here, then you must think the client could be having an MI. Remember Maslow: Fix physiologic problems before psychological problems. Determining whether the client has a history of cardiovascular disease, or even panic attacks, can help contribute to a positive outcome.
The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."
4. "I'm so sorry. This must be very difficult for you." 4. Correct: Nurses can best facilitate the family's expressions of grief by supporting and encouraging them to express themselves. This is the best option that best demonstrates that expressions of grief are acceptable and expected. Here, you are empathizing to provide emotional support during their grief and providing an open ended statement that would promote expression of the family members' grief.
An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"
4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress.
A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms
4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process.
An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.
4. Correct: Always assess why the client wishes to leave first. This will provide an opportunity to attempt to fix the problem and possibly revise the client's decision.
A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation
4. Correct: Compensation is consciously or unconsciously overemphasizing a characteristic to compensate for a real or imagined deficiency. Making up for deficits in one area by excelling in another helps to raise or maintain the client's self-esteem. 1. Incorrect: Projection is attributing one's own thoughts or impulses to another person as if they had originated in the other person. This is unconsiously done and usually includes intolerable wishes and emotional feelings. 2. Incorrect: Displacement is shifting or transferring the emotional element of a situation from a threatening object to a non-threatening object. This could include transferring emotions from a person, object or situation to another person, object or situation. 3. Incorrect: Sublimation is redirecting a socially unacceptable impulse into socially acceptable behavior. Examples include strong aggressive or sexual drives.
An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning
4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage. 1. Incorrect: Confabulation is the term used for creating imaginary events to fill in memory gaps. This is sometimes associated with dementia, but more often with disorders like Korsakoff's syndrome, traumatic brain injuries or tumors. 2. Incorrect: Apraxia is the term used for the inability to carry out motor activities despite intact motor function. 3. Incorrect: Pseudodementia is depression. Depression is the most common mental illness in the elderly, but it is often misdiagnosed and treated inadequately. Cognitive symptoms of depression may mimic dementia.
Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking
4. Correct: The client may use rhyming words, such as dog, bog, cog, jog. It is the meaningless rhyming of words, often in a forceful manner.
A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? 1. Encourage the client to watch TV with the other clients on the unit. 2. Engage the client in a game of ping pong. 3. Suggest that the client play monopoly with other clients. 4. Provide soft lighting in the client's room for reading.
4. Correct: The client needs minimal stimulation to help reduce activity level and encourage sleep. A quiet environment that is calm and dimly lit is ideal for the manic client.
A nurse caring for a terminally ill client with a Do Not Resuscitate (DNR) order who begins to cry. The client states "My family does not want me to give up." Which communication response would the nurse initiate? 1. "Your family will begin to understand your feelings." 2. "Follow your own thoughts about what you should do." 3. "What you can do is speak to your daughter when she comes." 4. "I notice that you appear to be upset about the family's comment."
4. Correct: The nurse is acknowledging the client's feelings of the family saying that you are giving up. This is the therapeutic communication of acknowledging the client's feelings. The nurse is recognizing and verbally accepting that the client is upset. When the nurse implements this communication technique, the client feels more comfortable to express further feelings and thoughts.