Psychosocial Integrity

Which activity should be recommended for long-term support of parents who have lost an infant due to sudden infant death syndrome (SIDS)?

attending support groups

A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet, repeatedly checking to see if clothing is arranged in the proper order. How does the nurse interpret this behavior?

compulsion

A client is admitted after being found on a highway, throwing rocks and debris and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." The nurse interprets the client's statement as indicating which condition?

delusional experience

The nurse is working with a client who has a heroin addiction. What is an underlying cause common to most abusers?

difficulty in effectively coping with stress

A client sees a spider while raking leaves. Immediately, the client's heart begins beating rapidly and the client breaks into a sweat. To which condition is the client's response related?

fear triggered by a known, specific object or event

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to:

fold towels and pillowcases.

A 15-year-old boy wants to try out for the football team. His parents are concerned that, because he's small for his age, he might be subjecting himself to ridicule. Which response by the parents best supports the adolescent's decision-making process?

"Whether or not you play football is your decision; tell us why you want to play."

When gathering data on a preschool-age child, the nurse finds multiple contusions over the body. Which statement indicates the findings that should be documented?

All lesions, including location, shape, and color, should be documented.

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?

"What do you think might happen if terrorists attacked?"

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 think they mixed up my test results."

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement by the client indicates an understanding of appropriate ways to deal with this deficit?

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

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."

While pacing in the hall, a client with schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

During the admission data collection, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me." The nurse's most supportive response would be:

"It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal."

A nurse is talking to grieving parents whose child died from sudden infant death syndrome (SIDS). What should the nurse emphasize to the parents?

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

A newly hired nurse is assigned to a mental health clinic and is unfamiliar with mental health nursing. The nurse asks another nurse what is the goal of crisis intervention. What is the best response by the nurse?

"The goal is psychological resolution of the immediate crisis."

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?

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

A client is hospitalized to rule out an acute myocardial infarction (MI). Laboratory studies indicate a normal lactate dehydrogenase level and an elevated troponin I level. The nurse enters the client's room and finds the client pacing the floor. Which statement by the nurse would be most appropriate in this situation?

"You seem upset. Why don't you get into bed and, if you wish, we can talk for a while."

A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer?

"You're feeling ambivalent, which is normal during the first trimester."

A client is admitted to a medical-surgical unit for treatment of an orthopedic injury. In addition to this admitting diagnosis, the nurse notes that the client has a history of borderline personality disorder with episodes of cutting/self- mutilation. Which type of behavior would the nurse expect to be present due to this self-mutilation history? (Select all that apply.)

-knife or razor in purse or bag -insistence on wearing long-sleeved shirt even in warm temperatures -overly hesitant behavior when the nurse attempts to assist with bathing or dressing

The nurse uses the PLISSIT model to help clients with gender issues or sexual problems. Place the levels in progressive order.

-permission giving -limited information -specific suggestions -intensive therapy

The nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply:

-talks and coos to her son -cuddles her son close to her -Takes a nap when the baby is sleeping

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client?

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client?

A 6-week-old infant who is not breathing is brought to the emergency department by the parents. A preliminary diagnosis of sudden infant death syndrome (SIDS) is made. Which nursing intervention is a priority?

Allow the parents to see their infant.

A client with schizophrenia reports that hallucinations have decreased in frequency. Which intervention would be appropriate to begin addressing the client's problem with social isolation?

Ask the client to participate in a group sing-along.

A nurse is collecting data from a client in labor and suspects that the client may have been physically abused by her male partner. Which intervention by the nurse would be most appropriate?

Collaborate with the health care provider to make a referral to social services.

A client with a diagnosis of bulimia nervosa is working on relationship issues. Which nursing intervention is most important?

Facilitate the client's ability to identify feelings about relationships.

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Following safe-sex practices

A healthcare provider informs a client that the client's diagnosis of ovarian cancer is terminal. The client, usually religiously observant, is expressing rage at God and the clergy. Which nursing intervention is appropriate for this client?

Help the client use effective coping strategies.

The nurse is interacting with a client experiencing delusions. Which action would be most appropriate for the nurse to do?

Identify the meaning of the delusion.

The nurse is reinforcing education for the parents of a child that has been diagnosed with celiac disease. To help promote a normal life for the child, which intervention should the nurse reinforce for the parents to use?

Introduce the child to a peer with celiac disease.

An adolescent, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The nurse identifies which defense mechanism the adolescent may be using to handle anger?

Introjection

The nurse is caring for a client with bulimia. The plan of care for this client includes strict management of dietary intake. Which other important nursing intervention would the nurse include in the plan of care?

Let the client choose his or her own food and stay with the client for 1 hour after each meal.

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this child?

Maintaining a consistent, structured environment

A client with alcohol withdrawal is pulling at the central venous catheter saying "I am swatting the spiders crawling over me." Which intervention is appropriate?

Protect the client from harm.

A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client?

Rape-trauma syndrome

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?

Request assistance by using the call system.

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increased client care needs

A nurse would observe a client undergoing electroconvulsive therapy (ECT) for which common adverse effect?

Short-term memory loss

A client is diagnosed with somatic symptom disorder. What understanding should the nurse have regarding somatic symptom disorder when rendering care to this client?

Symptoms are real to the client, even though there may not be an organic etiology.

Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his or her hands for 18 minutes, comb his or her hair 444 strokes, and switch the bathroom light on and off 44 times. When creating the plan of care, what is the most appropriate goal for this client?

Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.

Which communication strategy is best to use with a client with anorexia nervosa, who is having problems with peer relationships?

Teach the client to communicate feelings and express self appropriately.

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom?

Depression

The grandparents of a client with anorexia nervosa want to support the client, but are not sure what they should do. Which intervention is best?

Encourage positive expressions of affection.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

Encouraging visitation by his friends

A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight with a parent. Which nursing intervention would be most helpful?

Examine the relationship between feelings and eating.

The nurse is collecting data from a parent regarding the child's behavior. Which behavior is consistent with the diagnosis of conduct disorder in this child?

The child has purposely hurt animals.

The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day?

The client asks many questions about the baby's care.

A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. When collecting data on this client, which typical manifestation does the nurse anticipate?

The client assumes an attitude that is the opposite of an impulse that the client harbors.

The nurse is caring for a client with paranoid personality disorder. Which behavior observed by the nurse is documented as a sign of this disorder?

The client is afraid another person will inflict harm.

A client diagnosed as having panic disorder is admitted to the inpatient psychiatric unit. Until admission, he or she had been a virtual prisoner in the house for 5 weeks because of agoraphobia, afraid to go outside even to buy food. The nurse, when planning care for this client, determines which action as this client's overall goal?

To help the client function effectively in his or her environment

A recently engaged 22-year-old woman loses her fiancé in a drunken driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:

a crisis caused by traumatic stress.

Which plan is most appropriate for a discharge home visit to parents who lost an infant to sudden infant death syndrome (SIDS)?

as soon after death as possible

Nursing care for a client after electroconvulsive therapy (ECT) should include:

assessment of short-term memory loss.

The nurse finds a client with Alzheimer's disease wandering in the hall at 3 a.m. The client has removed all clothing and says to the nurse, "I'm just taking a stroll through the park." What is the priority action by the nurse?

immediately help the client back to his or her room and into some clothing

A client with depression doesn't respond to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). The nurse knows that most people respond negatively to the thought of an electric current passing through the brain. Therefore, when discussing ECT with the client, the nurse should:

refer to the procedure as a "treatment" instead of "shock therapy."

A nurse is assisting with the development of a plan of care for a client with anorexia nervosa. Which action would the nurse expect to implement as part of the plan?

reinforcing a strict refeeding plan for the client

The nurse is caring for a client with posttraumatic stress disorder (PTSD) experiencing a frightening flashback. The nurse can best offer reassurance of safety and security through which nursing action?

staying with the client

A client tells the nurse "my coworkers are sabotaging my computer." When the nurse asks questions, the client becomes argumentative. Which intervention would be most appropriate for the nurse to implement?

talk with the client about the realistic situations

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain?

willingness to learn