Passpoint - Basic Psychosocial Needs

A licensed practical nurse is attending an in-service program about postpartum affective disorders. The LPN demonstrates understanding of the information by identifying that which percentage of postpartum clients experience "postpartum blues"? 90% 30% 20% 80%

80%

The mother of a three-year-old has been told that her child has a brain tumor. She initially begins to cry and accuses the physician of lying. Which of the following stages is the mother most likely experiencing? psychotic episode acceptance denial anger

anger

A client on an inpatient psychiatric unit is pacing the hallway and appears agitated. When nurse approaches, the client says loudly, "Leave me alone." Which response by the nurse would be best? Say nothing and pace with the client. Summon help in case the client becomes aggressive. Say, "You sound upset. I'd like to help." Say "okay" and walk away.

Say, "You sound upset. I'd like to help."

A client is admitted to the inpatient unit of a mental health center with a diagnosis of schizophrenia, shouting, "The government of France is trying to assassinate me!" Which response by the nurse would be most appropriate? "This is unlikely. You are safe here, but you must feel frightened by this." "You've got to be wrong. France is an ally of the United States. Their government wouldn't try to kill you." "A foreign government is trying to kill you? Please tell me more about it." "You're wrong. Nobody is trying to kill you."

"This is unlikely. You are safe here, but you must feel frightened by this."

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle? Maturation Relevance Initiative Motivation

Relevance

A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best? "I'll tell you what the monitors show." "It's too early to tell anything." "I can't answer that question." "I don't know for sure."

"I'll tell you what the monitors show."

A hospitalized client becomes angry and belligerent toward a nurse after speaking on the phone with a parent. The nurse learns that the parent cannot visit as expected. Which interventions might the nurse use to help the client deal with the displaced anger? Select all that apply. Assist the client in identifying alternate ways of approaching the problem. Suggest that the client direct the anger at his mother. Explore the client's unmet needs. Avoid the client until he apologizes. Invite the client to a quiet place to talk.

Explore the client's unmet needs. Invite the client to a quiet place to talk. Assist the client in identifying alternate ways of approaching the problem.

The nurse at a substance abuse center is talking to a probation officer on the phone. The probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement best describes the nurse's response? correct because she didn't give out information about the client a breach of the principle of veracity because the nurse is misleading the officer a violation of confidentiality because she informed the officer that the client wasn't there illegal because she's withholding information from law enforcement agents

a violation of confidentiality because she informed the officer that the client wasn't there

A nurse is caring for a client who practices the Mormon faith. Which nursing actions would be most helpful in meeting the client's spiritual needs? Select all that apply. offering to contact a clergy member to provide support to the client supporting the client's decision not to accept blood transfusions accepting belief in divine healing through "laying on of hands" providing tea or coffee as the fluid to accompany the client's meals allowing the client to wear a special undergarment, even during hygiene procedures

accepting belief in divine healing through "laying on of hands" offering to contact a clergy member to provide support to the client

A nurse cares for a client who reports experiencing feelings of loss, grief, and intense sadness since the death of the client's spouse. Which stage of death and dying should the nurse determine this client is in? acceptance depression denial anger

depression

A nurse is reinforcing preoperative education with a client who is expressing concerns about a breast mass. In this session, the nurse places a hand gently on the client's shoulder and asks if the client would like to talk about the client's feelings. What emotion is the nurse conveying to the client? sympathy pity empathy indifference

empathy

A client with advanced cancer is about to begin hospice care at home. Which statement shows that the client understands the primary focus of hospice care? "It will provide skilled nursing care." "It will enhance the quality of my life." "It will prolong what's left of my life." "It will eliminate pain and discomfort."

"It will enhance the quality of my life."

A nurse is obtaining data on a child with epiglottitis. Which action by the nurse is appropriate? Obtain a flashlight and tongue blade. Obtain a sterile tongue blade and Culturette swab. Ask the registered nurse to visualize the child's throat. Wait for visualization to be done by the anesthesiologist.

Wait for visualization to be done by the anesthesiologist.

A client becomes extremely agitated and attempts to remove the endotracheal tube. The primary health care provider orders physical restraints. Which action indicates that the nurse has correctly applied the restraints? The restraint is attached to the side rails. The hands are restrained tightly and cannot be moved. Leather restraints are applied. A quick-release knot is used to tie the restraint.

A quick-release knot is used to tie the restraint.

The nurse is caring for a client with dementia that has a tendency to wander into other client areas, posing a safety risk for the client and others. Which method would be most beneficial for this client to promote safety that is the least restrictive? Have the client sit in a reclining chair with a sheet tied around them. Use an electronic monitoring system. Place a lap tray on a wheelchair. Place the client in the bed with four side rails elevated.

Use an electronic monitoring system.

A client who arrives for a follow-up visit after a severe wrist fracture 3 months ago is tearful and expresses helplessness, frustration, and anxiety over the event. The client's level of function is severely compromised. Which response by the nurse would be best? "You're overly anxious. These injuries take time to heal, and you just have to be patient with the process." "I know how you must feel. I broke my arm a long time ago, but I'm fine now. You'll be as good as new soon." "I can see how upsetting this is for you. It must be very difficult to be unable to function independently." "I know it's difficult, but do you have anybody that you can ask to come help you out until things get better?"

"I can see how upsetting this is for you. It must be very difficult to be unable to function independently."

A nurse working with the family of a client with Alzheimer's disease notes that the client's spouse is too exhausted to continue as the sole caregiver. The adult children live too far away to provide relief on a regular basis. Which nursing interventions would be most helpful? Select all that apply. Suggest that the spouse seek psychological counseling to help cope with exhaustion. Call a family meeting to tell the absent children that they must participate in the client's care. Recommend community resources for adult day care and respite care. Recommend that the client be placed in a long-term care facility. Ask whether friends can help with errands or provide short periods of relief. Encourage the spouse to talk about the difficulties of care giving.

Recommend community resources for adult day care and respite care. Encourage the spouse to talk about the difficulties of care giving. Ask whether friends can help with errands or provide short periods of relief.

To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as clarification. Which statement is an example of the clarification technique? "For now, I would like to concentrate on...." "How is it going?" "What do you mean when you say...?" "You say you aren't concerned, but you've asked me many questions on this same subject."

"What do you mean when you say...?"

A client is brought to the crisis unit by the police after having escaped unharmed from an apartment fire caused by the client smoking in bed. The nurse observes the client sitting silently, almost motionless. Which response by the nurse would be best? "Boy, that must have been scary. You must consider yourself very lucky." "You've been through a very difficult experience. Let's move to a quiet area so we can talk." "I hope you won't smoke while you are in bed anymore and that you learned your lesson today." "Would you like to change your clothes? The odor of smoke must be very disturbing."

"You've been through a very difficult experience. Let's move to a quiet area so we can talk."

The nurse is caring for a terminally ill client with cancer who is receiving hospice services with an advance directive. Which nursing action is a priority? Monitor airway status and prepare to assist with intubation. Assist with the administration of chemotherapeutic agents. Maintain hydration status with IV fluids. Care for elimination needs.

Care for elimination needs.

A nurse is caring for a client with a terminal illness. The nurse determines that a client has entered the first stage of the grieving process when the client makes which statement? "I can go in peace. I saw the wedding." "I did everything I was supposed to do and what good did that do?" "I just want to see my daughter get married. Then, I can go." "I think they mixed up my test results."

"I think they mixed up my test results."

When the nurse enters a client's room, the client frowns and states, "I've had my light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." Which statement(s) by the nurse would be the most therapeutic? Select all that apply. "Your concerns are very important to me. Please tell me about them." "Are you ready for your medications?" "I understand that you must be frustrated. What can I do to help you?" "You seem upset this morning." "I'm sorry; I was busy with another client."

"I understand that you must be frustrated. What can I do to help you?" "You seem upset this morning." "Your concerns are very important to me. Please tell me about them."

A toddler is in the hospital. Which response to the parents, who are concerned about the seriousness of the child's illness, would be the most appropriate? "If you look around, you'll see other children who are much sicker." "What seems to concern you about your child being hospitalized?" "It must be difficult for you when your child is ill and hospitalized." "Please try not to worry. Your child will be fine."

"It must be difficult for you when your child is ill and hospitalized."

A client exhibits signs of mild anxiety. Which response by the nurse is most likely to reduce the client's anxiety? "Everything will be fine. Don't worry." "Read this manual and then ask me any questions you may have." "Why don't you listen to the radio?" "Let's talk about what is bothering you."

"Let's talk about what is bothering you."

A geriatric client is admitted to acute care following a fall. The client is only able to provide a name during the admission phase. The caretaker reports that the client is usually alert and oriented and expresses concern about the client's confusion. Which response is most appropriate? "The client may have bumped his/her head in the fall." "Depression can cause confusion in older adult clients." "Stress related to an unfamiliar situation can cause short-term confusion in older adult clients." "Altered long-term memory can be sudden."

"Stress related to an unfamiliar situation can cause short-term confusion in older adult clients."

The nurse is gathering data from a newly admitted client. The client states, "I have been taking my high blood pressure medicine, but not like I am prescribed to take it." Which response is appropriate for the nurse to make in response to this information? "Tell me what you mean by not taking the medicine as prescribed." "Have you been taking the medicine every day?" "I would like to concentrate on how you have been taking your medicine." "I heard you say that you aren't taking your medicine."

"Tell me what you mean by not taking the medicine as prescribed."

Which statement indicates that a newly hired nurse needs further training regarding confidentiality? "I can't discuss your client's condition in the hallway, doctor. Let's move into the conference room." "Thank you for stopping by to see your neighbor. She's in surgery right now, but I'd be glad to update you on how she has been doing." "I'd be happy to discuss your care plan with your daughter, but first I need your signature giving me permission to do so." "I understand your need for the health record, but even though you're a representative of the insurance company, I can't divulge that information without my client's consent."

"Thank you for stopping by to see your neighbor. She's in surgery right now, but I'd be glad to update you on how she has been doing."

A client is being admitted to the facility and the spouse asks the nurse why they must sign a statement confirming the client is informed of rights to communicate wishes about life support and resuscitation. Which statement(s) by the nurse are congruent with Health Insurance Portability and Accountability Act regulations? Select all that apply. "We want to be sure that the client is able to make an informed decision about the care they choose to receive." "Everyone has to sign this. We need to know what we should do in case something unexpected happens." "It is important for your spouse as a consumer of health care to be able to have specific rights regarding health care and to have their wishes respected." "I hate talking about this because it may upset you, but federal law requires her to sign this and there is nothing we can do." "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." "We want to be sure that the client is able to make an informed decision about the care they choose to receive." "It is important for your spouse as a consumer of health care to be able to have specific rights regarding health care and to have their wishes respected."

A client taking antidepressant medication reports a decreased desire for sex, which is causing significant marital stress. Which response by the nurse would be most appropriate? "Doesn't your spouse understand the importance of your medication?" "Don't stop taking the medication." "What are your thoughts on how you should handle this?" "Have you discussed this with your health care provider?"

"What are your thoughts on how you should handle this?"

The nurse is trying to establish rapport with a newly admitted client. Which statements will facilitate effective communication? Select all that apply. "Tell me about your treatment so far." "Everything will be all right." "What did your physician tell you about your need for hospitalization?" "Did you take your medicine yesterday?" "Why are you crying?"

"What did your physician tell you about your need for hospitalization?" "Tell me about your treatment so far."

A pregnant client in the first trimester comes to the clinic. During the visit, the client says, "My husband is so excited, but I'm worried because I'm not feeling the same way. Does this mean that I will be a bad mother?" Which response by the nurse would be most appropriate? "What you're feeling right now is entirely normal for where you are at this stage." "You are right to be concerned. Let's see if we can get you some counseling." "It's best to talk this over with your husband so he can help you out when the baby comes." "Maybe you should try discussing your feelings with someone who is emotionally close to you."

"What you're feeling right now is entirely normal for where you are at this stage."

A mother asks a nurse about measures for disciplining her toddler. Which recommendation by the nurse is best? "When using a time-out, make sure your child knows the rules ahead of time." "Use a time-out, but limit the time-out to 2 minutes per year of age." "Provide your child with a detailed explanation of why the behavior leading to a time-out is unacceptable." "Place your child in a stimulating environment for time-out."

"When using a time-out, make sure your child knows the rules ahead of time."

An older adult client, who is admitted for treatment of a colon tumor, asks the nurse, "Do I have cancer?" Which responses by the nurse demonstrate therapeutic communication? Select all that apply. "Your physician can discuss this in more detail." "You sound concerned about what is happening." "You'll have to have some tests before cancer can be ruled out." "Most people your age develop some type of colon problem." "What has your physician told you about your treatment so far?"

"You sound concerned about what is happening." "What has your physician told you about your treatment so far?"

An older adult client's husband tells the nurse he's concerned because his wife insists on talking about events that happened to her years ago. The nurse finds the client alert, oriented, and answering questions appropriately. Which statement made to the husband is correct? "Your wife should be discouraged from talking about the past." "Your wife is reviewing her life." "Your wife is regressing to a more comfortable time in the past." "A spiritual advisor should be notified."

"Your wife is reviewing her life."

A nurse is caring for a terminally ill client. Place the following five stages of death and dying described by Elisabeth Kübler-Ross in the order in which they occur. 1 bargaining 2 denial and isolation 3 acceptance 4 depression 5 anger

1 denial and isolation 2 anger 3 bargaining 4 depression 5 acceptance

Which nursing intervention is best to help a 2-year-old child adapt to a hospitalization? Allow the child to have any favorite toys. Explain procedures in simple terms. Allow the child to play with equipment used on him. Ask one or both parents to stay with the child.

Ask one or both parents to stay with the child.

A client in college who has recently been diagnosed with human papillomavirus (HPV) infection comes to the health clinic and is anxious and tearful. Which nursing intervention would be most appropriate? Discuss the dangers of multiple sex partners. Provide the client with reliable information about this condition. Refer the client to a gynecologist. Ask the client to discuss concerns.

Ask the client to discuss concerns.

The nurse overhears a group of students discussing their client in the elevator. What is the nurse's best action? Select all that apply. Ask the students not to discuss the client among themselves. Complete an incident report and submit to the nurse manager. Ignore the students and continue on. Notify the instructor about the students' violation of client confidentiality. Ask them to take the conversation to a private place.

Ask the students not to discuss the client among themselves. Notify the instructor about the students' violation of client confidentiality.

The nurse is admitting a client who is a suspected to be a victim of domestic abuse. Which actions should the nurse take? Select all that apply. Assess the client's readiness to leave. Refer the client to a substance abuse program. Question the client regarding barriers to leaving the situation. Assess the client's knowledge of available resources. Consult with social services for temporary assistance.

Assess the client's readiness to leave. Assess the client's knowledge of available resources

An 18-year-old client who died in a car accident has an organ donation card consenting to donate both kidneys. Which nursing action is done immediately after the client is pronounced dead? Ask the family to sign consent to harvest the organs. Contact the organ procurement organization (OPO). Call the doctor to begin harvesting the organs. Contact the organ procurement and transplantation network (OPTN).

Contact the organ procurement organization (OPO).

While providing care for a married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The colors of the ecchymotic areas range from blue to purple to yellow. When the nurse asks the client how she got the bruises, the client responds, "Oh, I tripped." How should the nurse respond? Select all that apply. Contact the local authorities to report suspicions of abuse. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. Tell the client that she needs to leave the abusive situation as soon as possible. Assist the client in developing a safety plan for times of increased violence. Provide the client with telephone numbers of local shelters and safe houses. Call the client's husband to arrange a meeting to discuss the situation.

Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. Assist the client in developing a safety plan for times of increased violence. Provide the client with telephone numbers of local shelters and safe houses.

A client in a senior center informs the nurse, "My spouse recently passed away and a few weeks later two of my friends and a family member died." Which action should the nurse implement to assist this client? Recommend that the client move on with life. Suggest that the client move into a senior residence. Ignore the client's statements because it is part of grieving. Encourage the client to seek grief counseling.

Encourage the client to seek grief counseling.

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? Obtain a thorough health history from the client. Explore her own personal beliefs and feelings about contraception. Help determine the most appropriate contraceptive method for the client. Perform a complete physical assessment of the client.

Explore her own personal beliefs and feelings about contraception.

A nurse receives a change-of-shift report for an older adult client who had a total hip replacement. The client is not oriented to time, place, or person and attempts to get out of bed, pulling out an IV line that is supplying fluids and antibiotics. The client's primary health care provider ordered a vest restraint and bilateral soft wrist restraints. Which actions by the nurse would be appropriate? Select all that apply. Frequently monitor and document the behavior that requires continued use of restraints. Tie the restraints in quick-release knots. Tie the restraints to the side rails of the bed. Ask the client they need to go to the bathroom; provide range-of-motion (ROM) exercises every 2 hours. Position the vest restraints so that the straps are crossed in the back. Document the client's response to the intervention.

Frequently monitor and document the behavior that requires continued use of restraints. Tie the restraints in quick-release knots. Ask the client they need to go to the bathroom; provide range-of-motion (ROM) exercises every 2 hours. Position the vest restraints so that the straps are crossed in the back. Document the client's response to the intervention.

An older client brought to the emergency room by the caretaker has bruises around the wrist and neck. The client appears unkempt and emaciated. What is the nurses' best action? Inquire if the client is on anticoagulant therapy. Notify an adult protective agency. Notify the nursing supervisor. Document the findings in the client's chart.

Notify an adult protective agency.

The LVN/LPN is transporting a surgical client to the operating room when the client says, "I am not sure what they are going to do to me." What is the nurse's best action? Document the client's concern in the chart. Send the client to the operating room, and the nurse will explain the procedure there. Notify the surgeon about the client's concern. Do nothing, because the client already signed the consent form.

Notify the surgeon about the client's concern.

A client diagnosed with multiple myeloma has a poor prognosis. The client is tearful and has difficulty talking about feelings. Which action by the nurse is appropriate? Tell the client the nurse will return in 20 minutes to discuss the client's feelings. Ask if the client wants to speak with someone from pastoral care. Inform the client there is always hope, and tell the client not to give up. Offer to sit quietly with the client to allow time for expression.

Offer to sit quietly with the client to allow time for expression

A nurse is caring for a client who has lost the ability to express words. What should the nurse plan to do when caring for this client? Use complex sentences to acknowledge the client's intelligence. Provide opportunities for the client to repeat words and point to objects. Communicate with the client's family, who can answer the nurse's questions. Limit communication to speech therapy sessions so the client does not become tired.

Provide opportunities for the client to repeat words and point to objects.

A client is admitted to a semiprivate room on a medical surgical unit. Which nursing action is best to maintain the privacy of client information? Select all that apply. Take the client to a private room for admission interview. Pull the curtains when interviewing the client. Speak in a low tone if there is another client in the room. Wait until the other client is asleep before interviewing the client. Interview the client at the nurses' station.

Pull the curtains when interviewing the client. Speak in a low tone if there is another client in the room. Take the client to a private room for admission interview.

A parent who brings a preschooler to the emergency department for treatment of a dislocated shoulder states the injury occurred when the child fell down the stairs. When gathering data on the client, which behavior would lead the nurse to suspect that the child was abused? The child pulls away from contact with the health care provider. The child cries uncontrollably throughout the examination. The child does not cry when the shoulder is examined. The child fails to make eye contact with the nurse.

The child does not cry when the shoulder is examined.

A female client experiences alopecia resulting from chemotherapy. Which action would best indicate that the client is meeting the goal of improved body image and self-esteem? The client begins to discuss the future with her family. The client cries openly when discussing her disease. The client requests that her family bring her makeup and a wig. The client reports less disruption from pain and discomfort.

The client requests that her family bring her makeup and a wig.

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitis who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply. The client talks repeatedly about her death. The client reports having many hobbies and interests outside of the home. The client spends a great deal of time reflecting back on her teen years. The client voices concerns about recovering quickly so that she might return back to work in the next month. The client is talkative about her spouse and children.

The client talks repeatedly about her death. The client spends a great deal of time reflecting back on her teen years.

The nurse is assisting with preparing a plan of care plan for a school age child with poor eye contact, flat affect, and negative behavioral changes. Which action by the parents indicates that the interventions to improve self-esteem were successful? Select all that apply. The parents used physical discipline when necessary to reinforce rules. The parents maintained variable boundaries to challenge decision-making. The parents offered praise for positive behaviors. The parents communicated as a team in order to provide consistency in parenting. The parents followed consistent limits for non-acceptable behaviors.

The parents followed consistent limits for non-acceptable behaviors. The parents offered praise for positive behaviors. The parents communicated as a team in order to provide consistency in parenting.

A visitor of a client overhears two nurses discussing the client in a secluded are of the cafeteria. What are the ramifications associated with the nurses' discussion of the client in a public place? None, because the person who overheard is a friend of the client. None, because they were in a quiet, secluded area. They can be charged with libel because of their statements. They could face a lawsuit due to breech of confidentiality.

They could face a lawsuit due to breech of confidentiality.

The Patient Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. What should the nurse tell the client about such advance directives as living wills and health care power of attorney? Select all that apply. The advance directive is only valid in the state where it was written and subject to that state's laws. They guide the client's treatment in certain health care situations. They can't provide do-not-resuscitate (DNR) orders for clients with terminal illnesses. They permit physicians to give DNR orders. They allow physicians to make decisions about treatment.

They guide the client's treatment in certain health care situations. The advance directive is only valid in the state where it was written and subject to that state's laws.

The nurse is caring for a client, newly diagnosed with cancer, who speaks limited English. The client's family speaks limited English also, and a friend drives the client to all doctor's appointments. Which nursing interventions would be best to facilitate the passage of information to the client? Select all that apply. Obtain common pictures to provide a common ground for understanding. Ask the client's driver to interpret the conversation. Obtain a "type to speak" computerized translation dictionary to express information. Work with an interpreter to discuss the situation. Provide a brochure on the cancer and treatment options. Assess any community resources for support groups and communication.

Work with an interpreter to discuss the situation. Assess any community resources for support groups and communication. Obtain a "type to speak" computerized translation dictionary to express information. Obtain common pictures to provide a common ground for understanding.

A chronically ill school-age child is admitted to the hospital. What action by the nurse addresses the child's vulnerability to a common stressor? provides opportunities for the child to express feelings arranges for the hospital teacher to visit checks in with the child routinely provides a picture book of common equipment in the hospital setting

arranges for the hospital teacher to visit

A nurse is caring for a client with multiple myeloma. Which finding indicates that the client is not coping well with the prognosis? asks questions about the prognosis becomes tearful when discussing his or her condition voices concern about family during treatment avoids conversations concerning his or her health

avoids conversations concerning his or her health

A client is admitted to the neurologic unit after a sudden onset of blindness the day before an important project is due at work. Preliminary evaluation and testing yield no positive findings. The health care provider confers with the multidisciplinary team and discusses the client's situation. The team suspects the client may be demonstrating which defense mechanism? transference reaction formation conversion repression

conversion

Clients diagnosed with a chronic illness exhibit a general pattern of adaptation. What are the stages of the pattern of adaptation? Select all that apply. integration disbelief ambivalence retrospective thinking developing awareness

disbelief integration developing awareness

During which phase of the therapeutic relationship should the nurse begin preparing the client for termination of the relationship? when the client can function independently at the time of discharge during the initial meeting at the midpoint of the relationship

during the initial meeting

At 36 weeks' gestation, a client gives birth a neonate who dies shortly after birth. When working as part of the team providing care to the client, which nursing intervention would be most appropriate for this client? limiting the information she receives about the neonate encouraging her to see, touch, and hold the neonate letting the client's partner decide what information she should receive avoiding the giving of any information about the neonate

encouraging her to see, touch, and hold the neonate

A nurse is caring for a 40-year-old client. When gathering data about the client's cognitive development, which behavior would the nurse identify as appropriate for this client? assuming responsibility for actions experiencing perceptions based on reality demonstrating maximum ability to solve problems and learn new skills generating new levels of awareness

generating new levels of awareness

A client comes to the clinic for an evaluation and reports difficulty coping with things. Which lifestyle factor would the nurse most likely consider as playing a role in this client's condition? divorce adoption of a child job promotion inadequate diet

inadequate diet

A nurse cares for a client who has a chronic illness. Which factor provides the best evidence that the client is at risk for difficulty coping? lack of social support poor sleeping habits adverse drug effects presence of panic disorder

lack of social support

The parents of a 6-month-old diagnosed with a terminal brain tumor have chosen palliative care for their child. What is the priority nursing intervention for this infant? surgery to remove the tumor pain management, comfort measures, and support for the parents chemotherapy and radiation therapy all care provided only by the parents

pain management, comfort measures, and support for the parents

The nurse is gathering data from a newly admitted client. When obtaining family data, who should be considered as part of the client's family? Select all that apply. people whom the nurse thinks are important to the client people related by blood or marriage people whom the client views as family people who provide for the physical and emotional needs of the client people who live in the same house people of the same racial background who live in the same house as the client

people whom the client views as family people who provide for the physical and emotional needs of the client

A client with prostate cancer and metastasis to multiple sites is admitted to a medical unit from a skilled nursing facility in significant respiratory distress. The client's advance directive states that the client does not want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which interventions would the nurse most likely note in the client's plan of care? Select all that apply. checking on the client once per shift limiting client turning only when there is noticeable pain providing pillows for positioning to promote comfort providing mouth care based on family requests raising the head of the client's bed to ease breathing

providing pillows for positioning to promote comfort raising the head of the client's bed to ease breathing

Which interventions should the nurse perform when caring for a client who is an organ donor and considered brain dead? Select all that apply. allowing flexible times for the family to visit with the loved one obtaining informed consent for organ procurement from the next of kin providing an area where the family can have some privacy notifying the immediate family that the client is deceased maintaining the client's dignity while providing compassionate care reinforcing information that has been provided to the family

reinforcing information that has been provided to the family providing an area where the family can have some privacy allowing flexible times for the family to visit with the loved one maintaining the client's dignity while providing compassionate care

A student nurse is assigned to care for a client dying of cancer on the oncology unit. What factors does the nurse identify that will be required to build a strong therapeutic nurse-client relationship? Select all that apply. self-awareness sincere desire to help others understanding of personal feelings sound knowledge of psychiatric nursing acceptance of others

self-awareness understanding of personal feelings

Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child? physiologic maturational situational unplanned

situational

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "I think the surgeon is rude, and clients always end up with infections." The nurse is at risk of being accused of which of the following? assault libel negligence slander

slander

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? using an abrupt, forceful manner to communicate with the client encouraging the client to suppress his or her feelings regarding obesity reinforcing the client's concerns over physical appearance teaching the client alternative ways to lose weight

teaching the client alternative ways to lose weight

A nurse is caring for an older adult client admitted for metastatic colon cancer. What is the most important factor directly influencing this client's mental health? grief issues related to loss, role changes, and physical stamina the number of children and grandchildren in the client's family the client's attitude toward life circumstances the client's age, education level, and socioeconomic level

the client's attitude toward life circumstances

A client states he has little or no sexual desire and says this is causing great distress in his marriage. What further information would be most useful in assessing the situation? Select all that apply: the client's age when he had his first girlfriend when the problem first appeared and potential contributing factors medications and dosages report of recent bladder or prostate problems age of the client's wife

when the problem first appeared and potential contributing factors medications and dosages

A nurse is caring for a client whose cultural background is different from the nurse's own. Which actions are appropriate? Select all that apply. Understand that all cultures experience pain in the same way. Ask the client if there are cultural requirements that should be considered during the client's care. Respect the client's cultural beliefs. The nurse should explain the nurse's beliefs so that the client will understand the differences. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures.

Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs. Ask the client if there are cultural requirements that should be considered during the client's care.

Which of the following clients should the nurse question about their signed consent form for surgery? a 54-year-old client with a fractured femur committed to a mental health unit a 21-year-old client scheduled for resection of a brain tumor a 46-year-old client receiving chemotherapy a 76-year-old client living in the nursing home

a 54-year-old client with a fractured femur committed to a mental health unit

A 10-year-old child with sickle cell anemia continues to wet the bed at night. The child feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which response by the nurse would be most appropriate? "A bladder training program may help to decrease nighttime wetting." "Force fluids during the day and restrict fluids after 7 p.m." "Perhaps your friends could sleep over at your house instead." "Decrease fluid intake during the day and take no liquids before bedtime."

"A bladder training program may help to decrease nighttime wetting."

A client states, "I am stressed by my job but enjoy the challenge. What is the best response by the nurse? "Take stress management classes." "Don't take your work home." "Spend more time with your family." "Switch job positions."

"Take stress management classes."

The nurse noted on the progress note of a 17-year-old client scheduled for surgery that the surgeon has explained the procedure, including benefits and adverse effects. However, the consent was signed by the surgeon and not the client. What should the nurse do? Ask the parents to sign the consent. Ask the client to sign the consent. No consent is required because the client is still a minor. Ask the manager to sign the consent.

Ask the parents to sign the consent.

A client lives with a parent and the client's three children. Which type of family does this describe? nuclear blended dysfunctional extended

extended

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle? beneficence fidelity respect veracity

veracity

A nurse is providing care for a client with multiple myeloma. Which resource may best help the client adapt to the disease? support group hospice care family pastoral care

support group

A mother and father of Iranian heritage bring their 14-month-old son to the health care facility, and he is subsequently admitted for leukemia. When the female pediatric oncologist introduces herself, the parents become uncooperative and refuse treatment. The nurse interprets which condition as being most likely responsible for the change in the parents' behavior? fear of being accused of child abuse and neglect by an authority figure religious barriers preventing acceptance of care from someone who is not of their faith the gender of the health care provider who will be treating their child aggressiveness that characterizes individuals from the Middle East

the gender of the health care provider who will be treating their child

A nurse is gathering data from a client who has been raped. Which strategy would be most effective when talking with this client? talking to the client about rape in detail using open-ended questions and listening intently using closed-ended questions and nodding listening without asking questions

using open-ended questions and listening intently

A client who has difficulty sleeping is asked to keep a sleep diary. Which information should the nurse instruct the client to keep in this diary? fluid intake daily weight foods consumed before bedtime usual bedtime

usual bedtime

A client with newly diagnosed breast cancer asks the nurse, "Why me? I've always been a good person. What have I done to deserve this?" Which response by the nurse would be most therapeutic? "Would you like to talk about this?" "Don't worry. You'll probably live longer than I will." "You seem upset. Let's talk about something happy." "I'm sure a cure will be found soon."

"Would you like to talk about this?"

While making rounds in a senior citizens' housing complex, a visiting nurse discovers a client sobbing in a darkened apartment. The nurse learns that the client's pet cat of 15 years had been put to sleep the day before. Which response by the nurse would be best? "I'm so sorry that your pet had to be put to sleep. It sounds like your cat was important to you." "It's probably best for the cat because it was so old and ill." "It shouldn't be hard to find another cat. You'll feel better when you have another pet." "It was only a cat. Why are you allowing yourself to be so upset? It would be different if it were a person."

"I'm so sorry that your pet had to be put to sleep. It sounds like your cat was important to you."

Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for chemotherapy. When the nurse enters the client's room, the client is sobbing and states, "I thought the chemotherapy would help, but now I feel worse." Which response by the nurse would be most therapeutic? Select all that apply. "I'll sit here with you for a while. Would it help you to talk about it?" "Don't worry. I'm sure everything will be okay if you just give it time." "I'll bring you a sedative to calm you down." "You probably should have had surgery sooner so the tumor could have been caught earlier." "You're feeling worse since chemotherapy started?"

"I'll sit here with you for a while. Would it help you to talk about it?" "You're feeling worse since chemotherapy started?"

An adolescent admitted with a fractured femur had an open reduction and internal fixation two days ago and is currently in traction and asks the nurse what would happen if a terrorist decided to bomb the hospital. What's the nurse's best response? "That's silly thinking. Why would anyone bomb a hospital?" "We have plans to call your parents and take care of you if there's a problem." "What do you think might happen if terrorists attacked?" "I wouldn't worry about that. Spend your energy on getting well and going home."

"What do you think might happen if terrorists attacked?

The nurse is assessing the psychosocial status of a postpartum client. Which statement indicates that the mother is likely to have a successful parent-neonate attachment? "My previous experience was so awesome!" "I want to bond with my baby right away." "Bonding is important to my baby's development." "I want to lie skin to skin with my baby for as long as possible after delivery."

"I want to lie skin to skin with my baby for as long as possible after delivery."

A client receiving chemotherapy reports decreased energy leading to boredom from a lack of activity. Which statement by the client indicates an understanding of appropriate ways to deal with this lack of diversional activity? "I'll bowl with my team after discharge." "I'll eat lunch in a restaurant every day." "I'll play card games with my friends." "I'll take a long trip to visit my aunt."

"I'll play card games with my friends."

The nurse is providing personal hygiene measures to a client who is morbidly obese and diabetic when the client states, "I've heard the nurses and others joking about me. Could you be my nurse tomorrow?" Which response by the nurse would be most appropriate? "I'll check with the nurse-manager." "I'm going to report your concerns to my supervisor, and if I return I'll come see how you are." "I'll make sure the other nurses don't talk about you anymore." "I can't promise that, but I'll make nurses know how you feel."

"I'm going to report your concerns to my supervisor, and if I return I'll come see how you are."

A client expressed interest in using complementary alternate modalities for health benefits and asks the nurse to provide information about meditation. The nurse would provide which appropriate response to this client? "It consists of deep personal thoughts and breath control to help decrease anxiety." "It applies external pressure to the energy points for pain control between acupuncture treatments." "It teaches that each person is surrounded by an energy field and helps restore harmony." "It is seen as natural and promotes health through the use of plants and herbs."

"It consists of deep personal thoughts and breath control to help decrease anxiety."

A client has been admitted for surgery and seems preoccupied and anxious the night before the operation. Which comment by the nurse would demonstrate therapeutic communication? Select all that apply. "Your doctor performs this surgery every day. I'm sure you'll be fine." "I would be happy to discuss any concerns you have regarding your surgical procedure." "It isn't unusual to worry about surgery. If you'd like, I'll ask the physician for something to help you sleep." "You seem worried about something. Would it help to talk about it?" "Let's talk about your procedure for tomorrow."

"Let's talk about your procedure for tomorrow." "I would be happy to discuss any concerns you have regarding your surgical procedure." "You seem worried about something. Would it help to talk about it?"

A nurse is talking to grieving parents whose child died from sudden infant death syndrome (SIDS). What should the nurse emphasize to the parents? "You must allow an autopsy to confirm the diagnosis." "You should place other infants on their backs to sleep." "The death couldn't have been prevented and isn't your fault." "You are still young and can have more children."

"The death couldn't have been prevented and isn't your fault."

A client says to the nurse, "I know that I'm going to die." Which response by the nurse would be best? "We have special equipment to monitor you and your problem." "Why do you think you're going to die?" "Don't worry. We know what we're doing, and you aren't going to die." "Oh no, you're doing quite well considering your condition."

"Why do you think you're going to die?"

The LPN/LVN is assisting the RN to develop a plan of care for a client who will be having surgery. What statement(s) by the LPN/LVN demonstrates the importance of prevention of postoperative complications? Select all that apply. "Do you have any hesitations about surgery?" "You can expect to control any pain with medications." "You are less likely to get pneumonia if you cough and deep breathe following surgery." "Do you understand the risks of your surgery?" "I am concerned that your surgery will take several hours."

"You are less likely to get pneumonia if you cough and deep breathe following surgery." "You can expect to control any pain with medications."

A client must be placed on airborne precautions for several days. To help meet the client's emotional needs, what should the nurse do? Describe the reasons for isolation and how it's carried out, and provide reassurance. Tell the client to bring whatever personal items are desired into the isolation unit. Gently explain that the client's movements must be limited while in the isolation room. Tell the client that family members and significant others can't visit but may telephone at any time.

Describe the reasons for isolation and how it's carried out, and provide reassurance.

An adult client scheduled for surgery chooses to waive the right to informed consent. What should the nurse do? Obtain consent from another family member. Document that the client waived the right in the medical record. Inform the client that the hospital will not be liable if anything goes wrong. Decline to send the client for the surgery until consent is assigned.

Document that the client waived the right in the medical record.

An 18-year-old client has suffered a C5 spinal cord contusion that resulted in quadriplegia. The parent is crying in the waiting room two days after the injury. When the nurse sits down to talk, the parent asks if the child will ever play sports again. Which response from the nurse would be best? Reassure the parent that, given time and motivation, the child will return to normal function. Tell the parent that the primary health care provider will be available to talk right away. Encourage the parent to express any feelings and fears about the child's injury. Advise the parent that it is not in the child's best interest to be so upset.

Encourage the parent to express any feelings and fears about the child's injury

A client who has discovered a breast lump is tearful and expresses concern regarding the situation. What is the best response by the nurse? Ask the client to talk to a chaplain. Give the client any reassurance needed. Recommend a support group. Encourage verbalization of fears.

Encourage verbalization of fears.

A nurse is caring for a client with advanced cancer. After reading the nursing note below, determine the nurse's next intervention. Progress notes: 1/7, 1545 Ct. states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital; I want to be in my own bed." R. Daly, RN Reread the Patient's Bill of Rights to the client. Tell the client that adequate pain relief is possible only in the hospital. Call the client's spouse to discuss the client's statements. 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.

A preschooler is admitted to the hospital the day before scheduled surgery. The child has never been hospitalized before. What can the nurse do to help reduce the child's anxiety about surgery? Explain that the child will be "put to sleep" during surgery and will not feel anything. Give the child dolls and medical equipment to play out the experience. Begin preoperative teaching immediately. Describe preoperative and postoperative procedures in detail.

Give the child dolls and medical equipment to play out the experience.

A nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which of the following concepts about families should the nurse keep in mind when providing care for this client? Select all that apply. A family member may perform more than one role at a time. Changes in sleeping and eating patterns may be signs of stress in a family. Illness in one family member can affect all members. The effects of an illness on a family depend on the stage of the family's life cycle. Children typically are not affected by adult illness. Family roles do not change because of illness.

Illness in one family member can affect all members. A family member may perform more than one role at a time. The effects of an illness on a family depend on the stage of the family's life cycle. Changes in sleeping and eating patterns may be signs of stress in a family.

A nurse is providing care for a client who experienced an extensive myocardial infarction (MI). The client exhibits behavior characteristic of the denial stage of the grieving process. What is the priority action by the nurse? Explain to the client the need to accept the diagnosis. Reinforce and support the client's denial. Let the client know that the nurse is available to talk. Identify other clients who had an MI and are doing well.

Let the client know that the nurse is available to talk.

Which nursing action facilitates communication with a client who has conductive hearing loss caused by otosclerosis? Say the client's name loudly before starting to talk. Use exaggerated lip and mouth movements when talking. Make sure to face the client when speaking.

Make sure to face the client when speaking.

For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep? Encourage less activity during the day. Provide a cup of coffee and a snack in the evening. Increase the client's activity two hours before bedtime. Play soft or soothing music.

Play soft or soothing music.

During rounds, a client who was admitted with gross hematuria asks the nurse about the admitting diagnosis. To facilitate effective communication, what is the nurse's best response? Change the subject to something more pleasant. Give the client honest advice. Provide privacy for the conversation. Ask the client what the concerns are about being hospitalized.

Provide privacy for the conversation.

A client is beginning rehabilitation following a stroke. The family is very demanding and never leaves the client's bedside. Which dynamic should the nurse recognize as having a critical impact on the client's well-being? A complete recovery is based on the involvement of the family. The client's condition has an effect on every member of the family. The client has the choice of allowing family members in the room. Only the client's spouse and children should be involved in the care.

The client's condition has an effect on every member of the family.

A father arrives in a busy emergency department and is upset with his wife for bringing their two-year-old child with epiglottitis in for treatment. Which intervention by the nurse is best? Recognize the father's behavior as his attempt to cope with the situation. Call for security. Leave the room. Tell both parents to leave because they're upsetting the child.

Recognize the father's behavior as his attempt to cope with the situation.

After receiving a visit from the spouse, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels unable to handle the situation. What should the nurse do at this time? Instruct the client to stop pounding on the overbed table. Tell the client that the spouse is probably under a lot of stress. Call facility security to control the situation. Request assistance by using the call system.

Request assistance by using the call system.

A client states, "I'd feel so much better if I could just sleep!" What method to promote sleep can the nurse reinforce to the client? Resist napping during the day. Drink a glass of wine before going to bed. Perform exercises before bed to help with relaxation. Take sleeping pills to help with falling asleep.

Resist napping during the day.

A client at an inpatient psychiatric unit suddenly becomes loud and visibly anxious. What is the best action for the nurse to take? Face the client squarely and say, "You must be quiet." Say to the client, "Let's go talk in your room." Summon help, and escort the client to his/her room. Say to the client, "Calm down; you're safe here."

Say to the client, "Let's go talk in your room."

A client who has been married for 10 years arrives at the psychiatric clinic stating, "I can't live this lie any more. I wish I were a woman. I don't want my wife. I need a man." Which nursing intervention would be most appropriate? Sit down with the client and talk about his feelings. Call the primary health care provider. Encourage the client to speak to his wife. Admit the client.

Sit down with the client and talk about his feelings.

A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which nursing intervention would be most appropriate? Suggest methods and measures that conserve energy. Refer the couple to a sex therapist. Tell the client to discuss it with her husband. Refer the woman to a gynecologist.

Suggest methods and measures that conserve energy

A client with chronic renal failure plans to receive a kidney transplant. Recently the health care provider told the client that the client is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes. 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 response by the nurse is appropriate? Select all that apply. Say to the client, "The treatments are only three days per week. You can live with that." Say to the client, "We all have days when we don't feel like going on." Say to the client, "You're feeling upset about the news you got about the transplant." Leave the room to allow the client to collect his thoughts. Take a seat next to the client and sit quietly.

Take a seat next to the client and sit quietly. Say to the client, "You're feeling upset about the news you got about the transplant."

The nurse is caring for a client diagnosed with diabetes mellitus. When collecting data from this client, what finding best indicates the client is not coping with the disease? The client omits the insulin dose if a meal is missed. The client cries whenever diabetes is mentioned. The client is monitoring blood glucose levels. The client demonstrates a recent weight gain of 2 lb (0.9 kg) over 1 month.

The client cries whenever diabetes is mentioned.

The nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which behavior should be brought to the attention of the nurse-manager? The nurse keeps communication channels open among the family, primary provider, and other health care providers. The nurse has developed education skills to instruct the family members so they can accomplish tasks independently. The nurse works with the family members to find ways to decrease their dependence on health care providers. The nurse attempts to influence the family's decisions by presenting his/her own thoughts and opinions.

The nurse attempts to influence the family's decisions by presenting his/her own thoughts and opinions.

An 80-year-old client has an advance directive that states "do not keep alive by any heroic means." The client suffered a heart attack, and the family is requesting full code. Which nursing action taken by the nurse is correct? Initiate only cardiopulmonary resuscitation (CPR). Call a code and resuscitate the client as requested by the family. Transfer the client to the intensive care unit for ventilator support. Use only pain medication to keep the client comfortable.

Use only pain medication to keep the client comfortable

A child who is hospitalized with a fractured left arm, a concussion, and multiple bruises in various stages of healing appears withdrawn. Emergency department staff report suspected child abuse to the authorities. Which behavior does the nurse anticipate observing in the child? maintaining good eye contact with the parents happily smiling and laughing when seeing new people crying with acutely sensitive reactivity to pain acting quietly and passively about the pain

acting quietly and passively about the pain

A nurse observes a client touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission. These are examples of which condition? passive-aggressive behavior. antisocial behavior. poor boundaries. manipulation.

poor boundaries.

The nurse distinguishes which assessment as evidence of an adult's developmental stage? pulse rate height and weight blood pressure previous problem-solving strategies

previous problem-solving strategies

A client becomes angry and belligerent toward a nurse after speaking on the phone with a parent. The nurse recognizes this behavior as reflecting which coping mechanism? rationalization suppression displacement repression

displacement

A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on life with satisfaction. According to Erickson, which stage is this client currently experiencing? ego integrity. ego identity. industry. intimacy.

ego integrity.

The nurse is providing care to a newly admitted client with a mental health disorder. Which of these actions by the nurse violates the client's privacy? checking the identification bracelet before administering medication leaving the client's medication administrative record at the nurses' station discussing the client's information with the health care provider putting the client's name outside of the client's room

putting the client's name outside of the client's room

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. The nurse identifies which assessment as evidence that the client has achieved an increased level of psychological comfort? sleeping undisturbed for three hours asking to see family members joking about the present condition making decreased eye contact

sleeping undisturbed for three hours

Six months after the death of her infant son, a client is diagnosed with dysfunctional grieving. Which behavior would the nurse expect to find? going to the infant's grave weekly crying when talking about the loss overactive without a sense of loss stating the infant will always be part of the family

overactive without a sense of loss

A client with renal cancer who has not yet been informed of his diagnosis asks the nurse what his test results showed. How should the nurse respond? "It must be difficult for you not to know the results of your test." "It's nothing to worry about." "The report isn't back yet." "You should probably talk to your physician."

"It must be difficult for you not to know the results of your test."

A nurse is caring for a client with tuberculosis who is on a regimen of four medications. The nurse discovers that the client is not taking all of the medications. What should the nurse say to the client? "You need to take your medications as you were instructed. Do you need supervision?" "Taking many medications can be difficult. Tell me about the difficulties you're having." "Why aren't you taking your medications? Don't you want to get better?" "Don't you realize that resistance can develop if you don't take your medications properly?"

"Taking many medications can be difficult. Tell me about the difficulties you're having."

The parents of a child who is dying of leukemia asks a nurse about the family participating in the care of the child. What would be the best response by the nurse? "A member of the nursing staff must provide all of the child's physical care." "This type of care is only available if your child is in a hospice facility." "You will be required to sign a release stating you are taking responsibility in case any injury occurs. "We encourage all members of the family to be as involved with the care as they are comfortable with."

"We encourage all members of the family to be as involved with the care as they are comfortable with."

After contributing to a health education class on heart attack prevention, a nurse encounters a student from the previous year, who happily reports applying much from the class to everyday life. During the 5-minute meeting, the nurse notes that the former student is approximately 50 lb (22.7 kg) overweight, smokes, and is eating a bag of potato chips. Based on this information, what can the nurse conclude? The student did not attend the entire class. The application of behavioral changes needs to be reevaluated. A demonstration of accurate knowledge of heart attack prevention is evident. The student may have a hearing impairment.

The application of behavioral changes needs to be reevaluated.

The nurse observes a client's health and home environment. Which finding requires the nurse to obtain a referral from the health care provider for an assistive device? The family corrects safety hazards that are identified during home visits. The client successfully completes activities of daily living at each visit. The client uses handrails when in the shower and for climbing stairs. The client does not demonstrate any confidence in an ability to walk.

The client does not demonstrate any confidence in an ability to walk.

A client underwent a urinary diversion procedure and now has a continent ileal reservoir (Kock pouch). Which action indicates to the nurse that the client is coping with an altered body image? The client states, "Next week, the surgeon is going to change me back." The client avoids caring for the stoma. The client is wearing street clothes and has combed hair. The client is confrontational when someone speaks to him/her.

The client is wearing street clothes and has combed hair.

A registered nurse (RN) is supervising a licensed practical nurse (LPN). The LPN is caring for a client diagnosed with a terminal illness. Which statement by the LPN should the RN correct? "Some people choose to tell their health care provider they don't want to have cardiopulmonary resuscitation." "Some clients write a living will indicating their end-of-life preferences." "You could designate another person to make end-of-life decisions when you can't make them yourself." "The law says you have to write a new living will each time you go to the hospital."

"The law says you have to write a new living will each time you go to the hospital."

A client is admitted for a wedge resection of the left-lower lung lobe after a chest radiograph revealed a lesion. The client is anxious and asks to smoke. Which statement by the nurse would be most therapeutic? "Smoking now is okay, but it's contraindicated after your surgery." "The health care provider left orders for you not to smoke." "You seem anxious about the surgery. Do you see smoking as helping?" "Smoking is the reason you're here."

"You seem anxious about the surgery. Do you see smoking as helping?"

A client is admitted to the hospital with an exacerbation of chronic systemic lupus erythematosus (SLE). The client starts yelling at the nurse when the call bell is not answered immediately. What is the most appropriate response for the nurse? "I can see you're upset. I'll come back when you've calmed down." "Would you like to talk about the problem with the nursing supervisor?" "You seem to be angry. Tell me about what you are feeling." "Calm down. You know that stress can make your symptoms worse."

"You seem to be angry. Tell me about what you are feeling."

A client who was admitted to a hospital two days ago for disrupting a town meeting, shouting religious delusional remarks, and fighting with police now refuses to take prescribed haloperidol, saying, "It will hurt me. I don't want it." Which response by the nurse would be best? "This medicine will help you feel better." "You must take it or get an injection." "You sound apprehensive. Let's talk about it." "What are you so afraid of?"

"You sound apprehensive. Let's talk about it."

A client who has been deemed competent and requires long-term mechanical ventilation privately tells a nurse that he or she wants the ventilator withdrawn. Which response by the nurse is best? "What about your family?" "You have been doing so well." "You are asking us to do something we can't do." "Tell me how you are feeling."

"Tell me how you are feeling."

A primigravida client had an emergency cesarean birth because of fetal distress. Three days after the birth, the client seems preoccupied and troubled, and a nurse observes her crying in her room after visitors leave. She tells the nurse that her incision is ugly and that she "feels like a failure." In responding to the client, the nurse should consider which factor? The client is grieving the loss of her anticipated birth experience. The client is experiencing abnormal feelings and needs psychiatric care. The client is in the dependent taking-in phase described by Rubin. The client is tired and upset from having too many visitors.

The client is grieving the loss of her anticipated birth experience.

A nurse receiving morning report is told that the family members of a terminally ill client require a lot of attention. Which intervention should the nurse implement to meet the psychosocial needs of the family? flexible visitation, allowing participation in client care, and rest breaks for the family and client unconstrained visitation, informing the family about imminent death, and responding to family needs short, frequent visitation, participation in care decisions, and extended rest breaks for the client extended visitation, frequent client status updates, and limits to the number of family in the room

flexible visitation, allowing participation in client care, and rest breaks for the family and client

Although a client's physiological response to a health crisis is important to the health outcome, which nursing intervention must also be addressed? helping the client effectively cope with the crisis educating the family on how to care for the client educating the client on basic information about the illness maintaining IV access, medications, and diet

helping the client effectively cope with the crisis

Which dimension of care is the primary focus for the nurse providing care to a client who is dying of lung cancer? emotional spiritual physiological social

physiological

A client with terminal cancer tells a nurse, "I've given up. I have no hope left. I'm ready to die." Which response is most therapeutic? "Now, you shouldn't give up hope. There are cures for cancer found every day." "You should talk to your health care provider about your fears of dying so soon." "You've given up hope?" "We should talk to a social worker about the subject of dying."

"You've given up hope?"

A nurse is inquiring about pain in a client with appendicitis. Which initial response by the nurse would be most effective in eliciting information? "Coughing makes your pain worse, doesn't it?" "Does your pain medication relieve your pain?" "Point to where you feel pain." "Tell me how you are feeling."

"Tell me how you are feeling."

A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse? "Don't worry. The child is going to be fine." "Why didn't you watch your child more closely?" "You shouldn't feel guilty. You didn't know their cleaners weren't locked up." "Tell me more about your feelings."

"Tell me more about your feelings."

As the nurse helps a client to the bathroom, the client says, "When you get to the point where you can't even go to the bathroom by yourself, you might as well be dead." Which response by the nurse would be most therapeutic? "Why are you feeling so down today? This isn't like you." "Keep your chin up. Things will look better tomorrow." "You're making great progress. A week ago, you couldn't even get out of bed." "You sound really discouraged today."

"You sound really discouraged today."

A prenatal client says she can't believe she has such mixed feelings about being pregnant. She tried for 10 years to become pregnant and now feels guilty for her conflicting reactions. Which response by the nurse is best? "You're experiencing the normal ambivalence pregnant mothers feel." "Let's make an appointment with a counselor." "These feelings are expected only in women who have had difficulty becoming pregnant." "You need to talk to your midwife about these feelings."

"You're experiencing the normal ambivalence pregnant mothers feel."

The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, "I don't know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway." Which response by the nurse would be most therapeutic? "You're wondering whether you've made the right decision about the treatment." "Many people beat cancer. You need to keep a positive attitude." "Colon cancer can now be cured in many cases. Let's hope you'll be one of the lucky ones." "Everyone with cancer worries, but you have every reason to be hopeful."

"You're wondering whether you've made the right decision about the treatment."

A nurse is conducting an admission assessment with a 23-year-old male client. The client states that he recently became engaged and purchased a house. The nurse concludes that this client is effectually managing which developmental task of Erikson's developmental model? trust versus mistrust intimacy versus isolation industry versus inferiority generativity versus stagnation

intimacy versus isolation

A nurse observes a medical student walk into a client's room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene? Stay with the client until the medical student finishes his questions. Explain to the client that she has the right to refuse to answer questions asked by the medical student. Encourage the client to cooperate with the medical student. Tell the client that the only way for the medical student to learn is for clients to cooperate with him.

Explain to the client that she has the right to refuse to answer questions asked by the medical student.

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate? inviting a client with a similar experience to speak with the client referring the client to a psychiatrist referring the client to a sex therapist discussing the client's concern with the husband

inviting a client with a similar experience to speak with the client

The nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers that the client is not taking all of the prescribed medications. What is appropriate for the nurse to say to the client? "Why aren't you taking your medications? Don't you want to get better?" "Taking many medications can be difficult. Tell me about the difficulties you're having." "Don't you realize that resistance can develop if you don't take your medications properly?" "You need to take your medication as you were instructed. Do you need supervision?"

"Taking many medications can be difficult. Tell me about the difficulties you're having."

As a result of a serious motorcycle accident, a client suffers paraplegia. When the nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to. What good will they do?" Which action by the nurse would be most appropriate? exploring how the client's feelings affect the decision to refuse medication reporting the client's comments to the health care provider insisting that the client take the medication explaining the consequences of not taking the medication

exploring how the client's feelings affect the decision to refuse medication

A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse? "You shouldn't feel guilty. You didn't know their cleaners weren't locked up." "Don't worry. The child is going to be fine." "Why didn't you watch your child more closely?" "Tell me more about your feelings."

"Tell me more about your feelings."