Psychosocial integrity 3
The nurse notes that the spouse of a client, having a routine physical examination, died 2 months ago of colon cancer. Which initial statement is most appropriate for the nurse make to this client? 1. "I understand that your spouse died 2 months ago." 2. "I am so sorry that you lost your spouse." 3. "What brings you here today?" 4. "What can we do for you?"
1 (1) CORRECT - Caring, direct acknowledgment aids in the grieving process. 2) INCORRECT - Euphemisms that tend to avoid the word death can postpone grief. 3) INCORRECT - Avoiding the subject about the spouse's death does not give recognition to the client's recent stressor. 4) INCORRECT - The nurse should not avoid talking about the spouse's death. )
The home health nurse visits a client who is rehabilitating after colostomy surgery. The client says to the nurse, "Can you smell me?" Which response is best by the nurse? 1. "Are you having second thoughts about the surgery?" 2. "Tell me about your specific concerns." 3. "Are you having problems with gas?" 4. "I have a cold and can't smell anything."
2 (1) INCORRECT— This is not an appropriate response because the client already had the surgery. In addition, it is a closed question that may not elicit much information from the client. The therapeutic response is to ask the client an open-ended question. 2) CORRECT— This response uses therapeutic communication because it acknowledges the client's feelings and allows the client to express concerns about the colostomy. 3) INCORRECT— This is not a therapeutic response because it is a closed (yes/no) question. 4) INCORRECT— This response focuses on the nurse and does not respond to the client's concerns.)
After a client completed 6 months of multidisciplinary treatment for anorexia nervosa, the nurse evaluates whether the client has met the goal of balanced nutrition sufficient to meet metabolic demands. Which is the best indicator that the goal has been met? 1. The client no longer sees herself as fat or overweight. 2. The client eats balanced meals without obsessive behaviors. 3. The client's menstrual period has returned and is regular. 4. The client's ideal body weight has been attained.
3 (1) INCORRECT - This is a positive outcome related to disturbed body image, not nutrition. 2) INCORRECT - This is a positive outcome that implies improvement of eating behavior and control of anxiety, not nutrition. 3) CORRECT - Return of menses implies sufficient intake of fat to maintain follicle-stimulating hormone (FSH) and luteinizing hormone (LH). 4) INCORRECT - There is no guarantee that underlying metabolic disturbances have been corrected just because the weight has been corrected, though this is a positive outcome overall. )
The home health nurse visits a client with cancer undergoing anti-cancer treatment. The nurse asks how the client is coping, and the client cries and with an angry voice says, "Nobody understands. I am hanging on, trying to take one day at a time, but it is all I can do to get up in the morning." How does the nurse best respond? 1. "What kind of support do you think would be most helpful to you at this time?" 2. "I would be upset too if the people around me didn't act like they cared." 3. "Dealing with family is a challenge, even for people who are feeling healthy." 4. "Why don't you attend a support group for women who are going through the same thing?"
1 (1) CORRECT - This is an open-ended question that focuses in on the client's underlying message, encourages discussion and problem-solving, and implies that some support will be offered directly by the nurse once the client's needs are known. 2) INCORRECT - This statement focuses on the nurse and does not directly address what the client said. 3) INCORRECT - Lack of family support is only part of the challenge when the client says "nobody" understands. This does not address the client's statement fully and dismisses the feelings that were shared, stating that they apply to others as well. 4) INCORRECT - A support group may be useful, but assessment is required before possible referral. This solution may be too simple for the nature of the problem.)
The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose the client's own activities. 3. Allow the client time to get acclimated to the milieu before scheduling activities. 4. Allow the client to rest quietly to restore energy level.
1 (1) CORRECT— The client displays symptoms of depression. For the client with depression, a regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required. Participating in activities will increase self-esteem and assist the client to engage with others. 2) INCORRECT - The client is having difficulty making decisions. Choosing or planning the client's own activities will increase social isolation, increase impairment, and decrease self-esteem. 3) INCORRECT - This will increase social isolation. 4) INCORRECT - The client is having difficulty making decisions. Allowing the client to rest quietly will increase social isolation, increase impairment, and decrease self-esteem.)
The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action? 1. Give the client a brief orientation to the unit. 2. Explain the activities available to the client. 3. Introduce the client to the nursing staff. 4. Ask the client to choose activities in which to participate.
1 (1) CORRECT— The client experiencing depression will benefit from a brief orientation to the unit upon admission. A more in depth orientation can occur at a later time. 2) INCORRECT - Explaining available activities may not be of interest at this time or may overwhelm the client. The nurse avoids long, complex explanations. 3) INCORRECT - Introducing the nursing staff may overwhelm the client. If possible, it is important to provide consistent daily care with the same nurse. 4) INCORRECT - The nurse avoids giving choices. It is important to provide a structured written schedule.)
After being admitted involuntarily to a mental health facility, a client with a history of assault calls the nurse a "racist bigot." Which action is the most appropriate for the nurse to make? 1. Leave the room after informing the client of returning in 30 minutes. 2. Ask another nurse of the same ethnic background as the client to provide care. 3. Remain sitting quietly until the client is ready to cooperate. 4. Ignore the client's comment and provide care.
1 （1) CORRECT - The history of assault makes this client potentially violent. The nurse's safety is a priority. The nurse should provide the client with time to calm down. 2) INCORRECT - Asking someone else to provide care is inappropriate. It will validate the client's remark and set the stage for staff splitting. 3) INCORRECT - Staying in the room is inappropriate at this time. The client needs time alone to grasp the situation. 4) INCORRECT - Ignoring the comment may intensify the client's anger and make the nurse the target of violence. ）
The nurse provides care to a client who is scheduled to undergo a craniotomy the following day. Which client data does the nurse recognize as being an indication for insertion of an indwelling urinary catheter? (Select all that apply.) 1. The client is diagnosed with severe urinary retention. 2. The client requires evaluation of residual urine volume. 3. The client is scheduled for a lengthy surgical procedure. 4. The client is at risk for developing a pressure injury. 5. The client requires strict monitoring of intake and output.
1, 3, 5 (1) CORRECT - Indications for insertion of an indwelling urinary catheter include treatment of urinary retention, as urinary retention may cause health alterations including urinary tract infection (UTI) and kidney stones. 2) INCORRECT- Measurement of residual urine is not a routine indication for insertion of an indwelling urinary catheter. Preferred approaches include using a noninvasive device, such as a bladder scanner, to estimate residual urine. 3) CORRECT - Lengthy surgical procedures performed under anesthesia may be an indication for insertion of an indwelling urinary catheter. 4) INCORRECT- Risk for developing a pressure injury is not an indication for insertion of an indwelling urinary catheter. However, an existing pressure injury that cannot be kept clean may be an indication for indwelling urinary catheter insertion. 5) CORRECT - Indications for indwelling urinary catheter include when accurate intake and output are necessary to closely monitor fluid volume status.)
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, "Became angry and physically abusive." Which action does the nurse take first? 1. Encourage the client to verbalize feelings. 2. Assess the client for physical trauma. 3. Provide a list of shelters appropriate for the situation. 4. Assist the client to identify a support system.
2 ( understand the question wrong, when the client express the spouse is abusive and angry, first access the client's physical trauma. i am think about the spouse. 1) INCORRECT - It is very important for the nurse to encourage the client to verbalize about the incident and relationship, but assessment for injuries is first. 2) CORRECT— First assess for trauma to determine the client's physical needs. 3) INCORRECT - This is an appropriate action, but the nurse would first assess the client prior to implementing approriate interventions. 4) INCORRECT - This is an important assessment question to ask during the interview, but it does not take priority over the physical assessment of the client.)
The nurse provides care for a client diagnosed with schizophrenia. Which problem does the nurse identify as being a priority for the client? 1. Acting-out behaviors. 2. Having difficulty forming relationships. 3. Acting in a compulsive way. 4. Having multiple personalities.
2 (1) INCORRECT - Acting-out behaviors are actions that express unconscious feelings or conflicts. The client with schizophrenia may or may not have these behaviors. 2) CORRECT— The marked inability to trust others, a hallmark of schizophrenia, makes it difficult for the client to form relationships. 3) INCORRECT - A compulsion is an irrational drive. This is a hallmark of obsessive-compulsive disorder, not schizophrenia. 4) INCORRECT - The presence of more than one personality is referred to as dissociative identity disorder and is a failure to integrate various aspects of one's identify, memory, and consciousness. This is not an issue associated with schizophrenia.)
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first? 1. Monitor vital signs every 15 minutes. 2. Administer bromocriptine as prescribed. 3. Administer the haloperidol as prescribed. 4. Assess the client's level of consciousness.
2 (1) INCORRECT - The client's symptoms are consistent with neuroleptic malignant syndrome (NMS), which is a serious complication of antipsychotic drugs. The symptoms include sudden high fever, rigidity, tachycardia, hypertension, and decreased level of consciousness. While monitoring vital signs frequently is appropriate, it does not address the client's current problem. There is an implementation that the nurse should take immediately to provide for client safety. 2) CORRECT- NMS is a life-threatening complication. The nurse needs to manage fluid balance, reduce client temperature, and monitor for complications. The nurse should discontinue antipsychotic medications and administer bromocriptine (a medication to counteract the effects of NMS) and dantrolene as prescribed. 3) INCORRECT - The nurse should immediately discontinue the antipsychotic medication, as this is what is causing the NMS. 4) INCORRECT - While assessing the client's level of consciousness is appropriate, it will not ensure client safety in the here and now. There is another priority implementation that the nurse should take.)
The nurse supervises hospice care for a client who practices orthodox Judaism. Which observation best indicates to the nurse that the care of this client is appropriate? 1. The client is given a wafer which is placed on the tongue. 2. The client has a continuous intravenous morphine infusion. 3. The client is turned to face east as signs of death appear. 4. The client is provided the sacrament of the sick.
2 (1) INCORRECT - The wafer, known as the Eucharist, is offered to Roman Catholic clients and may be given by lay persons. Eucharist, or Communion, is also a rite of worship in some Protestant faiths. This item is not appropriate for an orthodox Jewish client. 2) CORRECT- Pain management is appropriate for many clients at the end of life. Some members of the orthodox Jewish faith may wish for all of the following from caregivers at the end of life: facilitating lucidity, maximizing function, pain management, providing peace, and respecting dignity. Therefore, pain management with a continuous morphine infusion is considered appropriate care. 3) INCORRECT - End-of-life care in the Islamic religion requires the dying to face east towards Mecca. 4) INCORRECT - The sacrament of the sick, or last rites, may be performed for clients who are Catholic at the end of life.)
A young female client hospitalized on the inpatient psychiatric unit receives treatment for anorexia nervosa. Which statement made by the client to the nurse best indicates improvement? 1. The client states, "I realize I am too thin and that it is not good for me, but I do not know how to eat more without getting fat." 2. The client requests a sanitary pad, saying, "I did not think to bring anything with me. I have not had a period for months." 3. The client states, "Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals." 4. The client asks for her discharge date to be delayed and says, "I do not feel ready yet to deal with the tension in my family and their demands for perfection."
2 (1) INCORRECT - This is not the best indicator of improvement, although it does at least verbally manifest insight and openness to and readiness for client teaching. 2) CORRECT ndash Amenorrhea, a definite physiologic symptom of anorexia, is resolved. Menstruation is usually absent in anorexic women. Its return is a measure of successful treatment. The DSM-5 describes amenorrhea as a criteria measure for the diagnosis of anorexia and defines it as the absence of at least three consecutive menstrual cycles in a post-menarchal female. 3) INCORRECT - This is not the best indicator of improvement, although it does at least verbally convey interest and willingness to eat more, which will result in weight gain. However, it may be said to please the nurse and does not necessarily indicate that the client is consuming more food. Anorexia nervosa has little to do with appetite and more to do with fear of obesity and of losing control over food intake. 4) INCORRECT - This does not indicate improvement, although it does convey recognition of the family component to her condition.)
The psychiatric inpatient unit has four new admissions. Which client does the nurse see first? 1. A salesperson diagnosed with depression after the baby was born with Down syndrome and the spouse threatened to file for divorce. 2. A police officer with a history of post-traumatic stress disorder (PTSD) who was admitted with agoraphobia after two of his co-officers were killed. 3. A computer programmer admitted with a diagnosis of generalized anxiety disorder who has extensive debt and just filed for bankruptcy. 4. A college student admitted for depression and anxiety after a sibling committed suicide and a parent was recently diagnosed with lung cancer.
2 (1) INCORRECT — This client has experienced two losses—one actual loss in terms of not having the anticipated well child and one potential loss in terms of the spouse leaving. While depressed and probably anxious, this client is likely to benefit from clarification of issues and sharing of support and referral options. 2) CORRECT — This client has a high potential for violence to self and/or others. There is easy access to weapons and knowledge of how to use them. Agoraphobia particularly causes this client to be uneasy in the new surroundings and potentiates acting out in fear. 3) INCORRECT — Unemployment or financial problems are particular risk factors for suicide, but the scenario does not point to any particular sign of suicide lethality potential. 4) INCORRECT — Siblings of a person who committed suicide (especially if prior to adulthood) often feel despair and survivor guilt, putting themselves at risk for suicide. This client has experienced two serious losses—one actual and one potential. In the scenario described, the priority is the client's safety from self-harm or harming others)
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.) 1. Keep the voice even throughout conversations. 2. Explain the sounds in the environment. 3. Decrease background noise before speaking. 4. Stay in the client's field of vision. 5. Identify self by name and staff position.
2, 4, 5 (1) INCORRECT - Keeping an even tone when speaking is an intervention for a client with a hearing impairment. 2) CORRECT - Explaining environmental sounds is appropriate for this client. 3) INCORRECT - Decreasing background noise while conversing is an intervention for a client with a hearing impairment. 4) CORRECT - Remaining in the client's field of vision helps the client best see the nurse. 5) CORRECT - Stating name, position, and intent will help the client recognize the person providing care. )
An older adult client with Alzheimer disease wanders into other clients' rooms. Which nursing action is appropriate? 1. Ask the health care provider for a prescription for a tranquilizer. 2. Place the client in a geriatric chair with a clipboard to complete a puzzle. 3. Encourage the client to assist with sorting the linen. 4. Explain to the client that leaving the room is not allowed. View Explanation
3 (1) INCORRECT - Asking for a prescription for a tranquilizer eliminates the need for the nurse to interact with the client. Sedating the client does not support the client's needs or best interest for care. 2) INCORRECT - The client will not be able to complete a puzzle due to cognitive dysfunction, and using a geriatric chair may increase confusion or possibly encourage combativeness. A geriatric chair is considered a form of restraint. 3) CORRECT— Having the client sort linen keeps the client active and independent, and it structures the environment, promotes socialization, orients the client, and preserves dignity. This action does not block wandering behaviors but uses them constructively while protecting other clients from intrusion. 4) INCORRECT - The client may not be able to understand and/or control the wandering behavior. The nurse needs to provide a calm, predictable environment with a regular routine and give clear and simple explanations. )
The nurse provides care to a client who practices Orthodox Judaism. When collaboratively planning the client's meals, which food selection does the nurse offer the client? 1. Meat lasagna. 2. Broiled shrimp. 3. Smoked salmon. 4. Pork chops.
3 (1) INCORRECT - Individuals who practice Orthodox Judaism do not combine milk products with meat. As such, meat lasagna would not be an appropriate food selection for the client. 2) INCORRECT - Orthodox Judaism forbids consuming shellfish. Because shrimp are a type of shellfish, any preparation of shrimp would not be an appropriate food selection for the client. 3) CORRECT— Salmon is acceptable for consumption by individuals who practice Orthodox Judaism. Dietary products that are forbidden by Orthodox Judaism include pork products, shellfish (such as shrimp), and foods that combine dairy products and meat (such as lasagna). 4) INCORRECT - Because Orthodox Judaism forbids the consumption of pork, all pork products must be excluded from the client's diet. )
The nurse visits the home of a family whose mother died 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1. A 3-year-old explains that mother is sleeping at grandmother's house. 2. A 6-year-old experiences enuresis and temper tantrums. 3. A 9-year-old states that no one will play with him. 4. A 12-year-old spends time away from home with friends.
3 (1) INCORRECT - Infants and toddlers have no concept of death. The 3-year-old is behaving appropriately for the developmental level. 2) INCORRECT - Regressed behaviors are a common response to the death of a parent. 3) CORRECT - The inability to enjoy play is masked by this typical statement and is a hallmark sign of depression in children. 4) INCORRECT - Spending time with friends is an expected early adolescence response to grief and is a way of coping with the loss. )
The nurse provides care for an older adult client who screams frequently. The nurse plans a behavior modification program to deal with the screaming. Which action by the nurse is best? 1. Monitor client's ability to perform daily activities. 2. Assess the client's pain level and characteristics. 3. Observe the client's behavior at regular intervals. 4. Ask the client why the client is screaming.
3 (1) INCORRECT - The client's ability to perform normally in activities would not give much information about why the client is screaming. 2) INCORRECT - The nurse should not assume that pain is causing the client to scream. The nurse should ask this as part of the overall assessment, but pain is subjective. In this case, the nurse should make objective observations prior to engaging the client about the behavior. 3) CORRECT - To design an effective behavior modification program, accurate baseline data about the behavior in relation to frequency, amount, time, and precipitating factors must first be collected. 4) INCORRECT - Generally speaking, it is non-therapeutic communication to ask 'why' questions. In this instance, it makes sense for the nurse to ask this, but it will not yield as much information as an objective assessment.）
The Suicide Prevention Hotline nurse receives a call from a client who reports the intention to commit suicide. Which question is most important for the nurse to ask? 1. "Do you really want to die?" 2. "When did you start to feel this way?" 3. "How do you plan to kill yourself?" 4. "What has happened to cause this?"
3 （1) INCORRECT - This elicits a yes or no answer only and does not help the nurse determine the next step needed to prevent harm to the client. 2) INCORRECT - This does not help the nurse determine the immediate needs for the client's safety, which is the priority assessment. 3) CORRECT— This lets the nurse prioritize interventions to assure the client's safety. Clients with a suicide plan have the highest lethality. 4) INCORRECT - This does not help the nurse determine the immediate need for safety of the client and causes the client to create reasons to support the idea. ）
The nurse interacts with a client verbalizing a cocaine craving. The nurse acknowledges the client's discomfort. Which is the best activity for the nurse to suggest to the client? 1. Rest quietly alone in the client's room. 2. Do a crossword puzzle. 3. Say prayers for strength. 4. Walk laps around the activity area with another client.
4 (1) INCORRECT - The nurse should encourage the client to engage in activities that dissipate anxiety and increase self-esteem. Being alone does not increase self-esteem and does little to dissipate anxiety. 2) INCORRECT - Doing a crossword puzzle is mentally engaging and may distract the client, but there is another option that is even better for the nurse to recommend. 3) INCORRECT - While some clients may find religious engagement to be comforting and may reduce anxiety, this does not increase self-esteem and may not be relevant for all clients. 4) CORRECT - Low-impact physical activity will dissipate anxiety, helps to avoid weight gain that may occur with recovery, and stimulates the release of endorphins, which aid in boosting self-esteem. This is the best activity for the nurse to recommend. )
A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion. 2. Allow time in the client's private assigned room for reflection. 3. Redirect the client to a quiet activity such as journaling. 4. Assist the client to express feelings of anger and frustration.
4 (1) INCORRECT - The nurse speaks calmly and in a normal tone of voice and attempts to de-escalate the client's behavior. The client may be placed in seclusion at a later time for escalating or violent behavior. 2) INCORRECT - Do not leave the client alone, use threatening body language, or block the exit. While the client may benefit from decreased stimuli, it is not appropriate to leave the client unattended. 3) INCORRECT - Journaling is a technique that may be used for clients to gain insight into their own actions. During an acute episode of agitation is not the time for this type of reflective activity. 4) CORRECT— This behavior indicates increased agitation and may indicate impending violence. The nurse de-escalates the client's behavior. The nurse will help the client to verbalize feelings, avoid disagreeing with or threatening the client, and remove threatening components of the environment. )
The nurse on the psychiatric unit finds a client crying. As the nurse approaches the client, the client states, "What do you want? Go away. I hate you, and I hate myself." Which response by the nurse is appropriate? 1. "Why is it that you don't like me or you?" 2. "I will come back later when you are in a better mood." 3. "It is difficult for me to communicate with you when you talk this way." 4. "You seem to be in pain, so I will stay with you."
4 （1) INCORRECT - The nurse should not ask "why" questions, as these are confrontational and judgmental. 2) INCORRECT - The nurse should not leave the client alone. 3) INCORRECT - This answer choice focuses on the nurse. The nurse should maintain focus on the client and do what is best for the client. 4) CORRECT— This conveys support and understanding. Depressed clients are frequently angry, but the anger is displaced inwardly.）
