Coordinated Care

A nurse is caring for a client who has a new diagnosis of chronic renal failure. The nurse should recognize which of the following client statements as an indication of anticipatory grief?

"I just can't believe that my whole life is going to be ruined by dialysis."

A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?

"You feel as though your life is ending?"

A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?

A client tells the nurse that his dentures are missing.

A nurse is explaining different types of complementary and alternative healing modalities to a client who has chronic pain. Which of the following healing modalities should the nurse describe as the use of needles to stimulate specific points on the body to relieve discomfort, promote health, and cure disease?

Acupuncture

The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?

Allow the family to view the body privately.

A nurse is caring for a client who has is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.

Aromatherapy

A nurse is reinforcing teaching with a client how to use meditation and progressive relaxation techniques to manage stress. Which of the following physiologic outcomes should the nurse instruct the client to expect? (Select all that apply.)

Arousal reduction Decreased blood pressure Decreased heart rate

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?

Biofeedback

A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?

Caffeinated coffee

A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher meal tray.

A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?

Continue the discussion while avoiding eye contact.

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using?

Distraction

A nurse is caring for a client who is postoperative following knee surgery. In addition to analgesia, the nurse suggests that the client imagine herself relaxing on a beach and enjoying the tropical breezes. Which of the following nonpharmacologic interventions for pain management is the nurse using?

Guided imagery

A nurse is caring for a client who signed an informed consent in preparation for a procedure. The client tells the nurse, "I have decided not to have the procedure." Which of the following actions should the nurse take?

Inform the provider that the client is withdrawing consent.

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals.

A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions is should the nurse take to help the client cope with his feelings of loss?

Listen attentively when the client talks about the past.

A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Provide routine analgesia to minimize episodes of breakthrough pain

A nurse on a medical-surgical unit is providing care for a client who is a hospital employee. Several nurses have called seeking information about the client. Which of the following actions should the nurse take in response to inquiries from the nurses?

Refer questions to the nursing supervisor.

A nurse is reinforcing teaching with a newly licensed nurse about zones of personal space. Which of the following examples should the nurse include as representing the personal zone?

Reinforcing teaching with a client.

A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority?

Schedule pain medication on a routine basis.

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the client's meals?

Steamed vegetables

A nurse is discussing cultural concepts in mental health nursing with nursing staff. When discussing Native American clients, the nurse should identify which of the following as an increased risk for this cultural group?

Substance use.

A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

The client achieves optimal personal growth.

A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse-client relationship?

Use active listening when with the client.

A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?

Use pictures to reinforce instructions given to the client.

A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?

Yoga

A nurse in an acute care facility is caring for a preschool-age child who is terminally ill and receiving palliative care. The parents tell the nurse that they have decided to take their child home. Which of the following responses should the nurse make?

"I will help you get ready to leave."

A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? (Select all that apply.)

"Music therapy can help her verbally express emotions." "Music therapy works as a distraction and can help alleviate her pain." "Music therapy can help facilitate movement in some clients who have mobility limitations."

A nurse is caring for a client whose parent has died. The client asks the nurse, "Why do I feel relief now that my dad is gone?" Which of the following responses should the nurse make?

"Tell me what you are thinking."

A nurse is reinforcing preoperative teaching with a client of Chinese heritage who speaks limited English. Which of the following methods of communication by the nurse demonstrates cultural competence?

Address the client by her last name.

A nurse is interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?

Arrange to complete the data collection with only the client and a translator present.

A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence? (Select all that apply.)

Culture Dexterity Motivation

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?

Denial

A nurse is providing palliative care to a client who is receiving hospice care and is approaching death. Which of the following actions should the nurse take? (Select all that apply.)

Do not force the client to stay awake. Position the client on her side. Perform mouth care with moist swabs.

A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?

Do not schedule diagnostic tests for Saturday.

A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?

Does not eat birds of prey.

A nurse is planning client care for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measuring a client's intake and output for the shift

A nurse is caring for a client who has schizophrenia. The client asks the nurse about her prescribed medications and their effects. The nurse asks the client why she wants to know this information. Which of the following nontherapeutic communication techniques is the nurse using?

​Asking for explanation

A nurse is caring for a client within the intimate zone of the client's personal space. Which of the following activities by the nurse occurs in this space? (Select all that apply.)

​Auscultating heart sounds ​Changing a wound dressing

A nurse is having difficulty caring for a client due to interpersonal variables affecting the communication process. Which of the following is an interpersonal variable? (Select all that apply.)

​Education ​Gender ​Perception

A nurse is caring for a client and asks the client to share personal stories. The nurse is using which of the following interventions to promote the nurse-client relationship?

​Narrative interaction

A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?

​Prepares to cleanse the client's body

A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?

​Request a meal tray without pork.

A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

​The shoulders droop. ​The facial muscles relax. ​​The pulse is within the expected range.

​A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?

​Use intermittent eye contact.