Basic Psycosocial Needs NCLEX

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate?

3. Inviting a client with a similar experience to speak with the client

The nurse is caring for a terminally ill hospice client who has an advance directive. Which nursing intervention is no longer a priority?

3. Monitoring vital signs

The nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells her that he doesn't wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client's problem is:

3. Disturbed body image.

A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis. Two days later, the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of Hopelessness. To address this diagnosis, the nurse should include which intervention in the plan of care?

3. Encouraging the client to verbalize his feelings

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?

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

An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that the nurse has applied the restraints correctly?

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

The nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate?

1. Considering that nonverbal cues, such as eye contact, may have a different meaning in different cultures, 2. Respecting the client's cultural beliefs, 3. Asking the client if he has cultural or religious requirements that should be considered in his care

While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?

1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries., 3. Assist the client in developing a safety plan for times of increased violence., 6. Provide the client with telephone numbers of local shelters and safe houses.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful?

3. Recommending community resources for adult day care and respite care, 4. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease, 5. Asking whether friends or church members can help with errands or provide short periods of relief

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

3. To reduce the risk of postoperative complications

The nurse is collecting data on an adult's developmental stage. The nurse should consider:

3. previous problem-solving strategies.

A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the client's anxiety?

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

The nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. What is appropriate for the nurse to say to the client?

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

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?

4. "Would you like to talk about this?"

In her stages of death and dying, Elisabeth Kubler-Ross attributes loss, grief, and intense sadness to which stage?

4. Depression

The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family?

2. All the people whom the client views as family, 6. People who provide for the physical and emotional needs of the client

A hospitalized client states that he's having difficulty resting. Which intervention would help promote rest?

2. Assisting the client with deep-breathing exercises

Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my husband." Based on this statement, which nursing diagnosis is most appropriate?

2. Disturbed body image

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of the client's spouse. Which nursing diagnosis is most appropriate for this client?

2. Dysfunctional grieving

The nurse is caring for a 54-year-old client with chronic back pain. The client states that heat helps relieve the pain. Which action by the client indicates proper heat application?

2. Limiting application to 20-minute intervals

Which factor would have the most influence on the outcome of a crisis situation?

2. Previous coping skills

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

2. Situational

The Client 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?

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

A client who has difficulty sleeping is asked to keep a sleep diary. Which information should the nurse instruct the client to keep in his diary?

1. Usual bedtime

A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on his life with satisfaction. According to Erickson, the nurse concludes that the client is in a stage of:

1. generativity.

A client states, "I'd feel so much better if I could just sleep!" The best advice for this client is to:

1. resist napping during the day.

A client with a terminal illness has just been informed of his diagnosis. Indicators of the first stage of grieving include:

1. shock and dismay.

The physician prescribes bupropion (Wellbutrin), 150 mg by mouth twice per day to treat symptoms of depression. The nurse has 75-mg tablets on hand. How many tablets should the nurse administer with each dose?

2

The nurse explains hospital policies to a newly admitted 24-year-old client. Which statement by the client indicates the need for further teaching?

2. "I have the right to smoke in my room."

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?

2. "I'll sit here with you for a while. Would it help you to talk about it?"

A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which responses by the nurse would be appropriate?

2. "Let's talk about your mother's illness and how it will progress.", 3. "You sound like you have some questions about your mother dying. Let's talk about that.", 5. "Tell me how you're feeling about your mother dying."

The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client?

1. Illness in one family member can affect all members., 3. A family member may have more than one role at a time in a family., 5. The effects of an illness on a family depend on the stage of the family's life cycle., 6. Changes in sleeping and eating patterns may be signs of stress in a family.

For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep?

1. Play soft or soothing music.

The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife and becomes tearful. He expresses that he's been spoiled by a happy, satisfying sex life with his wife and says he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?

1. Situational low self-esteem

Which statement indicates that a newly hired nurse needs further training regarding confidentiality?

2. "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."

As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond?

3. "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."

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

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

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." The nurse's best response would be:

3. "You seem upset this morning."

A client who has been admitted for surgery seems preoccupied and anxious the night before the operation. Which comment by the nurse would promote therapeutic communication?

3. "You seem worried about something. Would it help to talk about it?"

A client, age 68, admitted for treatment of a colon tumor, asks the nurse, "Do I have cancer?" Which response by the nurse would be best?

3. "You sound concerned about what is happening."

A client must be placed on airborne precautions for several days. To help meet the client's emotional needs, what should the nurse do?

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

The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?

3. Generates new levels of awareness

The nurse is trying to establish rapport with a newly admitted client. Which technique blocks effective communication with a client?

3. Giving advice

Which safety device is most restrictive for a client with dementia?

4. Lap tray placed on a wheelchair

The nurse receives a change-of-shift report for a 76-year-old client who had a total hip replacement. The client is not oriented to time, place, or person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which actions by the nurse would be appropriate?

1. Assess and document the behavior that requires continued use of restraints., 2. Tie the restraints in quick-release knots., 4. Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours.

A 26-year-old client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate?

1. Take a seat next to the client and sit quietly., 4. Say to the client, "You're feeling upset about the news you got about the transplant."

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?

4. "You sound really discouraged today."

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?

4. "You think you have cancer?"

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?

4. Request assistance by using the call system.

A client with chronic pain asks for assistance with pain relief techniques. Which technique doesn't need to be included in the teaching?

4. Self-education about methods to assist in becoming pain-free

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort?

4. Sleeping undisturbed for 3 hours

During the initial admission process, a geriatric client seems confused. What is the most probable cause of this client's confusion?

4. Stress related to an unfamiliar situation

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?

4. Teaching the client alternative ways to lose weight