Passpoint 3

A nurse is caring for a terminally ill client. The nurse assesses the client for identification of the psychosocial stage of acceptance. Place the following five stages of death and dying in the order in which Elisabeth Kübler-Ross noted that they most often occur. All options must be used. 1 denial and isolation 2 anger 3 bargaining 4 depression 5 acceptance

denial and isolation anger bargaining depression acceptance

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? "This subject seems to be troubling you. Let's walk to the activity room." "Describe the man who's out to get you. What does he look like?" "There is no reason to be afraid of that man. This hospital is very secure." "There is no need to be concerned about a man who isn't even real."

"This subject seems to be troubling you. Let's walk to the activity room." Explanation: This remark distracts the client from the delusion by engaging him in a less-threatening or more-comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the client's false belief. The other options focus on the content of the delusion rather than on the meaning, feeling, or distress it evokes.

A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique? Restating Making observations Exploring Focusing

Focusing Explanation: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question (restating technique) or ask further questions (exploring technique), and didn't make an observation.

Gastroschisis

Gastroschisis is a birth defect of the abdominal (belly) wall. The baby's intestines are found outside of the baby's body, exiting through a hole beside the belly button. The hole can be small or large and sometimes other organs, such as the stomach and liver, can also be found outside of the baby's body. *good survival rate

Venlafaxine

SNRI

SNRI

These are the SNRIs most commonly prescribed for anxiety. Similar to selective serotonin reuptake inhibitor (SSRIs), SNRIs increase the levels of specific neurotransmitters. They are called SNRIs because they increase both serotonin and norepinephrine. SNRI = Serotonin-norepinephrine reuptake inhibitor

agoraphobia

fear of open spaces

A client with alcohol dependence states, "I feel so bad because of what I have done to my wife and kids. I am just no good." Which response by the nurse is most appropriate? "Why do you think you are no good? " "They will need to forgive your shortcomings." "Alcohol dependence is a disease that can be treated." "Alcoholism is painful for everyone involved."

"Alcohol dependence is a disease that can be treated." Explanation: The most appropriate response is, "Alcohol dependence is a disease that can be treated" because it conveys hope. It also emphasizes that the client has a treatable illness, which is helpful in reducing denial and guilt and encouraging the client to seek and comply with treatment. Clients often cannot answer "why" questions. The other statements are judgmental and guilt-producing, possibly leading to denial and furthering the need for alcohol.

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. "He knows who we are, but that is about it. We do not know what to say to him." What should the nurse tell the family? Select all that apply. "Answer his questions simply, honestly, slowly, and clearly." "Correct him when he is hearing and seeing things that are not there." "Occasionally remind him of the time, day, and place when he does not remember." "Include him in your conversation, instead of talking about him while he is present." "Raise your voice a bit so you are sure he hears you."

"Answer his questions simply, honestly, slowly, and clearly." "Occasionally remind him of the time, day, and place when he does not remember." "Include him in your conversation, instead of talking about him while he is present." Explanation: Clear communication is crucial for a client with delirium. The family must include the client in all conversations and keep him oriented to time and place. It is inappropriate to argue with a client's hallucinations because they are real to the client. Speaking more loudly will not help this client hear more distinctly and may increase the client's confusion.

A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. What would be the nurse's best response? "I know how you feel, but the medication will make your child feel better." "I cannot let you do this without calling your health care provider first." "Can you tell me why you want to take your child home now?" "I can imagine how hard this is for you, but it is not what is best for the child."

"Can you tell me why you want to take your child home now?" Explanation: With a parent who is visibly upset, it is best to try to determine the cause. Therefore, asking the mother about why she wants to take the child home can provide insight into the problem. The nurse cannot stop the mother from taking her child home. However, the HCP should be notified about the mother's decision and efforts are needed to explain the ramifications of taking the child home. It is inappropriate for the nurse to say "I know how you feel" or "I can imagine how hard this is" unless the nurse has had the same experience.

A client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which response by the nurse is best? "I have a few minutes. I'll take you." "I'm sorry but I can't take you. I'm busy." "Smoking is harmful to your health. I don't want to contribute to your bad habits." "Clients are permitted to smoke at designated times. You have to follow the rules."

"Clients are permitted to smoke at designated times. You have to follow the rules." explanation: Consistency is essential when dealing with antisocial clients. They disregard social norms and don't believe the rules apply to them. Agreeing to give the client a smoke break would be detrimental to the client because it reinforces the client's acting-out behaviors. The nurse saying she is too busy avoids the client's attempt to manipulate. Telling the client that she won't allow the extra smoke break because smoking is harmful is inappropriate because the nurse is lecturing the client.

A 16-year-old girl is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on her nutritional intake, the nurse should ask: "What activities do you engage in during the day?" "Do you have any allergies to foods?" "Do you like yourself physically?" "What kinds of foods do you like to eat?"

"Do you like yourself physically?" explanation: Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Therefore, asking the adolescent whether she likes herself physically is appropriate. Questions about activities and food preferences elicit information about health promotion and health protection behaviors, not role and relationship patterns. Questions about food allergies elicit information about health and illness patterns.

The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my health care provider let me try that?" Which response by the nurse would be most appropriate? "It's the health care provider's prerogative to decide how to treat you. The health care provider has chosen what is best for your situation." "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." "That drug is used for cases that are more advanced than yours. You're not eligible for this treatment now." "Every person is different. What works for one client may not always be effective for another."

"Every person is different. What works for one client may not always be effective for another." Explanation: The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the HCP's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for advanced disease demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client that he or she is not eligible for the drug now is not within the scope of the nurse's practice.

A client who is experiencing hallucinations asks if a nurse hears the voices that are telling him he should never have been born. The nurse's most appropriate response would be: "I don't hear any voices, but I believe you can hear them." "The voices are a symptom of your illness and will go away." "Sometimes I hear voices. What are your voices saying?" "The voices are coming from inside you. They aren't real."

"I don't hear any voices, but I believe you can hear them." Explanation: The nurse admitting that she doesn't hear voices but that she believes the client can hear them is an honest, straightforward response that acknowledges the truth without negating the reality of the client's experience. The voices may be a symptom of the client's illness, but telling him negates his feelings and sense of reality. Although asking what the voices are saying provides an opportunity for the client to talk further, a nurse who makes this statement identifies too much with the client's hallucinations and gives them undue credibility. Telling the client that the voices he hears aren't real discounts his experience of reality.

The nurse is performing an admission interview when the client attempts to shift the session focus to the nurse by asking personal questions. Which statement by the nurse is most appropriate? "It is preferred for the nurses to control the interview." "It is not appropriate for you to ask me personal questions." "What do you want to know about me?" "I have a family. Tell me about you and your family."

"I have a family. Tell me about you and your family." Explanation: The nurse's self-disclosure should be brief, vague, and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion should not dwell on the nurse's experience. Telling the client that the nurse should control the conversation or not give personal personal information could be considered argumentative.

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? "When I get my prosthesis, I want to learn to walk so I can participate in walk-a-thons." "I hope to get skilled enough at using my prosthesis to help others like me adjust." "Whenever I start to feel sorry for myself, I remember that my buddy died in that accident." "I hope I can handle having a prosthesis, but I am really wondering what my wife will think."

"I hope I can handle having a prosthesis, but I am really wondering what my wife will think." explanation: The client expressing doubts about his wife's response to his amputation as well as possible doubt on his part is still struggling with body image issues. Looking forward to participating in walkathons and helping others indicates plans for the future that imply an acceptance of his amputee status. Remembering that his friend died in the accident that caused his amputation indicates that the client is aware that there was a worse end result to the accident than his amputation.

While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? "I'm a nurse. I'm not poisoning you. That would be a violation of the nursing code of ethics." "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." "I'm not poisoning you. And how could I possibly steal your soul?" "I sense anger. Are you feeling angry today?"

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Explanation: The nurse should directly orient a delusional client to reality, especially to place and person. Denying poisoning and offering delusion-related information may encourage further delusions related to the delusion. Validating the client's feelings occurs during a later stage in the therapeutic process.

The nurse is preparing a client for surgery and notices that the client looks sad. The client says, "I am scared of having cancer. It is so horrible, and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client? "It's okay to be scared. What is it about cancer that you are afraid of?" "It's normal to be scared. I would be, too. We will help you through it." "Don't be so hard on yourself. You don't know if your smoking caused the cancer." "Do you feel guilty because you smoked?"

"It's okay to be scared. What is it about cancer that you are afraid of?" Explanation: Acknowledging the basic feeling the client expresses—fear—and asking an open-ended question allows the client to explain any fears. The other options dismiss the client's feelings and may give false reassurance or label the client's feelings. The client should be encouraged to explore feelings about a cancer diagnosis.

An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply. "Our child is just trying to get attention." "Our child needs to learn new coping skills." "Our child doesn't understand how this affects the family." "Our child would not do this again." "Our child will be fine in a couple of days."

"Our child is just trying to get attention." "Our child would not do this again." "Our child will be fine in a couple of days." Explanation: Suicide should not be seen just as attention-seeking behavior. It has very serious consequences and should never be minimized. To believe that such an attempt might not happen again or that the adolescent will have resolved the problems that led to the attempt in a couple of days shows a lack of understanding of the seriousness of the situation.

A home health nurse is caring for client of the Catholic faith with Amyotrophic Lateral Sclerosis (ALS) who is asking for assistance ending his life. Using the Code of Ethics for Nurses, what responses by the nurse are appropriate? Select all that apply. "I understand wanting to alleviate your suffering, but that is not the right way!" "Participation in assisted suicide violates my nursing code of ethics." "This is not a state that has enacted laws for physician assisted suicide." "Why you aren't thinking clearly, Catholics can't go to heaven after suicide." "Can you rate your pain on a 1 to 10 scale so I can give you pain medication now?"

"Participation in assisted suicide violates my nursing code of ethics." "This is not a state that has enacted laws for physician assisted suicide." Explanation: Explaining that helping with assisted suicide violates the code of ethics explains to the client why you are unable to help him. Informing him that assisted suicide is illegal in that state is important. Nurses should not be judgmental, accusatory, or offer opinions on religious choices or care options. The client did not state that they were in pain.

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling? "My primary care provider just put me on an antidepressant, and I will be fine in a week or so." "My daughter sent me here. She is mad because I do not have the energy to take care of my grandkids." "Since I have gotten over the death of my husband, I have had more energy and been more active than before he died." "My son got worried because I made this silly comment about wanting to be with my husband in heaven."

"Since I have gotten over the death of my husband, I have had more energy and been more active than before he died." Explanation: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.

A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. The nurse should respond by saying: "You need to act like an adult." "You know better than to use that language." "Others can hear you." "Stop! Swearing is not appropriate behavior."

"Stop! Swearing is not appropriate behavior." Explanation: The nurse sets limits on unacceptable or threatening behavior to help the client regain control and preserve his self-esteem. Saying "You need to act like an adult" is an authoritarian comment that shames the client and diminishes self-esteem. Saying "You know better than that" shames the client and diminishes self-worth. Saying "Others can hear you" is not helpful because it does not identify the unacceptable behavior.

A client is a 25-year-old pregnant mother of two children under the age of 6. She is a very protective mother and will not allow her children play outdoors for fear of tick bites. She tells the nurse that she feels "worn out" from cleaning the house from top to bottom every day. She asks the nurse how she can stop worrying so much. What is the most appropriate response from the nurse? "Have you considered spraying your children with an insect repellent?" "Tell me your concerns about the children playing in your backyard." "Why do you worry about the children getting tick bites?" "Have you sprayed your backyard for ticks or other pests?"

"Tell me your concerns about the children playing in your backyard." Explanation: Asking the client to express her concerns assists the client to identify thoughts that are improbable or distorted. This is the beginning of the process of restructuring her cognitive thoughts and reducing anxiety. Offering advice such as spraying the children or yard with insecticides would be incorrect because these responses offers advice and do not allow the client to express her feelings. Asking, "Why do you worry about the children getting tick bites?" is incorrect because it challenges the client to defend her irrational fears and does not help her develop insight.

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client: "The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." "The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life." "The radiation is necessary to treat your tumor." "Careful shielding prevents the area above your waist from radioactivity."

"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." Explanation: The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears. The time required for a radioactive substance to be half-dissipated is called its half-life, but this does not determine discharge time. The client receiving sealed internal radiotherapy is not discharged until the radioactive source is removed. While the radiation is necessary for treatment, telling the client this does not provide information to address her concerns. With cervical implants, there is no way to shield the area above the waist from radiation.

The daughter of a client with Alzheimer's disease tells the nurse that her mother thinks someone is stealing her things. Which response by the nurse would be most helpful?

"We asked the health care provider to evaluate your mother for paranoid delusions, which are common in people with Alzheimer's disease."

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best? "Who are 'they'?" "No one will see me." "You have no reason to be afraid." "What will happen if they do see me?"

"Who are 'they'?" Explanation: Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion.

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which of the following statements is the most therapeutic response by the nurse? "You don't need to worry at this point about too much pain medication." "I am sure the doctor has ordered the appropriate amount of narcotic." "You are concerned that the client is receiving too much narcotic medication?" "Do you want me to call the doctor now and explain that you are concerned?"

"You are concerned that the client is receiving too much narcotic medication?" Explanation: Using a reflective statement without judgment allows the family to elaborate so the nurse can answer the specific concerns. The other options are not correct because they do not promote more conversation to help the family gain a better perspective on the treatment.

A client comes to a community mental health clinic for a psychiatric evaluation at his family's request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting? Hypomania Delirious mania Acute mania Dementia mania

Acute mania Explanation: The client is demonstrating an expansive mood, high-energy level, racing thoughts, and disjointed thinking. Any type of stimulation will distract the client from the current conversation. This behavior is indicative of the acute manic phase of mania. Hypomania is a mania phase characterized by an abnormally elevated mood, signs of inflated self-esteem, decreased sleep, flight of ideas, and pleasure-seeking behaviors. This phase lasts for 4 days or less. The delirious mania phase is when the client exhibits signs and symptoms of mania and delirium. Dementia mania isn't a phase of mania.

A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. The nurse should suggest that the family join which organization? Al-Anon Make Today Count Emotions Anonymous Alcoholics Anonymous

Al-Anon Explanation: Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces and then states, "Bastard," under his breath. Which nursing action is most appropriate? Ignore the client because he appears to be hallucinating. Approach the client to interrupt the hallucinations. Suggest the client spend some time in his room. Remind the client that vulgar language is not appropriate in the hospital.

Approach the client to interrupt the hallucinations. Explanation: The nurse intervenes with the client experiencing hallucinations to assist with increasing the client's awareness that the hallucinations are not part of reality but are a symptom of illness. The nurse does not ignore the client because the hallucinations can continue and escalate. Sending him to his room ignores the client's need, permits him to engage in his psychosis, increases confusion, and increases withdrawn behavior. Stating that vulgar language is not permissible ignores and dismisses the client.

A client scans the adult inpatient unit on arrival at the hospital. The client is neatly dressed and clutches a leather briefcase. The client refuses to let the nurse touch the briefcase to check it for valuables or contraband. Which action by the nurse would be best? Obtain help to take the briefcase away from the client. Ask the client to open the briefcase and describe its contents. Inspect the briefcase when the client is temporarily out of the room. Tell the client that he must follow hospital policy if he wishes to stay.

Ask the client to open the briefcase and describe its contents. Explanation: When a client refuses to have his belongings checked for valuables or contraband according to hospital policy, the least threatening course of action is to ask him to open his briefcase while he describes its contents. Getting help to take the briefcase away from the client is a threatening maneuver. Inspecting the briefcase while the client is out of his room involves secrecy and is less desirable than an open discussion with the client. Telling the client that he must observe hospital policy if he wishes to stay is threatening and probably inaccurate as well.

Which of the following is an important consideration when the nurse is providing culturally competent care in a community clinic? Knowing about different cultural practices and generalizing when caring for clients from that culture Asking about cultural beliefs related to health, illness, treatments, and dietary practices Informing the client about preferred health interventions and making decisions for the client Explaining that multiculturalism means all cultures melding to assimilate into one culture

Asking about cultural beliefs related to health, illness, treatments, and dietary practices explanation: It is a nursing obligation to practice in a culturally sensitive and competent manner. This answer elicits key information regarding the client's beliefs, values, and cultural practices. This also indicates willingness to learn and be respectful of different beliefs and practices. Knowledge is important, but individualizing rather than generalizing is critical. The other choices are inaccurate because they involve making decisions for the client and explaining that the aim is for all cultures to become one.

A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which of the following would be a priority intervention by the nurse to establish whether the client can have an epidural? Call a consult with anesthesia for an epidural. Measure the intensity of her contractions. Assess cervical dilation. Assess her response to intravenous morphine.

Assess cervical dilation. Explanation: It is imperative that the epidural be administered when the woman is in active labor and at a cervical dilation of 4-5 cm to receive optimal effect. The nurse would first assess whether the client is eligible for an epidural before consulting anesthesia. Measuring the intensity of the client's contraction would not give the nurse the information needed to make a clinical judgment. The client's response to IV morphine would not determine the client's eligibility to an epidural.

A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. How should the nurse respond to the husband and his family? Refer the family to pastoral care services. Encourage the husband to come to terms with his own grief. Suggest that the health care provider (HCP) tell the children about the seriousness of their mother's illness. Begin education about strategies for communication with his children.

Begin education about strategies for communication with his children. Explanation: Without clear, consistent communication, the parent-child relationship may become strained during the illness and subsequent death of a parent. A great number of parents do not know how to communicate with their children, especially about difficult emotional topics at a time when they are also under great emotional stress. The nurse should begin by providing information and developmentally appropriate books about the grieving process for children. Referral to pastoral care services may be appropriate; however, the nurse's direct intervention of beginning education about strategies for communication will be of immediate and long-term benefit. The grieving process cannot be rushed for the husband, nor should an opportunity for the father and children to communicate and grieve together be delayed. Excluding children from participating in the grieving ritual does not shield them from the sorrow and sadness, and having the HCP tell the children does not promote health communication between the father and the children.

Members of which of the following religious traditions are likely to have the most stringent restrictions and parameters placed on their medical care? Christian Scientist. Hinduism. Protestantism. Buddhism.

Christian Scientist. Explanation: Christian Science places significant restrictions on the use of drugs, medical procedures, therapies, and surgeries. The scope of these restrictions greatly exceeds that dictated by Hinduism, Protestant Christianity, and Buddhism.

An adolescent girl with severe malnutrition is admitted to an acute care facility. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the care plan for this client, the nurse is most likely to include which nursing diagnosis? Hopelessness Powerlessness Chronic low self-esteem Deficient knowledge (nutrition)

Chronic low self-esteem Explanation: Young women with Chronic low self-esteem are at highest risk for anorexia nervosa because they perceive being thin as a way to improve their self-confidence. Hopelessness and Powerlessness are inappropriate nursing diagnoses because clients with anorexia nervosa seldom feel hopeless or powerless; instead, they use food to control their desire to be thin and hope that restricting food intake will achieve this goal. Anorexia nervosa doesn't result from a knowledge deficit, such as one regarding good nutrition.

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!" What is the nurse's best response? "I'm sorry! I just have to ask that question for the record." "It's an important question, and we just have to check." "You will hear it again and again as you go through surgery." "This question is asked for verification and safety with each new phase of treatment."

Clients should be made aware that some questions are asked for verification and safety with each new phase of treatment.

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of his spouse. Which nursing diagnosis is most appropriate for this client? Activity intolerance Complicated grieving Ineffective role performance Low self-esteem

Complicated grieving explanation: Behavioral manifestations of Complicated grieving include changes in eating habits, sleep patterns, and activity levels. Diagnoses of Activity intolerance, Ineffective role performance, and Low self-esteem don't include these defining characteristics.

A patient from Pakistan informs the nurse of his cultural dietary requests. The nurse responds to the special dietary needs by stating, "You are now living in the United States, and you should try to start eating those foods common to an American diet." This inappropriate response is an example of: Cultural imposition. Cultural blindness. Cultural diversity. Cultural assimilation.

Cultural imposition. Explanation: The nurse's response is an example of cultural imposition, which is defined as the belief that everyone should conform to the majority belief system. Cultural blindness is the result of ignoring differences and proceeding as though they do not exist. In this situation, the nurse did not ignore the request but inappropriately responded to it. Cultural diversity is defined as a diverse group in society, with varying racial classifications and national origins, religious affiliations, languages, physical sizes, genders, sexual orientations, ages, disabilities, socioeconomic statuses, occupational statuses, and geographic locations. Cultural assimilation occurs when members of a minority group live within a dominant group and lose the cultural characteristics that make them different.

A partner of a man diagnosed with Karposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that, "He has just given up. I know if he just takes the medication he will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving? Denial stage Anger stage Bargaining stage Depression stage

Denial stage Explanation: Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering.

A client with a diagnosis of schizophrenia is experiencing paranoia and tells the nurse that he hears a voice saying, "Don't take those poisoned pills from that nurse!" The nurse can report which of the following objective assessments regarding this statement? Impaired verbal communication related to disturbances in thought process as evidenced by use of symbolic references Disturbed thought processes related to anxiety as evidenced by delusions of persecution Disturbed perceptions related to anxiety as evidenced by auditory hallucinations Increased anxiety-related delusions of persecution evidenced by distorted thought content

Disturbed perceptions related to anxiety as evidenced by auditory hallucinations Explanation: Hallucinations are sensory experiences of perception without corresponding stimuli in the environment. This client objectively reports to the nurse the fearfulness and experience of this hallucination—a perceptual disturbance. This differs from the thought disorder (delusions). The other responses are not founded in objective information based on the client's statement.

The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which of the following steps must be a priority for the nurse? Discussing the nurse's experience in detail Asking for the client's perception of what the nurse has revealed Ensuring relevance to, and quickly refocusing upon, the client's experience Allowing the client time to ask questions about the nurse's experience

Ensuring relevance to, and quickly refocusing upon, the client's experience explanation: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, the discussion should not dwell on the nurse's own experience.

Which would be most helpful when coaching a client to stop smoking? Review the negative effects of smoking on the body. Discuss the effects of passive smoking on environmental pollution. Establish the client's daily smoking pattern. Explain how smoking worsens high blood pressure.

Establish the client's daily smoking pattern. Explanation: 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 client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Explain all physical care activities in simple, explicit terms as though expecting a response. Maintain a quiet atmosphere, speaking as little as possible to the client. Provide as much sensory stimulation as possible using conversation, radio, and television. Ask the client to do exactly the opposite of what is desired.

Explain all physical care activities in simple, explicit terms as though expecting a response. Explanation: A client in a stuporous state is not in a position to negotiate, discuss, or gather insight. At this stage of a psychotic experience, a client requires clear and simple explanations of all activities. Not speaking much would be confusing and increase anxiety, but excessive information and stimuli would also not benefit goal-directed activities.

A preschool-age child has been scheduled for a cardiac catheterization. What should the nurse do to help prepare the family for the procedure? Advise the family to bring the child to the hospital for a tour a week in advance. Explain that the child will need a large bandage after the procedure. Discourage bringing favorite toys that might become associated with pain. Explain that the child may get up as soon as the vital signs are stable.

Explain that the child will need a large bandage after the procedure. Explanation: The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child's anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent's lap.

A nurse is caring for a client with advanced cancer. Based on the accompanying nursing progress notes, what should be the nurse's next intervention? Reread the document on patient/client rights to the client. Call the client's spouse to discuss the client's statements. Tell the client that only in the hospital can there be adequate pain relief Explain the use of an advance directive to express the client's wishes.

Explain the use of an advance directive to express the client's wishes. Explanation: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his or her own wishes. This document can include a living will, which instructs the health care provider to administer no life-sustaining treatment, and a durable power of attorney for health care, which names another person to act on the client's behalf for medical decisions if the client cannot act for self. By explaining the use of an advanced directive to the client at this time, the client has the opportunity to document future wishes. The document on client rights does not specifically address the client's wishes regarding future care. Calling the spouse is a breach of the client's right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge of the resources available in the community through hospice and home care agencies in collaboration with the client's health care provider.

A child with leukemia had been in remission for several years, but death is now imminent. The nurse is assisting the parents as they prepare for the child's death. Which approach will be most helpful? Reflect to the parents that the death of a child is more difficult than that of an adult. Help parents understand that grief is stronger when preceded by hope. Recognize that the parents have been prepared for this death since the time of diagnosis. Understand the parent's trust in the health care system will be undermined by the death of their child.

Help parents understand that grief is stronger when preceded by hope. Explanation: Parents often experience greater grief when they have experienced the hope provided by the remission of their child's disease. The nurse allows the parents to express this grief. Reactions to death of a family member are not based on the age of the dying family member. No matter how well prepared the parents may be for the death of their child, it will not make coping with death easier. Family members may displace anger and frustration on the health care system and health care providers (HCPs), but death does not necessarily undermine trust.

The nurse is admitting a client with a history of bipolar mania. Which of the following assessment findings is the priority when developing a plan of care? Bizarre, colorful, inappropriate dress Grandiose thinking, poor concentration Insulting, provocative behavior directed at staff Hyperactivity, ignoring eating, and sleeping

Hyperactivity, ignoring eating, and sleeping Explanation: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least a week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractability; and excessive involvement in activities with a high potential for painful but unrecognized consequences. As the nurse plans the care for the client, the need most in jeopardy is the physiological need of nutrition, sleep, and mobility. These needs must be fulfilled before the higher needs of hygiene, cognition, and esteem can be met. The client is not unsafe at this time, only sexually preoccupied.

A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind? Do not probe into emotional issues. Do not ask very personal questions. Sit at the other corner of the room. Maintain eye contact while talking.

Maintain eye contact while talking. Explanation: While interviewing a client of Anglo descent, the nurse should maintain eye contact, because it indicates openness and sincerity. Such clients freely express positive and negative feelings; therefore, the nurse may probe into emotional issues. Anglo culture is an open culture, and members of this culture don't mind providing personal information. Also, clients of Anglo descent are not threatened by closeness, so the nurse does not have to sit in another corner of the room.

A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which other disorder? Personality disorder Mood disorder Thought disorder Amnestic disorder

Mood disorder Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, schizoaffective disorder refers to schizophrenia with elements of a mood disorder, either mania or depression. The prognosis is generally better for schizoaffective disorder than for the other types of schizophrenia, but it's worse than the prognosis for a mood disorder alone. Personality disorders and psychotic illness aren't listed together on the same axis. Schizophrenia is a thought disorder in itself. Clients with schizoaffective disorder don't have an amnestic disorder.

During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption? Accept this behavior because it is culturally based Observe how the client and the client's family interact with each other and with other staff members Read several articles about this cultural group and their behaviors Ask staff members of a similar cultural group about their habits and behaviors

Observe how the client and the client's family interact with each other and with other staff members Explanation: Assessing a client's interactions with others is a helpful way to determine the client's usual behavior patterns. This may also help a nurse determine what a behavior means to a client. Reading and consulting others about a cultural behavior pattern is useful only in assisting an understanding of an individual client after a nurse has had an opportunity to assess and observe the client directly. The nurse has to be able to assess and care for the client as an individual as well as a member of a cultural community.

While performing an assessment of a 75-year-old female in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately? Notify the nursing supervisor. Notify the physician. Obtain more information from the client about the nurse's findings. Follow the facility's policy and procedures for reporting elder abuse.

Obtain more information from the client about the nurse's findings. explanation: The nurse should try to obtain more information from the client to complete the assessment. Without supporting information, she shouldn't assume the bruises indicate abuse, and she shouldn't notify her nursing supervisor until she has obtained additional facts. She should, however, inform the physician so he can examine the client. She should follow the facility's policy and procedure for reporting abuse. The nurse should make a report if, after the assessment, she has a strong suspicion that abuse is the cause.

A nurse is obtaining a history from a client. The client reports that he is a waiter. When asked about his work environment, the client says, "If customers confront me for not being attentive enough, I just spit on their food." The nurse suspects the client is prone to which type of behavior? Obsessive-compulsive Narcissistic Passive-aggressive Dependent

Passive-aggressive Explanation: This client exhibits a negative attitude and passive-aggressive behavior in response to word demands for adequate performance. Clients who are passive-aggressive won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive behavior involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self-worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted.

A woman arrives at the emergency department with a fractured arm. Her husband is constantly present, and the woman appears anxious. What is the nurse's priority action? Privately ask the woman if she is being abused During triage inquire if the woman is in a safe environment Clearly state that all clients are asked about abuse prior to any treatment Provide the woman with a written pamphlet about domestic abuse

Privately ask the woman if she is being abused Explanation: It is a priority to privately ask the client if she is being abused. Counseling, or printed resources should be given privately. Clarifying that all clients are asked about abuse prior to any treatment allows for the client to understand why these questions are being asked.

In the community room, a nurse observes a client who suffers from depression. She sees the client pace swiftly around the room, swing both arms, and rub both hands together. What term should the nurse use to describe these behaviors to members of the health care team? Psychomotor agitation Tardive dyskinesia Compulsions Mania

Psychomotor agitation Explanation: Psychomotor agitation is defined by constant motion, such as pacing, wringing hands, biting nails, and other types of energetic body movements. Tardive dyskinesia occurs with long-term use of antipsychotic agents. It's characterized by irregular, repetitive, involuntary movements of the mouth, face, and tongue, including chewing, tongue protrusion, lip smacking, and rapid blinking. Compulsions are ritualistic actions that the client feels compelled to perform. A client with mania has inflated self-esteem, and displays an abnormal and persistently elevated, expansive, and irritable mood.

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first? Explain the effects of stress on the mind and body. Reassure the client that her feelings are typical reactions to serious trauma. Reassure the client that her symptoms are temporary. Acknowledge the unfairness of the client's situation.

Reassure the client that her feelings are typical reactions to serious trauma. Explanation: The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.

A child with leukemia fails to respond to therapy. Which statement offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death? Knowing that the prognosis is poor helps prepare relatives for the death of children. Relatives are especially grieved when a child does well at first but then declines rapidly. Trust in health personnel is most often destroyed by a death that is considered untimely. It is more difficult for relatives to accept the death of a 10-year-old than the death of a younger child whose family membership has been short.

Relatives are especially grieved when a child does well at first but then declines rapidly. Explanation: It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child's death, that trust in health personnel is destroyed when a death is untimely, or that it is more difficult for parents to accept the death of an older child than that of a younger child.

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard him express feelings of hopelessness to other residents. Which intervention should the nurse perform first? Setting aside time to listen to the client Removing items that the client could use in a suicide attempt Communicating a nonjudgmental attitude Referring the client to a mental health professional

Removing items that the client could use in a suicide attempt explanation: The nurse's first responsibility is to protect the client from injuring himself. Listening and being nonjudgmental are important elements of the nurse's communication with the client but aren't immediate priorities. After the client's safety has been established, he would benefit from a referral to a mental health professional.

A client in the manic phase of bipolar disorder constantly belittles other clients and is demanding special favors from the nurses. Which intervention by the nurse would be most appropriate for this client? Ask other clients and staff members to ignore the client's behavior. Provide the client with an anti-anxiety agent whenever his/her belittling or demanding behavior occurs. Set limits with specific and consistent consequences for belittling or demanding behavior. Offer the client a variety of stimulating activities to distract him/her from other clients and from making demands on the nurses.

Set limits with specific and consistent consequences for belittling or demanding behavior. explanation: The nurse will need to set limits and consequences for belittling and being demanding of others because this is inappropriate behavior. Requiring that others ignore the client is likely to increase those behaviors. Offering the client stimulating activities would be counterproductive, and providing the client with anti-anxiety medication, while useful at times, does not address the impact of the client's behaviors or provide motivation for the client to adjust his/her behaviors.

A nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan? Restrict visits with family members until the client begins to eat. Provide privacy for the client during meals. Set up a strict eating plan with the client. Encourage the client to exercise, which will reduce her anxiety.

Set up a strict eating plan with the client. explanation: Establishing a consistent eating plan and monitoring the client's weight are important for treatment of this disorder. Because control issues play a central part in anorexia nervosa, clients are likely to be more compliant if they take part in developing the eating plan. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

A client is admitted to a rural general hospital in an acute manic phase of bipolar disorder. The hospital has no acute psychiatric unit. How should the nursing team approach care for the client during the manic state until the client can be transferred? Setting limits, providing a low-stimulation environment, and maintaining a neutral attitude from the staff Offering high-calorie meals and insisting the client finishes all meals Allowing the client maximum opportunity for freedom and self-expression Insisting that the client remains active throughout the day so he/she will sleep

Setting limits, providing a low-stimulation environment, and maintaining a neutral attitude from the staff explanation: Nurses in a generalist setting should be aware of attending to the special needs of the mental health clients on the general unit. Management of the health care environment will benefit the client as well as other clients on the unit. The nurse should set limits and create a low-stimulation, neutral environment to facilitate de-escalation of the client's manic state. High-calorie finger foods can be offered to supplement a client's diet if he/she cannot remain seated long enough to complete a meal.

Which change does a nurse demonstrate when she helps a young mother adjust to the birth of her child? Unplanned Situational Maturational Physiologic

Situational explanation: adjustment to the birth of a child is an example of a situational change, which arises from interaction between individuals and their environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to maturation associated with puberty. Physiologic change refers to events associated with aging and menopause.

A nurse is counseling a client with cancer who is experiencing anxiety. Which goal will provide the best long-term client outcome? Keep follow-up appointments with psychiatrists. Understand medication effects and adverse effects. Take medication as prescribed. Solve problems independently.

Solve problems independently. Explanation: The ultimate outcome is to have the client solve problems by himself, collaborating in his own care. Client follow-up with the mental health providers, while desirable, does not ensure that the client will fully comply with treatment or medication. Knowledge of the medication's effects and adverse effects and compliance can help the client but alone will not ensure success unless the client knows how to address and solve problems independently.

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

Spiritual alienation Explanation: Spiritual alienation occurs when an individual is separated from her/his faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. Which nursing diagnosis is most appropriate? Ineffective coping Spiritual distress Complicated grieving Chronic sorrow

Spiritual distress Explanation: The defining characteristic of Spiritual distress includes anger and refusing to interact with spiritual leaders. While anger is part of the grieving process, there's no indication that the parents aren't coping effectively or experiencing Complicated grieving. Since Chronic sorrow, as the name implies, occurs over a period of time and may be cyclical, this isn't an appropriate nursing diagnosis since the death has just occurred.

A client is playing music loudly in the music room, and other clients are complaining about the volume. What should the nurse do? Redirect the client to another activity. State to the client what volume is and is not permissible. Turn down the volume and say nothing. Tell the other clients that the time to use the room is almost over.

State to the client what volume is and is not permissible. explanation: Setting limits here is essential. The nurse should set limits by stating to the client what volume is and is not permissible. Limit setting is the art of clearly identifying acceptable and unacceptable behaviors that are objective, fair, and reflective of the situation at hand. Limits should be identified clearly and early, especially with clients who may "test the system." Redirecting the client does nothing to establish limits and does not help the client recognize unacceptable behaviors. Turning down the volume and saying nothing does not identify the limits for the client and may lead to repetition of the same behavior. Telling the other clients that the time to use the music room is almost over may cause them to feel that the nurse is unfair and not respectful of their needs.

A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy? Support from her partner The month of her due date Previous health promotion activities Readiness at home for the baby

Support from her partner explanation: Many factors can influence the smoothness of a pregnant client's psychosocial transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy. The month of her due date and previous health promotion activities don't affect her psychological transition. Readiness for the baby at home usually affects the client during the third trimester, not in the second month.

A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply. Take a seat next to the client and sit quietly to reflect on what was said. Say to the client, "We all have days when we don't feel like going on." Leave the room to allow the client privacy to collect thoughts. Say to the client, "You're feeling upset about the news you got about the transplant." Say to the client, "The treatments are now 3 days a week. Would you be willing to do two days per week?"

Take a seat next to the client and sit quietly to reflect on what was said. Say to the client, "You're feeling upset about the news you got about the transplant." Explanation: Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain a conversation. By reflecting on the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse would not leave the client alone abruptly stopping therapeutic communication. Negotiating treatment frequency is not in the scope of practice of the nurse.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially? The client will discuss her feelings related to her losses. The client will identify two positive qualities. The client will explore her strengths. The client will prioritize problems.

The client will discuss her feelings related to her losses. Explanation: The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan.

What short-term goal for a client hospitalized with a stress related disorder is most realistic? The client will demonstrate a positive self-image. The client will describe plans for how to get back into school. The client will write a list of strengths and needs. The client will practice assertiveness skills in confronting his mother.

The client will write a list of strengths and needs. Explanation: Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self-assessment.

A client was admitted to the inpatient unit 3 days ago with a flat affect, psychomotor retardation, anorexia, hopelessness, and suicidal ideation. The health care provider (HCP) prescribed 75 mg of venlafaxine extended release to be given every morning. The client interacted minimally with the staff and spent most of the day in his room. As the nurse enters the unit at the beginning of the evening shift, the client is smiling and cheerful and appears to be relaxed. What should the nurse interpret as the most likely cause of the client's behavior? The venlafaxine is helping the client's symptoms of depression significantly. The client's sudden improvement calls for close observation by the staff. The staff can decrease their observation of the client. The client is nearing discharge due to the improvement of his symptoms.

The client's sudden improvement calls for close observation by the staff. explanation: The client's sudden improvement and decrease in anxiety most likely indicate that the client is relieved because he has made the decision to kill himself and may now have the energy to complete the suicide. Symptoms of severe depression do not suddenly abate because most antidepressants work slowly and take 2 to 4 weeks to provide a maximum benefit. The client will improve slowly due to the medication. The sudden improvement in symptoms does not mean the client is nearing discharge, and decreasing observation of the client compromises the client's safety.

A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse? The nurse should listen attentively and provide realistic verbal reassurance. The nurse should report the client statements to the physician. The nurse should proceed with the assessment and preparation for surgery. The nurse should request an anti-anxiety medication from the anesthesiologist.

The nurse should listen attentively and provide realistic verbal reassurance. explanation: Clients routinely experience preoperative anxiety. Nurses should use basic communication skills to reduce their apprehension. Other answers are incorrect because they don't address the client's immediate need.

Shortly after an infant is returned to his room following hydrocele repair, the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which response by the nurse would be most appropriate? "Let me see if the surgeon has prescribed aspirin for him. If he did, I'll get it right away." "Can you wait in his room? Then you can ask me any questions when I get there." "What you are describing is unusual after this type of surgery. I will let the surgeon know." "This is normal after this type of surgery. Let us look at it together just to be sure."

This is normal after this type of surgery. Let us look at it together just to be sure." Explanation: Some swelling and bruising are normal postoperatively. By assessing the area with the mother, the nurse is conveying acceptance of the mother's concern. In addition, the nurse needs to inspect the area to determine if what the mother is describing is accurate. Doing so also provides an opportunity for teaching. Aspirin is not usually prescribed for children because of the link between aspirin and Reye's syndrome. Acetaminophen is commonly administered for fever or pain relief. Asking the mother to wait in the child's room ignores the mother's concerns. There is no need to notify the surgeon at this time.

A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizes loudly in the community room. To prevent injury while complying with the principle of the least-restrictive environment, which action should the nurse take to prevent escalation of the client's mood? Place the client in seclusion with the door open. Obtain a court mandate for a higher level of treatment. Try to channel the client's energy into appropriate activities. Monitor the client for escalation of manipulative behavior

Try to channel the client's energy into appropriate activities. Explanation: Constructive activities, such as painting, are a positive way to prevent inappropriate or destructive use of the client's excessive energy. Placing the client in seclusion with the door open allows the client to leave the seclusion room; this action doesn't comply with the principle of providing the least-restrictive environment. It isn't appropriate for the nurse to obtain a court order for a higher level of treatment. Monitoring the client's behavior isn't as effective as intervening before a crisis occurs.

When developing a teaching plan for a group of middle school children about the drug 3,4-methylenedioxymethamphetamine (Ecstasy), what information should the nurse expect to include? Select all that apply. Using Ecstasy is similar to using speed. Ecstasy is used at all-night parties. Teeth grinding is seen with cocaine, not Ecstasy use. It can cause death. It reduces self-consciousness.

Using Ecstasy is similar to using speed. Ecstasy is used at all-night parties. It can cause death. It reduces self-consciousness. Explanation: Ecstasy is chemically related to methamphetamine (speed) and is used at all-night parties (also known as "raves") to enhance dancing, closeness to others, affection, and the ability to communicate. Euphoria, heightened sexuality, disinhibition, and diminished self-consciousness can occur. Adverse effects include tachycardia, elevated blood pressure, anorexia, dry mouth, and teeth grinding. Pacifiers, including candy-shaped pacifiers and lollipops, are used to ease the discomfort associated with teeth grinding and jaw clenching. Hyperthermia, dehydration, renal failure, and death can occur.

hydrocele

a fluid-filled sac in the scrotum along the spermatic cord leading from the testicles

A 20-year-old single parent brings her 3-year-old son into the emergency department because he "fell." The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, "Sometimes I guess I am pretty rough with him. I am alone, and I just do not know how to manage him." The nurse should ask the mother if she would find it helpful to have a referral to: a support group for single parents. a parenting education program. a women's support group. a support group for abusive parents.

a parenting education program explanation: The mother's statements reveal that she is having problems with parenting. Therefore, a referral to a parenting education program is the most appropriate measure at this time.

A nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's: feelings. blocking. mood. affect.

affect explanation: Affect refers to a person's emotional expression (in this case, the manner in which the client talks about her experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.

Karposi's sarcoma (KS)

an HIV-related cancer that causes the growth of purple/red patches on the skin and other areas in the body

A client is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: antisocial personality disorder. borderline personality disorder. obsessive-compulsive personality disorder. narcissistic personality disorder.

antisocial personality disorder. Explanation: This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.

A client with schizophrenia tells the nurse that he does not go out much because he does not have anywhere to go and he does not know anyone in the apartment where he is staying. Which action is most beneficial for the client at this time? encouraging him to call his family to visit more often making an appointment for the client to see the nurse daily for 2 weeks thinking about the need for rehospitalization for the client arranging for the client to attend day treatment at the clinic

arranging for the client to attend day treatment at the clinic Explanation: Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client's needs off. Lack of social relationships is not a sufficient reason for rehospitalization.

What is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? repeating the directions until the client follows them asking the client to do one step of the task at a time demonstrating for the client how to do the task maintaining routine and structure for the client

asking the client to do one step of the task at a time Explanation: Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy would most the nurse expect to see included in the plan of care? insight therapy group therapy behavior therapy psychoanalysis

behavior therapy Explanation: The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder.

Which suggestion would be most helpful to the parents of a 2-year-old child when managing separation anxiety during hospitalization? Leave while the child is sleeping. Bring the child's favorite toys from home. Tell the child the time they are leaving and returning. Keep the visit time short.

bring the child's favorite toys from home explanation: Bringing a child's favorite toys, security blanket, or familiar objects from home can make the transition from home to hospital less stressful. The child receives comfort and reassurance from these items. Leaving without explaining may decrease the child's trust in the parents, ultimately adding to the child's level of anxiety. The parents should tell their toddler when they are leaving and when they will return, not by time but in relation to the child's usual activities (e.g., by bedtime). Typically, 2-year-old children have a limited sense of time. Short parental visits do not satisfy a toddler's overwhelming need for comfort because toddlers need to spend lots of time with parents due to separation anxiety.

The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care? leading a group activity watching television reading the newspaper cleaning the dayroom tables

cleaning the dayroom tables Explanation: The client with mania is very active and needs to have this energy channeled in a constructive task such as cleaning or tidying the dayroom. Because the client is distracted easily and can concentrate only for short periods, the successful completion of a helpful task would give the nurse the opportunity to thank the client for the help, thereby enhancing the client's self-esteem. Leading a group activity is too stimulating for the client. Participating in this type of activity also may cause the client to be disruptive. Watching television or reading the newspaper would be inappropriate for the client who cannot sit for a period of time.

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on: consistently enforcing unit rules and facility policy. isolating the client to decrease contact with easily manipulated clients. engaging in power struggles with the client to minimize manipulative behavior. using behavior modification to decrease negative behavior by using negative reinforcement.

consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these baby angels flying around my head." While waiting for medical and psychiatric consults, which needs have the highest priority? Select all that apply. decreasing as much "foreign" stimuli as possible avoiding challenging the client's perceptions about "baby angels" orienting the client about his medical condition gently presenting reality as needed calling the client's family to report his onset of dementia

decreasing as much "foreign" stimuli as possible avoiding challenging the client's perceptions about "baby angels" gently presenting reality as needed Explanation: The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate, but orienting the client to his condition is unlikely to be helpful. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.

A client who has had a total laryngectomy appears withdrawn and depressed. He keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would be most therapeutic for the client? discussing his behavior with his wife to determine the cause exploring his future plans respecting his need for privacy encouraging him to express his feelings nonverbally and in writing

encouraging him to express his feelings nonverbally and in writing Explanation: The client has undergone body changes and permanent loss of verbal communication. He may feel isolated and insecure. The nurse can encourage him to express his feelings and use this information to develop an appropriate plan of care. Discussing the client's behavior with his wife may not reveal his feelings. Exploring future plans is not appropriate at this time because more information about the client's behavior is needed before proceeding to this level. The nurse can respect the client's need for privacy while also encouraging him to express his feelings.

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? engaging in play therapy role-playing giving the child's drawings to the abuser reporting the abuse to a prosecutor

engaging in play therapy Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is mandatory, but does not help the child express feelings.

client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? helping the client feel safe and accepted introducing the client to other clients giving the client information about the program. providing the client with clean, comfortable clothes

helping the client feel safe and accepted explanation: The initial priority for this client is to help her overcome suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to: avoid shopping for large amounts of food. control eating impulses. identify a connection between anxiety and eating behaviors. restrict eating to three meals per day.

identify a connection between anxiety and eating behaviors. Explanation: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which of symptoms can the nurse anticipate that the client will have? impulsive acts of aggression sleep disturbance unable to recognize objects by touch difficulties with speech

impulsive acts of aggression Explanation: Impulsive acts of aggression and violence have been linked to dysregulation of the amygdala. The hypothalamus regulates basic human activities such as sleep-rest patterns. The parietal lobe contains the primary somatosensory area. The temporal lobes contain the primary auditory areas.

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior? resumption of former lifestyle increase in energy level at the point of deepest despair willingness to visit with an estranged brother

increase in energy level Explanation: The client's energy level is related to the danger involved. Suicide attempts are more likely carried out when the client has more energy to act on thoughts and impulses. A client may not have the energy to commit suicide during times of severe depression. Resuming a former lifestyle is usually a sign of improvement unless the lifestyle places the client in danger. Visiting an estranged sibling does not indicate that a suicide attempt is imminent.

Which client action should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy? insisting on wearing a T-shirt and gym shorts rather than pajamas avoiding interactions with other adolescents on the nursing unit refusing to fill out the menu, and allowing the nurse to do so not taking telephone calls from friends so he can rest

insisting on wearing a T-shirt and gym shorts rather than pajamas Explanation: Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism.

An elderly woman experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider (HCP) to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the woman: is experiencing the onset of Alzheimer's disease. is having trouble adjusting to living alone without her husband. is having delayed grieving related to her Alzheimer's disease. is experiencing delirium and a urinary tract infection (UTI).

is experiencing delirium and a urinary tract infection (UTI). explanation: Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit? watching television visiting with family reading the newspaper keeping the door closed to provide privacy

keeping the door closed to provide privacy explanation: Keeping the client's door closed is likely to contribute to feelings of isolation and sensory deprivation. Such activities as watching television, visiting with a relative, and reading a newspaper help prevent sensory deprivation and yet do not require physical effort.

A client in a long-term nursing care facility who decides to be placed on hospice care expresses to the nurse, "I have outlived my family and friends; I have lost hope and there is no need for me to continue on." What underlying client concerns would the nurse first address with this client? loneliness and feelings of isolation a sense of frustration and depression perceptions of survivor guilt and shame negative mood and mental illness

loneliness and feelings of isolation Explanation: At end-of-life when a person expresses a deep sense of loss, emptiness, and no hope for quality of life, it is frequently a reflection of severe loneliness and isolation. The client is experiencing more than frustration leading to depression, and survivor guilt is typically associated with a traumatic event. The current situation can negatively affect the client's mood, but it is not an indication of an incipient mental illness.

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: is responding appropriately to the antipsychotic. may be experiencing increased energy and is at increased risk for suicide. is ready to be discharged from treatment. is experiencing a split personality.

may be experiencing increased energy and is at increased risk for suicide. Explanation: As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until his risk of suicide has diminished. His elevated mood is a response to the antidepressant, not an indication of a split personality.

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first? family support marital communication financial concerns medication compliance

medication compliance Explanation: Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances, can be addressed as client stabilization is maintained.

A 15-year-old is a heavy user of marijuana and alcohol. When the nurse confronts the client about his drug and alcohol use, he admits previous heavy use in order to feel more comfortable around peers and achieve social acceptance. He says he has been trying to stay clean since his parents found out and had him seek treatment. When the nurse develops a plan of care with the client, what should be the highest priority to help him maintain sobriety? peer recognition that does not involve substance use support and guidance from his parents a strict no-drug policy at his high school the threat of legal charges if caught drinking or smoking marijuana

peer recognition that does not involve substance use Explanation: Peer acceptance and recognition is a very powerful force in the lives of adolescents, leading to positive or negative behavior depending on the child's peers. While the influence of parents remains strong, peer acceptance combined with the adolescent's desire for independence can lead to disobeying the parents. The sanctions provided at school and in the community by law enforcement will support those teens that have other support in their lives, but are generally not sufficient to prevent substance use in adolescents lacking support at home and with peers.

The nurse answers a call on a telephone hotline from a man who was at the crisis center once in the past when he made a suicide threat. The client says, "Do not try to help me anymore. This is it. I have had enough and I have a gun in front of me now." Then he hangs up the telephone. Which call should the nurse make first? client, to make an attempt to calm him police, to request their intervention client's wife at work, to suggest she hurry home neighbor, to request he go to the client's home immediately

police, to request their intervention explanation: The nurse's first responsibility when a client threatens suicide is to do whatever can be done most quickly to protect the client from himself. When the nurse is in a crisis center and the client is at home, it is best to call the police to intervene. They will be able to reach the client quickly and are experienced in handling such situations. It is appropriate to err on the side of safety rather than to assume that the client is not serious about a suicide threat. Attempting to call the client first would be a serious error in judgment because the client has a lethal means, a gun, readily available and is in immediate danger of killing himself. Asking the client's wife of neighbor to intervene is inappropriate because it may cause either to be hurt, especially since the client has a weapon.

A man is brought to the hospital by his wife, who states that he has refused all meals for the past week and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. A physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: preoccupation with persecutory delusions, anxiety, anger, and potential for violence. severe mood swings and periods of low to high activity. multiple personalities, one of which is more destructive than the others. auditory and tactile hallucinations.

preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Explanation: Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior are commonly evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. Severe mood swings and periods of low to high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; tactile hallucinations are more common in organic or toxic disorders.

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client? insight oriented medication management problem solving reality orientation

reality orientation Explanation: Because the client has confusion, short-term memory loss, and a short attention span, a reality-orientation group is recommended to help the client maintain an optimal level of functioning, decrease isolation, and increase self-esteem. Focus is on the "here and now" and provides reality testing, structure, and social support. A client with a cognitive disorder is unlikely to benefit from an insight-oriented group, where the focus is on role relationships. Short-term memory loss and confusion interfere with the ability to learn about medication management and the ability to describe and solve problems.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief? denial shock bargaining anger

shock Explanation: After a neonate is diagnosed with a birth defect, parents often go through stages of grief similar to those they would have if they had lost the child. The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition.

A right orchiectomy is performed on a client with a testicular malignancy. The client expresses concerns regarding his sexuality. What information should the nurse give the client to address his concerns? The client: is not a candidate for sperm banking. should retain normal sexual drive and function. will be impotent. will have a change in secondary sexual characteristics.

should retain normal sexual drive and function. Explanation: Unilateral orchiectomy alone does not result in impotence if the other testis is normal. The other testis should produce enough testosterone to maintain normal sexual drive, functioning, and characteristics. Sperm banking before treatment is commonly recommended because radiation or chemotherapy can affect fertility.

A client walks into the clinic and tells the nurse she has run out of money for crack, has crashed, and wants something to help her feel better. Which factor is most important for the nurse to assess? suspiciousness loss of appetite drug craving suicidal ideation

suicidal ideation Explanation: The nurse assesses the client for feelings of depression and suicidal ideation. After experiencing an instantaneous high from crack, a crash immediately follows, and the client has an intense craving for more crack. A crash commonly leads to a cocaine-induced depression when additional crack is unavailable. At times, the depression is so severe that users attempt suicide. Although suspiciousness, loss of appetite, and drug craving are also associated with cocaine use, they are less of a priority than suicidal ideation.

The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply. taking vital signs monitoring intake and output placing the client in restraints as a safety measure reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary

taking vital signs monitoring intake and output reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary Explanation: For the client experiencing symptoms of alcohol withdrawal, the nurse monitors vital signs and intake and output, reinforces reality for the client who is confused, disoriented, or hallucinating, explains that the symptoms of withdrawal are temporary, reduces stimulation, and stays with the client if he is confused or agitated. The nurse administers medications to prevent the progression of symptoms, such as seizures and delirium tremens, and to ensure the client's safety. Restraints are not used as a precautionary measure. Restraints are used only as a least restrictive measure to protect the client and others when the client is a danger to himself or others.

While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last drink was about an hour ago. This information helps the nurse to determine which factor? the severity of the disease the severity of withdrawal symptoms the possibility of alcoholic hallucinosis the occurrence of delirium tremens

the severity of withdrawal symptoms Explanation: The client's response helps the nurse determine the severity of withdrawal symptoms because the length and extent of drinking alcohol has an effect on the severity of symptoms the client experiences during withdrawal. Decreased use of alcohol can also result in withdrawal symptoms in the client who has developed a high tolerance to alcohol and is physically dependent. The severity of the disease, the possibility of hallucinations, and the occurrence of delirium tremens are not determined by the information given. The diagnosis of alcohol dependency is just that—it is not classified as mild, moderate, or severe. Alcoholic hallucinosis is a state of auditory hallucinations that develops about 48 hours after the client has stopped drinking. The client hears voices or noises within the context of a clear sensorium, meaning that the auditory hallucination is the only symptom the client experiences. Severe withdrawal symptoms that are not managed medically can progress to delirium tremens or a severe abstinence syndrome. Delirium tremens occurs about 3 to 5 days after the client's last drink and is characterized by confusion, agitation, severe psychomotor activity, hallucinations, sleeplessness, tachycardia, elevated blood pressure, elevated temperature, and possibly seizures.