Basic Psychosocial Needs

The nurse is obtaining the health history of a client who is pregnant. The client's background differs from the nurse's. Which question best assists the nurse in developing culturally appropriate care?

"Are there any cultural preferences we should be aware of when caring for you?"

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?

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

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 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 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"?

80%

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?

Ask the client to discuss concerns.

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?

Care for elimination needs.

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who is hospitalized with a fractured left arm, a concussion, and multiple bruises in various stages of healing appears withdrawn.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?

acting quietly and passively about the pain

A client who has discovered a breast lump is tearful and expresses concern regarding the situation. What is the best response by the nurse?

Encourage verbalization of fears.

An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client?

Ensure case management is actively involved in the client's care to facilitate care coordination.

A nurse is caring for a client who has conductive hearing loss caused by otosclerosis. Which nursing action best facilitates communication with the client?

Face the client when speaking.

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?

Notify the surgeon about the client's concern.

A client at an inpatient psychiatric unit suddenly becomes loud and visibly anxious. What is the best action for the nurse to take?

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

A client is being seen in the emergency department and starts speaking in language not spoken by nursing staff. What is the nurse's first intervention?

Seek out a facility-approved translator.

When interviewing the parents of an injured child, which is an indicator that child abuse may be a problem?

The injury is not consistent with the history or the child's age.

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

extended

A nurse is gathering data from a client who has been raped. Which strategy would be most effective when talking with this client?

using open-ended questions and listening intently

A nurse is concerned about a client's ability to retain information during education sessions. Which of the following techniques would enhance the retention of material in presentations?

using repetition

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."

A client who is newly diagnosed with 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?"

A client on an inpatient psychiatric unit is pacing up and down the hallway. The client has a history of aggression. Which comment made by the nurse would be the most appropriate?

"You are pacing. Let's walk together and talk about it."

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be

"You seem upset this morning."

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be

-"You seem upset this morning."

The nurse is caring for a Native American/indigenous client with type 2 diabetes who requests participating in a sweat lodge healing ceremony. The client has found these ceremonies to be helpful in the past. Which action(s) should the nurse take? Select all that apply.

-Ask the client about the processes and purpose of a sweat lodge healing ceremony. -Ask what the client knows about the possible health risks associated with sweat lodges. -Investigate empirical evidence available on the use of sweat lodges in medical literature.

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. -Notify the instructor about the students' violation of client confidentiality.

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 is wearing street clothes and has combed hair.

A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure?

The nurse should contact the person identified as the healthcare power of attorney.

A 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?

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

A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." What is the priority action by the nurse?

Help the client break down large tasks into smaller ones.

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

Speak to the charge nurse about the nurse's moral conflict.

A 5-year-old is admitted to the emergency department with a broken clavicle. The nurse notices bruises in various stages of healing on the torso and extremities. The parent enters the room and angrily demands to take the child home. Which action is most appropriate?

Step out of the room, notify the charge nurse, and then call security.

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?

Use an electronic monitoring system.

The nurse should question the signed consent form for surgery for which of the following clients?

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

A nurse is caring for a client with multiple myeloma. Which finding indicates that the client is not coping well with the prognosis?

avoids conversations concerning his or her health

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.

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?

introducing new issues to the client

Six months after the death of her infant son, a client is diagnosed with dysfunctional grieving. Which behavior would the nurse expect to find?

overactive without a sense of loss

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

physiological

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?

poor boundaries.

The nurse distinguishes which assessment as evidence of an adult's developmental stage?

previous problem-solving strategies

The parents of a 6-month-old infant diagnosed with a terminal brain tumor have chosen palliative care for their child. What is the priority nursing intervention for this infant?

providing pain management, comfort measures, and support for the parents

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should

take measures to ensure privacy during the counselor's visit.

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?"

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?

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

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 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 is best?

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

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."

The nurse is caring for a client on a regimen of four medications to treat tuberculosis (TB). 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?

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

A client says to the nurse, "I know that I'm going to die." Which response by the nurse would be best?

"Tell me why you think you are going to die."

The nurse is helping a client with a terminal illness understand advance directives. Which statement by the client demonstrates an understanding of these documents?

"They guide the client's treatment in certain health care situations."

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."

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?

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

The parent of a child with hypospadias approaches a nurse. The parent asks the nurse, "Why did this have to happen to my baby? Why couldn't my baby be perfect? How could this have happened?" What would be an appropriate response by the nurse?

"You seem upset. Tell me about how 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?

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

During an admission data collection, the nurse asks a client why he's being admitted to the facility. The client responds, "The physician found a lump in my prostate gland. I guess I have cancer." Which response by the nurse would be most therapeutic?

"You think you have cancer?"

An alert and oriented client refuses chemotherapy. The client's family believes that the client should receive it. Which is the nurse's best response to the client?

"You understand that this decision is ultimately yours to make."

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."

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."

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.

-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.

A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply.

-Request that a health related interpreter to come to the home. -Utilize a trained telephone interpreter while providing care.

The nurse is caring for an older adult client whose caregiver is present. Which behavior(s) by the caregiver should the nurse regard as evidence of possible elder abuse? Select all that apply.

-Requesting no information be shared with the client without the caregiver present. -Offering conflicting information about the client's abilities and health issues. -Responding defensively when asked about the client's home supports and care delivery.

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 application of behavioral changes needs to be reevaluated.

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

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

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?

intimacy versus isolation

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

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

A nurse writes a note in a client's chart that says: "The physician is incompetent because the physician ordered the incorrect drug dosage." This statement may lead to a charge of

libel