NCLEX Basic Psychosocial Needs

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?"

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?" The nurse should explore the client's feelings about the sexual relationship with her spouse as this was the topic of her statement. Platitudes that offer unfounded reassurance will not help the nurse explore the client's fears. The nurse should explore the client's feelings first, before offering any discussion with the spouse. Discussing reconstructive procedures is premature as the nurse has not assessed the client's goals yet.

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay?

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

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

"I won't continue to talk with you if you curse." Stating "I won't continue to talk with you if you curse" sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement "You're being very childish" reprimands the client, possibly causing the anger to escalate. The statement "I'm sorry if you can't wait" fails to provide feedback to the client about her behavior. The statement "Come back tomorrow, and your medication will be ready" ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.

A nurse performs a spiritual and religious assessment for a client. The client identifies as an atheist. Which statement made by the nurse ensures therapeutic communication?

"Is there anything you would like me to include in the spirituality part of your assessment?"

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." In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which statement by the nurse provides appropriate interpretation of the impact of stressors on the client's health?

"These life stressors place you at moderate risk for illness." Holmes and Rahe's theory of stress response suggests that all life events, whether positive or negative, cause stress. The Holmes and Rahe stress scale ranks life events according to how much stress they cause. Scores are interpreted based on points accumulated. Clients who accumulate points totaling up to 150 are considered to have a low risk of developing illness in the near future. Those with points between 150 and 299 are considered to be in the moderate- to high-risk category. Clients with scores 300 and higher are at the greatest risk of stress-related illness.

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?" The nurse should first clarify if the client's appearance as angry or defensive is actually related to the spirituality-related questions before making assumptions. Some clients are relieved to know that the spiritual aspect of their being is worthy of the nurse's concern. However, the nurse should not sound vague and judgmental by saying something like, "We ask because having a spiritual connection can really help you during this time." Saying something like, "Many clients get uncomfortable when asked about their spiritual beliefs" takes the focus away from this client. Just telling the client everyone is asked these questions does not explore the reaction.

The client states, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is most therapeutic?

"You must be feeling lonely at this time. Would you like to talk about your loss?"

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do?

Allow the client to see and hold the baby for as long as she desires.

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. Some cultures have no first or last names, and it is a sign of respect to ask the client how they wish to be addressed. Directing questions to the interpreter is culturally incongruent behavior. The interpreter will coach the nurse to direct questions to the client. The family should stay with the client so the nurse can determine who is the decision maker in the family. In some cultures, the matriarch or patriarch may be the designated decision maker and should be involved in decisions about the client's care. Some cultures believe health is a holistic balance between hot and cold. Therefore, before providing hot drinks or cold drinks, the nurse should determine the client's preferences.

A woman employed full-time wants to request a leave of absence to care for her father who is being treated for colon cancer 300 miles (480 km) away. What should the nurse advise the client to do first?

Contact her employee resources department about policies guiding leaves of absence. The nurse should advise the client to check with her employer to determine the policies and legislation followed there regarding leaves of absence. While the client can consider the other options, the first step is to obtain information from her employer.

The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family?

Contact the hospice agency to provide grief support for the family.

The hospice nurse is caring for a client who has been diagnosed with terminal cancer. The client breaks down in tears and shares with the nurse "I should just end it now so my kids can start moving on with their lives. They will be better off without me. When they come to visit tomorrow, just tell them I'm not up for visitors." The nurse understands the client is in which stage of the grief process?

Depression The client is in the depression stage of the grief process, which is characterized by withdrawal from life and loved ones, feelings of intense sadness, and feeling like there is no reason to go on. The denial stage is characterized by feeling of shock and numbness, disbelief that this is real. Acceptance is accepting the new reality, focusing on what time is left and trying to make the most of it. This client may be suicidal; however, this is not one of the five stages of grief.

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

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

Which approach would be the most therapeutic when working with the parent of a client presenting with quadriplegia as a result of a C-5 spinal cord injury?

Encourage the parent to express feelings and other fears about the injury.

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

Establish the client's daily smoking pattern. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

A new mother who is breastfeeding her baby has developed a deep vein thrombosis and needs to be started on a heparin drip for treatment. The client states, "I need to nurse my baby." How would the nurse respond to this client?

Explain the importance of the heparin in resolving the thrombosis and examine ways the baby could room in with the mother with assistance.

A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client has decided to continue the pregnancy based on religious beliefs and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate?

Explore the nurse's own feelings about the issues of anencephaly and organ donation.

A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do?

Gather more information about the client's feelings about the childcare arrangements.

The nurse manager has employed three nurses from a culture that is different from that of most of the nurses who currently work 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.

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. A thorough assessment is the initial step in providing nursing care of any type. Asking if the client wants to speak to the nurse daily or discussing spirituality with the client are not forms of assessment. Telling the client to speak to family members or friends about spirituality shifts the focus and removes the nurse's responsibility to the client.

The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client?

Plan and implement care in a way that is sensitive to the needs of the client.

A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply.

Report the behaviors to the unit manager for further investigation. Talk compassionately to the LPN/VN and discuss the RN's concerns and observations.

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

Sit down to talk with the client. Sitting down to talk with the client enhances communication because it shows a willingness to take the time to listen. Asking direct questions limits the communication and decreases the client's ability to discuss his or her concerns. Maintaining a distance of only 6 to 12 inches with a client is likely to make him/her uncomfortable as the nurse is in the client's personal space; 18 inches to 4 feet (not 6 to 12 inches) while speaking allows most clients to feel comfortable, thereby enhancing communication. A concerned expression, not a neutral one, demonstrates interest and attention.

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest?

Take stress-management classes.

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

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

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.

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

anxiety related to poorly functioning kidneys and body image disturbance

A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time?

feelings of anxiety Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority.

In working with a rape victim, which intervention is most important?

periodically reminding the client that she did not deserve and did not cause the rape Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted.

For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?

playing soft or soothing music

A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction?

providing the client with information about what to expect postoperatively Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.

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 The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

A nurse cares for a client who states that they believe that God can be seen in everything and every action. The nurse recognizes this as what characteristic of spirituality?

self-reflective The client is referring to self-reflection. Spirituality is based on self-reflection and not group-oriented like religion is. Spirituality is unorganized and subjective; it differs from person to person. There are no universal beliefs on spirituality. Rather, spirituality is based on experience and not rituals.

When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the

spiritual healer. Shamans and spiritual leaders are found among Aboriginal and many Southeast Asian groups

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.

In which situation can a client's confidentiality be breached legally?

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

A client has just lost her husband to an apparent suicide. In the emergency department, the client tells the nurse that she has never lost an immediate family member and "feels so numb right now." Which response by the nurse is best?

"His death is a terrible loss." The statement that his death is a terrible loss validates the bereaved person's sense of loss and communicates the message that she is understood and supported. The other statements are unhelpful and banal responses at the time of a loss. The statement that the deceased is no longer suffering does not respond to the emotional pain the client is feeling.

On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate?

"I am truly sorry you lost your baby."

The nurse cares for a middle-aged client with a below-the-knee amputation. What statement indicates the need for further assessment of the client's body image?

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

A client undergoing a mastectomy says, "I've been a basket case just thinking of what implications this has for my family." How should the nurse respond?

"This is a very difficult adjustment period for you and your family."

A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?

past and current life actions According to Hinduism, illness is the result of past and current life actions. The right hand is seen as holy, and eating and intervention need to be done with the right hand to promote clean healing. The spiritual health belief in Hinduism is not that illness is from consumption of dirty food, unhygienic habits, or poor worship of God.

The nurse is caring for a client who developed fluctuating moods related to a recent cerebral vascular accident. When discussing the client's mood in a family meeting, which statements confirm a family's understanding of how to support the client? Select all that apply.

"I allow my family member to vent feelings and then find a different topic to discuss." "Sometimes I sit down and cry too then I pick myself up and move on." "I do not take what the my family member says personally and try to address the issue of anger. Changes in the brain that occur following the cerebral vascular accident can lead to periods of an emotional outburst resulting in anger or depression. The family may experience changes in their loved one that include uncharacteristic verbal outbursts or crying (pseudobulbar affect) within usual conversation. It is important to identify that these outbursts are a result of the illness and not take the outburst personally. Allowing the client to vent feelings and experience the frustration allows for the sharing of emotions and provides emotional support. Afterward, moving on to a different topic or moving on within the day's activity does not allow the client to remain in the emotional state. Leaving the client or yelling at the client is not therapeutic to support the client through this time.

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client?

"You may want to have an abortion if you find out you are pregnant." This statement hinders the therapeutic relationship because it advises the client to make a personal choice that may be against the client's values and beliefs. This statement would block further communication about the options that are available to the client. The other statements appropriately respond to feelings a victim may have following sexual assault or violent attack and provide reassurance that the victim acted as rationally and appropriately as anyone could in a life-threatening situation and let the client know that the nurse understands the emotions one commonly feels following a violent attack.

A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?

Approach the client and ask if there are questions about the condition. This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.

A client's friend is visibly distressed by the client's condition and lack of improvement. The friend says they feel powerless and unable to help the friend. How should the nurse respond?

Ask the client's friend if they would like to help with comfort measures.

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. It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

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. Strong social support enhances mental and physical health, providing a significant buffer against distress. Relationships of low-quality support are known to impact a person's coping effectiveness negatively.

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 Anxiety in a preoperative client may be caused by many different fears, such as fear of the effects of anesthesia, the effects of surgery on body image, separation from family and friends, job loss, disability, pain, or death. However, fear of the unknown is most likely to be the greatest fear because the client feels helpless. Therefore, an important part of preoperative nursing care is to assess the client for anxieties and explore possible causes. Emotional support can then be offered so that the client is in the best possible psychological condition for surgery.

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 scenario reflects the nurse's interpersonal skills. It shows how a person relates with others. The nurse shows imaginal skills when envisioning a plan for adapting and personalizing client care. Instrumental skills are associated with basic physical and intellectual competencies. Systems skills are those that help the nurse see the whole picture and how various parts relate.

A client suspects the end of life is near. However, others talk about only pleasant matters and maintain a persistently cheerful facade. The nurse plans care for this client by recognizing that these behaviors will most likely cause the client to experience which feeling?

isolation Clients tend to experience isolation and loneliness when those around them are trying to hide or mask the truth. They are then left to face the realities of death alone. Clients do not experience relief or hopefulness when others are falsely cheerful. Independence is promoted by offering realistic choices about care at the end of life.

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 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 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 client is in the acceptance stage of grief regarding the divorce. The client has come to terms with the new reality, accepted the new reality, and is focusing on the positives and living life to the fullest. The bargaining stage of grief is characterized by making deals or promises of doing things differently if only there could be a different outcome. Depression would appear as intense sadness, feelings of hopelessness and often crying, and the client has most likely already worked through this stage, as the client reported struggling with depression over the last year since the divorce. Ongoing is not one of the stages of grief, and this client appears to be dealing with the grief well at this point.

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 family is grieving, and it is important to acknowledge and listen to them. They need to know what is happening. They also need to be encouraged to be involved in the client's care to give them an opportunity to connect and feel actively involved. It is difficult for them to give up hope and be realistic regarding the prognosis; they need to have time. Reassuring the family that it is normal to feel concerned is not therapeutic. Encouraging the family to stay positive is not realistic at this time.

A hospitalized 5-year-old child cries daily, is fearful and apprehensive about health care procedures, and does not want to cooperate with the nurse. What is the nurse's best action?

Offer verbal education and client/family teaching on coping skills. Fear and anxiety are normal reactions in the hospitalized pediatric client, and providing verbal education on coping skills would be the best initial intervention, and it is cost-effective. Outpatient counseling could be needed, but it would not be an initial intervention and would be more costly. A mental health consult would not be indicated as an initial intervention for a normal reaction to the stress of a hospitalization, and would be more appropriate for an acute mental health problem. Ignoring the situation is not the best intervention, as the client and family need assistance coping with the hospitalization.

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

After the spouse has visited, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels incapable of handling the situation. What should the nurse do at this time?

Use the call system to request assistance. A nurse who feels unable to handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client the spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

A group of nursing students are reviewing current nursing codes of ethics. Such a code is important in the nursing profession because:

nursing practice involves numerous interactions between laws and individual values

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?" The statement, "Your eyes look dark," is the least sensitive statement because it points out an obvious difference for no real purpose. The nurse has a reason to ask the client about favorite foods and needs to know about past health problems. Also, it is appropriate for the nurse to ask the client how she wishes to be addressed.

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 client may be describing symptoms of pain. Culture specific symptoms for "feeling bad" include numbness, thinking too much, feeling hot under the skin. Asian clients may describe pain in terms of Yin and Yang (hot and cold). Nurse's knowledge of pain associated with health problems is necessary to assist this client manage pain. Clients from some cultures may associate mental health symptoms with evil spirits and will not report them as being unusual. Clients from Asian cultures may not describe symptoms locally but in a diffuse fashion.

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?" To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.

An older adult with end-stage cancer needs assistance with arranging the finances for end-of-life home care. The nurse should refer the client to which person?

a social worker A social worker can provide information for supportive services and can help the client determine which resources are necessary at this time. The business office of the health care agency does not provide advice about managing finances. The HCP will be part of the team, but will focus on managing the client's health and end-of-life care. The client may or may not have a will; it is not the role of an executor to make financial decisions about health care.

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. Which of these best describes a subculture?

a unique cultural group that exists within the larger culture Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture but this is not their defining characteristic.

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

cultural habituation Cultural habituation reduces the extent to which people must take environmental cues into account; a predictable environment and being able to perceive the world as coherent are essential for human functioning. Assigning people to specific categories because of their culture, race, or ethnic emblems is stereotypical thinking; it is misleading and denies individuality. Ethnocentrism reflects a fear of difference from one's belief system, and consequent derision or disqualification of people and practices that do not conform to one's own view. Cultural shock is the acute experience of not comprehending the culture in which one is situated.

The nurse provides care to a verbally unresponsive client diagnosed with terminal cancer. The client's family refuses palliation on religious grounds. The nurse experiences great anxiety and distress when caring for the client due to the level of suffering perceived. What action should the nurse take?

Speak to the charge nurse about the nurse's moral conflict. The nurse is experiencing moral conflict and needs to discuss this with the charge nurse. The nurse is not able to simply ignore the feelings being experienced and accept the family's wish; if that were the case, there would be no issue to begin with. If there is an ethical breach related to the client's care, the nurse's first action is to speak with the healthcare team, not with the client advocate. In this case, a true ethical issue is not established. The goal is to strike a balance between the religious freedom of the client and family, the moral autonomy of the nurse, and the delivery of care that exhibits non-malfeasance. After consulting with the charge nurse, it may be decided to excuse the nurse from working with the client on moral grounds, or that the ethical committee needs to be consulted.

The nurse is caring for a client who recently lost an infant to sudden infant death syndrome (SIDS). The client talks about how 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 This client demonstrates acceptance of the new reality. The client shows both dealing with the grief and resuming a more normal life again, such as going back to work and planning another pregnancy. It is normal for the client to still experience times of happiness and sadness, but this shows the client has moved into the acceptance stage and is accepting the loss of the baby without trying to change it. Denial would be characterized by refusing to admit the loss of the baby was real, such as believing that the baby was not really dead. Delusion is not a stage of grief, but rather a false or irrational belief that a person holds strongly to despite proof to the contrary. Bargaining would be characterized by trying to make deals to change the outcome, such as "Take me instead and let my baby live."

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority?

explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP) The priority is to explain to the client that this information has to be shared immediately with the staff and the HCP because of its serious nature. Safety of all is crucial regardless of whether the client follows through on his plan. It is possible that the client is asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining with the client, such as warning him that his telephone privileges will be taken away if he abuses them, or offering to disregard his plan if he does not go through with it, is inappropriate. Saying nothing to anyone until the client has actually completed the call and then notifying the proper authorities represent serious negligence on the part of the nurse.

A client is experiencing stress in a change of role from married to divorced. The client states that the in-laws blame the client's drinking for the divorce. The client states, "These days, a couple of glasses of wine in the evenings helps calm my nerves." What is the best coping strategy for the nurse to offer the client?

Practice deep breathing and muscle relaxation. The client is experiencing stress due to a role change subsequent to the recent divorce. Using previously learned relaxation techniques would be an appropriate way of decreasing stress without using alcohol as a temporary fix. Ceasing contact with significant others is extreme and would not be recommended. Similarly, suggestions to rely on work colleagues would not be appropriate. While assertiveness techniques may be helpful in the long term, short term stress is well managed with relaxation techniques.

A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply.

identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs asking the client about original spiritual beliefs The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonable for the nurse to explore the client's faith origins as well as what the usual sources of spiritual support were or are. Commonly, a hospitalized client is separated from those of common faith practices so this should be explored. The nurse can also carefully explore what is contributing the challenges to faith the client is expressing. The scenario does not state that the client is Christian so reading from the Bible is an assumption by the reader, first. Second, the nurse would not take the step of reading to the client from a religious text unless this was a direct request by the client. Nurses should also not offer to pray with the client but should only engage in this if directly asked and if this is something the nurse is comfortable with.