Exam 3 HA

A nurse is planning care for a client who is terminally ill. The client's spouse still works fulltime in order to pay for medical bills. The nurse determines the priority nursing diagnoses appropriate for the family is: 1) Caregiver role strain 2) Impaired home maintenance 3) Disabled family coping 4) Impaired parenting

1: Rationale: Caregiver role strain is the most appropriate nursing diagnosis in this case. The client's spouse must continue to work while the client's health deteriorates. Impaired home maintenance and disabled family coping may occur due to the client's health, however, this is not the priority nursing diagnosis. Impaired parenting is not an appropriate nursing diagnosis for this instance. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analyzing

Which statement by an older dying client indicates to the nurse that spiritual needs have been met? 1) "There have been many positive things about my life, and I have hope." 2) "I no longer fear pain." 3) "Family is the most important part of my life." 4) "The afterlife is the best place."

1: Rationale: When the individual's spiritual needs have been met, the person can be expected to express feelings of satisfaction with one's life and develop a new understanding of hope. Feelings about pain and appreciation of family are not necessarily linked to spiritual needs. Some religious groups do not believe in an afterlife. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is admitting a client on the mental health unit. During the admission process the client complains of difficulty falling asleep and appears to be preoccupied with health and money issues. The nurse is aware the client most likely is suffering from which alteration in coping? 1) Generalized anxiety disorder 2) Phobia 3) Acute stress disorder 4) Panic disorder

1: Rationale: With generalized anxiety disorder the client experiences excessive worry about a number of everyday problems for at least 6 months, with anxiety that is more intense than the situation warrants. They can become preoccupied with health issues, money, familial problems, or challenges at work. They often have a difficult time relaxing and falling asleep. With phobias there is an intense, persistent, irrational fear of something dreaded; may be an object, situation, or activity that elicits panic. With panic disorder is a sudden attack of terror that produces somatic manifestations including heart pounding, rapid heart rate, dizziness and lightheadedness. Acute stress disorder may include flashbacks or nightmares. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The nurse is caring for a client admitted with alcohol abuse. During the assessment the nurse notes which as impacting cognitive ability? (Select all that apply.) 1) Decreases antibody synthesis 2) Impaired judgment 3) Slowed reaction time 4) Decreased inhibitions 5) Impaired memory

2,3,4,5 Rationale: Substance abuse can impact cognitive ability, including slowing reaction times, decreasing inhibitions, and impairing judgment and memory. Substance abuse can affect nutritional status by decreasing the body's ability to synthesize antibodies due to lack of appropriate intake. Nursing Process: Analysis Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The nurse suspects that a client is experiencing a social phobia when data collection reveals which finding? (Select all that apply.) 1) Fears flying 2) Is overwhelmingly anxious when eating in front of others 3) Is afraid of blood 4) Has low self-esteem 5) Has an extreme fear of meeting strangers

2,5: Rationale: The client with social phobia will present with extreme self-consciousness and an overwhelming anxiety. Fear of blood is hematophobia. Fear of flying is aviophobia. The client with a phobia may have low self-esteem, but it is not central to the disorder. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

Which fear stated by the client would indicate to the nurse that the client is agoraphobic? 1) Spiders 2) Leaving the home 3) Being embarrassed in public 4) Losing control

2: Rationale: Agoraphobia involves fear of being away from home and being alone in public places. Specific phobia involves unrealistic fear of a particular object (e.g., spiders) or situation. Social phobia is excessive fear of embarrassment and humiliation in public settings. Fear of loss of control is an aspect of most phobias. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A psychiatric nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). What does the nurse suspect this client has been diagnosed with? 1) Bipolar disorder 2) Major depressive disorder 3) Adjustment disorder with depressed mood 4) Postpartum depression

2: Rationale: Electroconvulsive therapy (ECT) is used to treat major depressive disorder. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A client diagnosed with a phobia states that it is not possible to avoid the phobia. The nurse realizes this client is at risk for which occurrence? 1) Suicide 2) Panic attacks 3) Post-traumatic stress disorder (PTSD) 4) Hurting others

2: Rationale: The client who has a phobia that cannot be avoided is at risk and should be monitored for symptoms of panic attack. This client is not likely to experience PTSD or to harm others or self. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is explaining treatment options to a client with erectile dysfunction (ED). The nurse knows the client understands that which treatment draws blood into the penis and sustains an erection with a ring? 1) Penile implant 2) Inflatable prosthesis 3) Vacuum constriction device (VCD) 4) An O-ring alone

3: Rationale: A VCD draws blood into the penis and sustains the erection by placement of the O-ring at the base of the penis. An O-ring alone does not bring blood to the penis, but works for the client who is able to attain an erection. Penile implant and inflatable prosthesis are surgical procedures. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is teaching a 4-year-old and the parents about an oral medication that the child will be taking for an illness. The nurse shows the child the medication and tells the child that: 1) The child should take one teaspoon. 2) The medication tastes like cherry candy. 3) The medication is needed because the child is sick. 4) The medication will make the child feel happy.

3: Rationale: Small children should be told that the medication is being given because they are sick. It is not appropriate for the nurse to tell the child that the medicine tastes like candy or that it will make the child feel happy. The child is too young to understand how much one teaspoon is. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A client with hematophobia has been admitted with a respiratory disorder and is refusing to have their blood drawn for testing. After gathering data, the nurse adds which nursing diagnosis to the client's plan of care? 1) Death Anxiety 2) Risk for Aspiration 3) Ineffective Coping 4) Self-neglect

3: Rationale: The client with a phobia is unable to form a reality-based appraisal of the stressor and is therefore not coping effectively. Risk for aspiration, death anxiety, and self-neglect are not appropriate for this client given the information presented. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse working on a pediatric unit is aware that which behavior is the most likely way a very young child will re-experience a trauma? 1) Talking about the traumatic event. 2) Playing or acting out the traumatic event. 3) Refusing to talk about the traumatic event for fear of a mental illness stigma. 4) Drawing a picture that symbolizes the traumatic event.

4: Rationale A very young child may draw pictures that symbolize the traumatic event. Children at the age of 6 years may play or reenact the traumatic event. Because many older adults were raised during a time when mental illness carried a heavy stigma they may be fearful to share. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application

Which response from the nurse is appropriate when a client expresses feelings of worthlessness? 1) "Are you feeling that you have been abandoned?" 2) "Can you tell me why you think I have caused this?" 3) "I understand how you feel." 4) "This must be a difficult time for you."

4: Rationale: The best response is a statement of empathy for the client. This response signifies that the nurse understands the feelings that are present in the client. Asking if the client feels abandoned and making assumptions about what the client thinks of the nurse puts the emphasis on the nurse and negates the client's feelings. "I understand how you feel" is patronizing and will not elicit further feelings from the client. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is developing the plan of care for a client addicted to alcohol. The nurse includes in the plan of care to educate the client on the purpose and characteristics of support groups. During a discussion with the client on the characteristics of a support group which client statement indicates a need for further education? 1) "Attendance is voluntary." 2) "Group members have equal power." 3) "This will provide me with a healthy support network." 4) "A support group will cure me of my addiction."

4: Rationale: Supports groups will not cure an addict. Support groups will provide education and to act as a crisis support, a source of referrals, and an advocate to help people get their needs met through the healthcare system. Because people with addictions typically have a very restricted social network, often comprising others with similar addictions, it is important to help clients form a healthier base of support. Attendance is voluntary and group members do have equal power. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Evaluation

The client's child died in a car accident while the client survived. The client tells the nurse, "I should have died. I've always been a failure." The nurse plans to respond with which of the following? 1) "You have everything to live for." 2) "You've been feeling like a failure for awhile?" 3) "I don't think you are a failure." 4) "These feelings are all part of depression."

Rationale: The nurse is using restating as a means of validating the client's feelings and eliciting more information. The other statements block communication and negate the client's feelings, which will block therapeutic communication. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is preparing to conduct a wellness promotion group on the mental health unit. Which nursing interventions are appropriate when promoting wellness for clients with stress-related disorders? (Select all that apply.) 1) Promote regular physical exercise 2) Encourage personal boundaries 3) Educate on relaxation techniques to promote sleep 4) Promote time management and balance of activities 5) Encourage intake of caffeine to promote energy

1,2,3,4: Rationale: Intake of caffeine and use of nicotine may interfere with sleep-rest patterns; therefore, the nurse should discourage the use of caffeine. Regular physical exercise offers physiologic benefits, including improved cardiac and pulmonary function, enhanced muscle tone and joint mobility, and weight control. Education on relaxation techniques will help to promote sleep and therefore enhance cognitive functioning. Effective time management is associated with increased sense of control and decreased sense of stress. Boundaries aid in determining the appropriateness of requests/demands made by others. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application

Which are considered complimentary therapies for nicotine cessation? (Select all that apply.) 1) Hypnotherapy 2) Massage 3) Acupuncture 4) Yoga 5) Nicotine replacement therapy

1,2,3,4:Rationale: A number of complementary therapies have been advocated as tools for quitting smoking, hypnotherapy and acupuncture among them. Generally speaking, any therapy that helps reduce client anxiety levels, such as yoga and massage, will lower the likelihood that the client will want to use nicotine to alleviate anxiety. There is conflicting evidence about the success of hypnotherapy as a smoking cessation tool. As with any type of therapy, the qualifications and experience of the therapist have an effect on the success of the therapy. To increase the likelihood of success, nurses should encourage clients who are considering hypnotherapy also to participate in more traditional cessation programs. Nicotine replacement therapy is not considered a complimentary therapy. br> Client Need: Physiological Integrity Nursing Process: Planning Cognitive Level: Evaluating

The nurse is caring for a 10-year old child who is a victim of physical and sexual abuse. Which assessment techniques should the nurse employ when assessing an abused child? (Select all that apply.) 1) Ensure the child's safety. 2) Develop a trusting relationship. 3) The nurse needs to assure the child that they believe them. 4) The nurse needs to let the child know that the abuser is a very bad person. 5) The nurse needs to make sure the admission process is not repetitive.

1,2,3,5 Rationale: The priority nursing consideration is to ensure the child's safety. It is also important to develop a trusting relationship, let the child know they believe them, and assure the admission process is not repetitive. It is inappropriate for the nurse to make negative comments about the abuser. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application

The nurse is preparing a violence prevention program for a group of adolescents. Which are warning signs of impending violence? (Select all that apply.) 1) Uncontrolled anger 2) Inappropriate behavior 3) Threatening language 4) Disagreeing 5) Aggression

1,2,3,5: Rationale: Individual violence prevention involves recognition of the warning signs of potentially violent behavior such as, uncontrolled anger, threatening language, and aggression. Assessing for inadequate coping mechanisms, signs of inadequate anger management, or inappropriate behavior can help to identify potentially violent tendencies and implement behavior therapy before someone is victimized. Disagreeing is not a warning sign of impending violence. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Comprehension

Which statement identifies the reasons for a thorough and comprehensive assessment for anxiety? (Select all that apply.) 1) There may be comorbidity with other anxiety disorders. 2) Anxiety may express itself indirectly through nonspecific somatic symptoms. 3) Anxiety disorders are the least common of all mental illnesses and may be present in a client whose chief complaint is not related to anxiety. 4) Individuals who succeed in avoidance behaviors may not demonstrate anxiety despite significant disabling effects. 5) Clients with panic disorder often appear asymptomatic.

1,2,4,5: Rationale: It is relatively common for a person to have one anxiety disorder coexisting with another. For such individuals, the problems with daily living may be identified only through active listening regarding patterns of daily living. Anxiety may express itself through mild somatic symptoms in which the existence of an underlying anxiety disorder is overlooked. Unless they are in the throes of a panic attack, clients with panic disorder may not exhibit anxiety. Anxiety disorders are some of the most common disorders of mental illness. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

Which essential factors does the nurse assess when determining the impact of a family member's serious illness on the family? (Select all that apply.) 1) Duration of the illness 2) The meaning of the illness to the family 3) The coping mechanisms used by other families with similar illnesses 4) The financial impact of the illness 5) The incidence of the illness in the community at large

1,2,4: Rationale: It is essential that the nurse determines the duration of the illness, the meaning of the illness, and the financial impact of the illness in order to completely plan to meet the family's needs as well as those of the client. Coping mechanisms used by other families are not relevant at this stage, as the nurse does not yet know what the family's needs are. Knowing the incidence of the illness in the community is important for the community health nurse, but will not help the nurse plan care for this specific family. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is teaching older women about health risks for the postmenopausal period and would include which as health risks? (Select all that apply.) 1) Breast cancer 2) Macular degeneration 3) Joint degeneration 4) Gout 5) Cognitive changes

1,2,5: Rationale: Due to hormonal changes, postmenopausal women have a greater risk for macular degeneration, breast cancer, and cognitive changes than do premenopausal women. Joint degeneration and gout are not associated with menopause. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is conducting a class for middle-aged males about risks for erectile dysfunction and includes which risks while teaching? (Select all that apply.) 1) The client takes propranolol. 2) The client has diabetes mellitus. 3) The client uses herbal supplements. 4) The client is more than 64 years old. 5) The client is morbidly obese.

1,2,5: Rationale: Hypertension and hypertensive medications, diabetes, and morbid obesity are all risk factors for erectile dysfunction that have little to do with sexual desire. Age and herbal supplements are not necessarily related to erectile dysfunction. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is caring for a client who is experiencing a divorce and has symptoms of depression. Which of the following nursing diagnoses would be appropriate for this client? (Select all that apply.) 1) Fear 2) Ineffective coping 3) Ineffective activity planning 4) Readiness for enhanced coping 5) Risk for confusion

1,2: Rationale: The client who is facing divorce and is depressed is not coping effectively. This client is also experiencing fear of, perhaps, the unknown or the future. The other nursing diagnoses are not associated with situational depression. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Applying

Which are nursing roles when considering health promotion and tobacco use? (Select all that apply.) 1) Serve as a role model by not smoking. 2) Prescribe a nicotine replacement patch. 3) Suggest resources such as hypnosis, lifestyle training, or behavior modification. 4) Prescribe varenicline (Chantix) for smoking cessation. 5) Provide education information regarding the dangers of smoking.

1,3,5Rationale: The nurse's role regarding smoking is to (a) serve as a role model by not smoking, (b) provide educational information regarding the dangers of smoking, (c) help make smoking socially unacceptable (e.g., by posting no-smoking signs in client lounges and offices), and (d) suggest resources such as hypnosis, lifestyle training, and behavior modification to clients who want to stop smoking. Nurses also can promote health related to tobacco by being aware of marketing efforts that target young adults. Nurses cannot prescribe. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Understanding

A client diagnosed with depression expresses feelings of hopelessness to the client's nurse. What is the best response by the nurse? 1) "Are you having thoughts of suicide?" 2) "Why do feel like this?" 3) "Don't worry. Once you have been treated for depression, these feelings will subside." 4) "I understand. Your condition can cause these feelings."

1: Rationale: A client with depression has an increased risk for suicide. If a client expresses feelings of hopelessness, the nurse must first assess for thoughts of suicide. The other responses are incorrect and inappropriate. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Applying

The nurse who reports an incident of suspected child abuse or neglect is covered legally under what law or principle? 1) Principle of Good Faith Immunity 2) Principle of Civil Protection 3) Whistleblower Protection Act 4) Health Provider Protection Law

1: Rationale: All states provide some form of immunity from liability for persons who in good faith report suspected instances of child abuse or neglect under the reporting laws. Immunity statutes protect reporters from civil or criminal liability that they might otherwise incur. This protection is extended to both mandatory and voluntary reporters. The term "good faith" refers to the assumption that the reporter, to the best of his or her knowledge, had reason to believe that the child in question was being subjected to abuse or neglect. Even if the allegations made in the report cannot be fully substantiated, the reporter is still provided with immunity. Nursing Process: Implementation Client Need: Safe and Effective Care Environment Cognitive Level: Applying

A 56-year-old client diagnosed with multiple sclerosis complains that she and her husband have not had sex since she stopped walking one year ago. She states, "We are still attracted to each other, but how can I have sex when I can't move my legs?" What is the priority nursing plan for this client? 1) Educate the client about changes in position and other ways to share intimacy. 2) Provide education in safe sex practices. 3) Ask the client if her husband has problems with erectile dysfunction. 4) Allow the client to communicate her anger and frustrations.

1: Rationale: Alteration in mobility can affect sexual relations; however the nurse can educate clients with mobility alterations about changes in positions that may facilitate coitus and to discuss other ways to share intimacy. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis

A palliative care nurse understands that nurses can employ various interventions to help clients with their grief. An example of an independent intervention which can be utilized is: 1) Using active listening techniques to show full engagement in the interaction 2) Facilitating meetings between the hospital chaplain and the client 3) Requesting a referral to group therapy, bereavement groups, and grief therapists 4) Requesting a referral to a social worker who can provide expert guidance about coping with loss

1: Rationale: An independent intervention for clients with alterations in grief include using active listening techniques to show full engagement in interaction. All other interventions are important, however, are collaborative in nature rather than independent. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

Which charge could the nurse be brought up on if the nurse were to restrain a client against his or her will? 1) Assault and battery 2) Defamation of character 3) Negligence 4) Slander

1: Rationale: Assault and battery is the charge that could be brought against a nurse who restrains a client against his will. Defamation of character is a spoken or written statement made maliciously and intentionally that may injure the client's reputation. Negligence is the failure of commission of an act, or the omission of an act that a reasonably prudent person would have performed in a similar situation, that leads to harming another person. Slander is malicious or untrue spoken words about another person that are brought to the attention of others. Nursing Process: Assessment Client Need: Physiological integrity Cognitive Level: Applying

A 22-year-old client is diagnosed with pelvic inflammatory disease (PID) after a pelvic examination. After the exam, the client touches her breast and offers the nurse oral sex. What is the appropriate response by the nurse? 1) "Your behavior is inappropriate and embarrassing. Sometimes individuals talk like that when they are concerned about their illness and sexual life. Would you like to talk about your fears?" 2) "Stop or I'm calling the authorities." 3) "Why are you doing this? Please stop; this is embarrassing." 4) "What did the doctor say? Can you still have sex?"

1: Rationale: Before implementing any nursing interventions, the nurse should first determine whether the behavior is inappropriate or an attempt to communicate a physical need. Communicate that the behavior is not acceptable; Tell the client how the behavior makes you feel; Identify the behavior you expect; Set firm limits; Try to refocus clients from the inappropriate behavior to their real concerns and fears; offer to discuss sexuality concerns; Report the incident to your nursing instructor, charge nurse, or clinical nurse specialist. Discuss the incident, your feelings, and possible interventions; Assign a nurse who will confront the behavior and relate to the client in a consistent manner; and clarify the consequences of continued inappropriate behavior. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Apply

A mental health nurse is working with a client who is experiencing a complicated grief reaction and is seeking treatment in the form of Complicated Grief Treatment (CGT). Which statement is false regarding CGT? 1) The use of antidepressants alone may be just as effective as CGT. 2) During the first process, the individual accepts the loss. 3) Combining the use of antidepressants with CGT has proved to be quite effective. 4) CGT has been shown to be helpful to clients on its own.

1: Rationale: Complicated Grief Treatment (CGT) is a form of psychotherapy administered over 16 sessions in accordance with a published manual that describes this treatment. During the first process, the individual accepts the loss; during the restoration process, the individual begins to move on to a life without the deceased. CGT has been shown to be helpful to clients on its own, but some have used it in combination with antidepressants. While recent studies have shown that antidepressants may be helpful to those with depression related to grief, they do not appear to be as effective for clients with complicated grief. However, combining the use of antidepressants with CGT has proved to be quite effective in helping clients to work through their grief. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A nurse is caring for an elderly client who is experiencing complicated grief after the death of the client's spouse. The nurse understands that complicated grief in the elderly manifests as all except the following: 1) Disbelief 2) Preoccupation and yearning 3) Trust issues 4) Client distancing self from close friends.

1: Rationale: Complicated grief in older adults manifests in feelings of unrelenting preoccupation and yearning resulting from the loss, experienced over at least 6 months. Clients may also manifest trust issues, suspecting once close friends and family members of judging their pain or not understanding their emotions. Because of these feelings of judgment or betrayal, the clients may appear distant and even uncaring. Disbelief is a normal manifestation of grief, not necessarily complicated grief. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The student nurse is studying the nursing process and plans of care with regards to stress and stress management. The student nurse is aware that during the stress response there is a release of catecholamines epinephrine and norepinephrine. Which nursing intervention would be most appropriate to manage the effects of this release of catecholamines? 1) Monitor B/P and heart rate 2) Monitor blood glucose 3) Monitor oxygen saturation 4) Provide education on relaxation techniques

1: Rationale: During the stress response there is a release of catecholamines epinephrine and norepinephrine. This release causes an increase in blood pressure and heart rate placing a client at risk for hypertension and complications such as cardiovascular disease, cerebrovascular accidents, and renal damage. Therefore, it is imperative the nurse monitor B/P and heart rate. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application

Which treatment modalities would the nurse recommend for a client experiencing symptoms of seasonal affective disorder? 1) Phototherapy 2) Nutrition therapy 3) Aromatherapy 4) Cognitive-behavioral therapy

1: Rationale: Exposure to light will increase melatonin production, a hormone that affects mood. Cognitive-behavioral therapy is used to treat clients with behavior issues. Aromatherapy may be helpful temporarily, but it is the lack of light that is causing the problem. Nutrition is not a therapy, although this client may benefit from help with nutrition. However, cravings will be helped when the mood rises. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

A 53-year-old woman asks the nurse if there are any definitive laboratory tests that would show that she has entered menopause. The nurse responds that which test is done to clarify the diagnosis? 1) Follicle-stimulating hormone (FSH) level 2) Complete blood count 3) Estrogen levels 4) Blood, urea, nitrogen (BUN) levels

1: Rationale: FSH blood testing can be done after the woman has gone one year without a menstrual cycle. If the FSH is high, a diagnosis of menopause can be made. Complete blood count, estrogen levels, and BUN blood tests are not diagnostic for menopause. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is instructing a group of families regarding positive coping methods when faced with stress. What would the nurse include in the teaching? 1) Families with open communication among members 2) Families exhibiting minimal violent behaviors 3) Families with no boundaries between members 4) Decision-making by one family member

1: Rationale: Families with open communication are families with the strength to cooperate and allow for growth of the group. Decision-making by one member may be considered belittling to the rest of the group. Any violence in the family group is dysfunctional. Families with no boundaries foster codependence in the group. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Understanding

A 30-year-old African client is a survivor of FGM. What assessment complications would the nurse expect to find with this client? 1) Chronic UTIs 2) Abnormal Pap smear 3) Cervical cancer 4) Bilateral nipple discharge

1: Rationale: Female circumcision, also known as female genital mutilation (FGM) or female ritual cutting is a dangerous practice that is common in parts of Africa. Removal of the clitoris may or may not be accompanied by removal of the labia and closure of the vaginal entrance except for a small opening. Long-term medical complications include urinary incontinence, chronic urinary tract infections, vaginal scarring, pain syndromes, infertility, and sexual dysfunctions. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis

A palliative care nurse is caring for a terminally ill client and his family. The nurse understands that nursing implications for the grieving family include all except: 1) Recognize complicated grief if symptoms occurs up to 2 months after a loss. 2) Help the dying client grieve for their own loss of life. 3) Provide referral to assistance such as support groups and spiritual resources. 4) Assist family members in understanding the signs of grief and acceptance of death.

1: Rationale: Grief is an important consideration when working with end-of-life clients. Not only are these clients learning how to come to terms with the loss of their own lives, but their families experience a variety of hardships during this time. Nursing implications for the grieving family include: helping the dying client grieve for their own loss of life; assisting family members in understanding the signs of grief and acceptance of death; and provide referral to assistance such as support groups and spiritual resources. Complicated grief is diagnosed if it occurs at 6 months after a loss. The normal process of grief begins to fade 3 to 6 months after the loss. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

Which behavior does the school nurse recognize as an indicator that a school-age child has been physically abused? 1) The child bullies other children and threatens them to "keep quiet about it." 2) The child acts obediently when a parent scolds the child to be quiet. 3) The child sits quietly with a friend in the schoolyard instead of playing kickball. 4) The child tells other children that they will get a "time-out" if they continue to misbehave.

1: Rationale: It is common for children to model the behaviors of parents, siblings, other adults, or actions they see on television. Therefore, children have a high likelihood of adopting abusive tendencies perpetrated by their parents or siblings. Acting obediently when being scolded indicates appropriate discipline by the parent. There may be many reasons why the child does not want to participate in a physical sport. An abused child may be withdrawn and isolated from peers. Nonphysical interventions such as time-outs are more effective than spanking at modifying unwanted behavior. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is educating an adolescent client and the client's family on the importance of combining pharmacologic therapy with nonpharmacologic therapy. Which is considered a nonpharmacologic therapy in the treatment of phobias? 1) Cognitive-behavioral therapy 2) Benzodiazepines 3) Antipsychotics 4) Alcohol

1: Rationale: It is critical that the nurse working with the phobic client explain the importance of cognitive-behavioral therapy (CBT) as a treatment for the client's phobia and that any medication used as treatment will be less effective if not used in combination with cognitive-behavioral therapy. Benzodiazepines and antipsychotics are examples of pharmacologic treatment. Alcohol would not be appropriate, although people with phobias are known to self-medicate with alcohol. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse on a mental health unit is interacting with a newly admitted client. Which action taken by the nurse would be inappropriate? 1) Use terms of endearment 2) Making eye contact 3) Having a nonthreatening stance 4) Validate the client's feelings

1: Rationale: It is not appropriate to address the client using terms of endearment. This action is impersonal and demeaning. The nurse should call the client by name when addressing the client. In an effort to promote trust and to calm an anxious client it is appropriate for the nurse to maintain eye contact, focusing on the client and to use a nonthreatening stance. It is also appropriate to validate the client's feelings. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application

The nurse is caring for a client diagnosed with a phobia. While teaching the client and the client's spouse passive technique or activity, which should the nurse recommend to promote relaxation? 1) Listen to soothing music. 2) Paint a picture. 3) Take a walk. 4) Organize a closet.

1: Rationale: Listening to soothing music is passive because the client is not performing an action. Walking, organizing a closet, and painting a picture are active techniques to relieve anxiety. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

To prevent accidents due to sensory deprivation in the older adult, the nurse plans to teach the client to: 1) Obtain regular vision and hearing assessments. 2) Refrain from cooking on a hot stove. 3) Keep all doors open for easy escape. 4) Wear reading glasses at all times.

1: Rationale: Many accidents in the older client are due to sensory deprivation. The nurse will encourage this client to have regular hearing and vision assessments to prevent injury. The older client can cook on a hot stove but should be cautioned regarding the use of long, loose sleeves that could catch fire. The older client should keep doors locked when in the home. Reading glasses are not worn for distance viewing. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Understanding

The adult child of an elderly client with depression asks the nurse why elderly people are at higher risk for developing depression. Which response by the nurse is most appropriate? 1) "Older clients have higher levels of an enzyme that slows signals to the brain, causing depression." 2) "Older clients have a higher level of a thyroid hormone that can lead to depression." 3) "Older adults have enlarged ventricles of the brain, which can lead to depression." 4) "Older adults have higher levels of chemical messengers in the brain that result in depression."

1: Rationale: Older adults, especially women, have higher levels of monoamine oxidase, which deactivates neurotransmitters, resulting in decreased impulse transmission that can cause depression. The other explanations are inaccurate. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is assessing a 65-year-old client who complains of priapism after "taking the little blue pill" 6 hours ago. What is the nurse's priority intervention for this client? 1) Ice packs to reduce swelling and pain to prepare for aspiration 2) Lubrication to prevent clothing friction 3) Lidocaine to decrease penile pain 4) Estrogen to counteract the testosterone in the Viagra

1: Rationale: Priapism is a persistent penile erection unrelated to sexual stimulation that last 4 or more hours and can lead to scarring and permanent erectile dysfunction. Treatments include Ice packs to reduce swelling; surgical ligation of artery; intracavernous injection; aspiration; and surgical shunt of blood flow. Lubricants are used to lubricate the vagina for sexual stimulation, lidocaine is used for vaginal pain during or after intercourse, and hormonal therapy is used to control vaginal bleeding. Nursing Process: Intervention Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is providing an in-service for peers regarding safety in the workplace to prevent injury. The nurse would include: 1) Assuring proper posture when using the computer 2) Using only the staff elevators 3) Keeping computers turned away from the unit 4) Talking with colleagues in a private area

1: Rationale: Proper posture when working on the computer can help prevent low back injury. Using staff elevators, turning computers away from the unit and talking in private all speak of methods of protecting client information. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A client arrives at the emergency department in a severe state of anxiety following a motor vehicle accident. Which is the most appropriate action for the nurse to take? 1) Remain with the client. 2) Put the client in a room alone. 3) Teach relaxation breathing exercises. 4) Encourage the client to talk about the experience.

1: Rationale: Remaining with the client may help decrease the anxiety level. Leaving the client in a room alone may elicit feelings of abandonment and increase anxiety levels. The client in a severe state of anxiety is not ready for teaching. The client is not encouraged to talk about the feeling initially, as this will reinforce the anxiety. When the anxiety has decreased and some distance has occurred, then the client is better able to process the trauma. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

A client with a head injury is being verbally abusive to the nurses and staff on the neuro unit. The nurse knows that which intervention is the best for this situation 1) Decrease stimuli and sit with the client until calm. 2) Administer Haldol 1 mg IM per orders. 3) Administer Ativan 1 mg PO. 4) Apply wrist restraints and check vital signs every 5 minutes.

1: Rationale: Restraints are warranted when a client is at risk of injuring himself or others. Restraints can be physical or chemical; however, unless injury is imminent, the least invasive and less restrictive measure should be implemented and determined ineffective prior to implementation of more restrictive measures. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Analyzing

A 13-year-old client has started her menstrual cycle 6-months ago. The frustrated client complains, "my period never comes on at the same time!" What is the best response made by the nurse? 1) "Wearing panty liners every day until your cycle becomes regular is an option so your clothes won't get stained." 2) "Are you taking any birth-control pills?" 3) "Do you have cramping before it comes on?" 4) "Make sure you use condoms whenever you have sex to prevent STIs and pregnancy."

1: Rationale: Teenage girls may have irregular menstruation initially, which can lead to embarrassment because of stained clothing. Girls should also be counseled regarding the variety of feminine hygiene products available (e.g., sanitary pads and tampons) so that they can make intelligent choices. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The nurse is working with a client who has been treated for depression in the past and is planning on getting married in a few weeks. The nurse is aware that marriage could cause symptoms of depression since this is considered a: 1) Maturational crisis 2) Behavioral crisis 3) Spiritual crisis 4) Coping crisis

1: Rationale: The client who has been treated for depression in the past may be at risk for maturational crisis (depression due to normal life changes). Even though this is a happy occurrence, the client could experience symptoms of depression during this normal time. The other options are not considered crises but skills that the nurse assesses the client for. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A 25-year-old pregnant mother of two is very protective and will not allow the children to play outdoors for fear of tick bites. The mother asks the nurse how she can stop worrying so much. Which response by the nurse would be most appropriate? 1) "Tell me your concerns about the children playing in your backyard." 2) "Why do you worry about the children getting tick bites?" 3) "Allow the children to play outside after they are sprayed with tick repellent." 4) "Have you sprayed your backyard for ticks?"

1: Rationale: The nurse is helping the client explore unrealistic fears. This is the beginning of the process of restructuring her cognitive thoughts and reducing anxiety. Spraying the children or yard does not affect the client with unreasonable anxiety, but getting at the cause of the irrational thinking does. Asking the client why she is worried is a challenge and risks losing the nurse-client trust relationship. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

During a home visit, the nurse notes that the parent is allowing the preschool child to help with the preparation of dinner. The nurse plans to teach the parent that: 1) Hot pots should be placed on the back burners. 2) The child should not be taught to clean the counters. 3) Children should not be in the kitchen during food preparation. 4) The child should be told not to touch the knives.

1: Rationale: The nurse would teach the parent to keep hot pots on the back burners to prevent accidental scalding of the child. It is good to allow children to prepare meals under supervision that is age appropriate. Knives should be kept out of the child's reach at this age. Children can help clean the counters with noncaustic agents such as soap and water. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse is caring for a client 'who has developed symptoms associated with neuroleptic malignant syndrome (NMS). The priority of action for the nurse is to: 1) discontinue the client's neuroleptic medication and report the symptoms to the physician immediately. 2) Chart the assessment findings and report them to the primary nurse at change of shift. 3) Continue the medications and perform more frequent assessments of the client. 4) Discontinue the neuroleptic medication and document assessment findings as the cause for the action.

1: Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), a potentially fatal idiopathic response to high-potency neuroleptic medications. The medication should be discontinued and the physician notified immediately. NMS is an emergency and must be reported immediately to the physician before charting. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

A client tells the nurse that he has been diagnosed with generalized anxiety disorder. He also states that his brother has a separation anxiety disorder, which has been hard on the family. Which is the nurse's best response to this client? 1) "Anxiety can be characterized by excessive worry. It's the same for your brother, who excessively worries when being apart from your parents." 2) "It may be that your brother is aware of something that you've repressed." 3) "Some believe that clients who have separation anxiety are just trying to get attention." 4) "Do you know of any physical abuse in your brother's childhood?"

1: Rationale: This statement imparts information and promotes recognition of the commonality between the disorders. It would not be proper to ask the client about a sibling in a group or otherwise. Telling the client what some people believe about separation anxiety is showing possible bias and is not appropriate. It is inappropriate to suggest that the brother is aware of something the client has repressed. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is conducting a support group for those clients who have been in an abusive relationship. Which is an accurate description of abuse? 1) A pattern of behavior that takes away freedom of choice 2) The taking of one's own life 3) Injury incurred from an act of violence 4) A fatal injury incurred from an act of violence

1: Rationale: Abuse is described as a pattern of behavior that dominates, controls, lowers self-esteem, or takes away freedom of choice. Can include elder abuse, child abuse, intimate partner abuse, and sexual abuse. Suicide is the taking of one's own life. Assault is described as injury from an act of violence where physical force is used with intent to harm and homicide is injury from an act of violence where physical force is used to kill. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The school nurse teaches elementary school teachers about occurrences of violence towards children. The nurse knows that further teaching is necessary if a teacher makes which statement? 1) "Children with special needs are less vulnerable to physical abuse than other children." 2) "Poor hygiene and inappropriate clothing are possible signs of child abuse." 3) "Physically abused children may appear overly submissive and eager to please their teacher." 4) "Children who are physically abused by their parents are more likely to abuse siblings."

1: Rationale: Caregiver stress and frustration may lead to abuse or even homicide of children with special needs. Children who are physically abused by their parents are more likely to abuse siblings; sibling abuse is the most unrecognized form of abuse. Physically abused children may appear overly submissive and eager to please their teacher; abused children are frequently overly compliant in response to all adults. Inadequate physical care or lack of care for a child may be a sign of child abuse. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse working on a behavioral unit is aware that nursing interventions for clients with addictive behaviors primarily focus on which of the following? (Select all that apply.) 1) Moderate family cohesion 2) Promoting healthy client coping skills 3) Establishing boundaries 4) Treating specific symptoms 5) Developing therapeutic relationships

2,3,4,5: Rationale: Nursing interventions for clients with addictive behaviors primarily focus around nursing care for any specific presenting symptoms, developing and maintaining the therapeutic nurse- client relationship (including establishing and maintaining appropriate boundaries), and promoting healthy client communication and coping skills. See the module on Stress and Coping for a discussion about defense mechanisms and nursing interventions to help clients develop healthy coping skills. The goals of family therapy, a collaborative intervention, are to help families cope, improve their communication and interpersonal skills, establish boundaries, and moderate family cohesion and flexibility. Families strive to maintain balance and harmony. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. The nurse advises the mother that she should: 1) Omit the afternoon nap. 2) Place a crib net over the top of the crib. 3) Restrain the child if he gets up more than once. 4) Remove all objects from around the crib.

2: Rationale: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Just removing objects from the floor around the crib would not prevent a child from climbing out of a crib. Restraining the child would be dangerous and contribute even more to his determination to get out of the crib. A child of 2 years should still be taking a nap; it poses a dangerous situation, naptime or bedtime, if the child is still crawling out of the crib. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A nurse is caring for the family of a client who died. The nurse observes the family celebrating with music and dancing. The appropriate response from the nurse is: 1) Observe the practice but notify the family that the practice is inappropriate. 2) Observe the practice but do not intervene unless asked by the family. 3) Observe the practice and suggest a different coping mechanism for the family. 4) Observe the practice and participate once it appears appropriate.

2: Rationale: Accurate assessment of the grieving process requires awareness of an individual's cultural influences. Certain cultures see death as a beginning rather than an end and choose to celebrate the individual's life on earth and the movement to the next life. The nurse should observe the practice but do not intervene unless asked by the family. A nurse who suggests a different coping mechanism or tells the family the practice is inappropriate, is not culturally aware of the variety of mourning practices. The nurse should not participate in the celebration unless asked by the family. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is instructing a 68-year-old client with a history of MI and erectile dysfunction about adverse effects of taking tadalafil (Cialis). The nurse instructs the client to notify the physician if he experiences: 1) one erection in 36 hours. 2) an erection lasting more than 4 hours. 3) disinterest in sexual activity. 4) sleeping for 9 hours.

2: Rationale: An erection that last more than 4 hours is an adverse effect and needs immediate attention to prevent damage to the penis. One erection in 36 hours is an expected effect. Disinterest in sex and sleeping for 9 hours are not effects of the medication. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

A 10-year-old whose dog died last year is in the clinic for an annual physical examination. The nurse determines that goals for the child have been met when the child states which of the following? 1) "I don't like dogs." 2) "I have asked for a new dog for Christmas." 3) "I still cry at night because I miss my dog." 4) "My mother wants a new dog."

2: Rationale: Asking for a new dog indicates that the child has resolved the feelings related to loss of the dog that died. Continuing to cry or developing a dislike of dogs indicates that there are still feelings of unresolved grief, and may indicate depression. If the child states that the mother wants the dog, he is refusing to let his own feelings out and has probably not resolved the hurt. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Applying

Which intervention should the nurse include when planning the care for an adolescent female who is pregnant and lives alone? 1) Notify social services. 2) Assess the client for strengths and resources. 3) Advise the client to give the baby up for adoption. 4) Refer the client for welfare.

2: Rationale: Before planning care for this client, the nurse would assess the client for strengths and resources that are available to support the client in her wishes. Referring the client for welfare or social services, unless requested by the client, is a disservice to the client who is ready and able to plan her own life. A nurse does not recommend adoption to a client: if the nurse observes evidence that the client cannot care for herself or the infant, a referral might be made to social services. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse has assessed an older client in the unit who is experiencing confusion and a severe ear infection. When planning priority of care for this client, the nurse includes measures to: 1) Prevent the client from ambulating in the halls. 2) Prevent falls. 3) Prevent skin breakdown. 4) Prevent violence to others.

2: Rationale: Clients with ear infections are apt to experience dizziness and need to be protected from falls. The client may ambulate but with assistance. Skin breakdown prevention is necessary, but prevention of falls is the priority. There is no evidence that the client has the potential to be violent. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse is assessing a 78-year-old client and is determining the client's risk for injury status. The nurse would concentrate a safety assessment on: 1) Unsafe work environment 2) Cognitive awareness 3) Brand of car used 4) Number of children in the home

2: Rationale: Clients with impaired cognitive ability are at risk for injury. When caring for the older client, the nurse would want to determine the cognitive awareness of the client. Clients at age 78 are likely retired. The brand of car driven and number of children in the home are not relative to risk for injury. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A nurse is planning for the discharge from the clinic of a client who experienced depression following the loss of a job. The nurse understands that the client's unresolved feelings of loss may resurface during which phase of the nurse-client therapeutic relationship? 1) Orientation phase 2) Termination phase 3) Working phase 4) Trusting phase

2: Rationale: Ending treatment in the termination phase may cause some clients to have a resurfacing of the feelings of loss, so the nurse plans for this issue. Feelings of loss of the relationship with the nurse do not occur during the other phases of the therapeutic relationship. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Understanding

The nurse is caring for a client with an endometrial implant. The client asks the nurse what happens to the implant now that she is experiencing menopause. The best reply by the nurse is that the implant: 1) tends to become malignant. 2) tends to atrophy and disappear. 3) increases in numbers. 4) enlarges in size.

2: Rationale: Endometrial implants tend to atrophy and disappear after menopause since ovarian hormones no longer stimulate them. Implants do not tend towards malignancy and, with no or little hormone stimulation, will not increase in size or number. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Understanding

A nurse is caring for a client who is grieving the loss of a spouse. The nurse understands that grief is a combination of various factors including all except: 1)Behavioral 2) Moral 3) Biological 4) Psychological

2: Rationale: Grief is the combination of various psychological, biological, and behavioral responses to a loss. Morality is not a factor in grief. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

Which intervention will the nurse initiate for the family of a client with a terminal illness who wishes to be at home for end-of-life? 1) Point out the hardships of having a dying client in the home. 2) Refer the family to hospice care. 3) Refer the family for counseling before allowing the client to go home. 4) Notify the physician of the client's wishes.

2: Rationale: Hospice services provide care to the family and to the client who prefers to die in the home. Pointing out the hardships to the family is not the role of the nurse or the physician unless there is a fear the client will not receive appropriate care. Referring the client to counseling before there is evidence of a need is not appropriate. The physician is not involved in nursing decisions. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

A client tells the nurse that the family will be having a reunion at the local park this summer. The nurse teaches the client that: 1) It is important to drive safely to the reunion. 2) All perishable food should be kept chilled. 3) Playground equipment should be checked for safety. 4) Overdressing may cause heatstroke.

2: Rationale: In the summer, the nurse would remind the client to keep foods containing mayonnaise and other perishables in a chilled container to prevent food poisoning. Driving safely, checking equipment safety, and avoiding overdressing are good advice but not as important for this client as food safety. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

During the examination portion of her annual checkup, a 55-year-old client has several new complaints. Which subjective symptoms of menopause would the nurse expect to find during data collection? 1) Hair growth on the upper lip 2) Night sweats 3) Decreased skin elasticity 4) Rise in vaginal Ph

2: Rationale: Night sweats is the only symptom that is subjective, reported by the client. Facial hair, decreased skin elasticity, and a rise in vaginal pH are all objective signs that can be observed by the nurse. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Applying

The graduate nurse is in orientation and is learning about basic competencies that are required for employment. In order to improve safety through communication, the nurse plans to become proficient at: 1) Monitoring for equipment failure 2) Using the hospital informatics system 3) Communicating with clients 4) Creating a culture of trust

2: Rationale: Nurses need to be competent in using computers as a way of communicating with the healthcare team members in an effort to promote safety. Monitoring equipment failure is not communication. Communicating with clients is not necessarily a competency that promotes safety for all clients. It is the responsibility of the administrative staff to promote a culture of trust. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Remembering

The nursing instructor is discussing National Patient Safety Goals (NPSG) with the students and asks a student to explain the reason and purpose of these goals. The instructor concludes that the student has understood the teaching when the student responds: 1) "NPSG focuses on the person making the error." 2) "NPSG increases awareness of patient safety needs." 3) "NPSG increases safety in hospitals only." 4) "NPSG does not address safety regarding clinics."

2: Rationale: One purpose of NPSG is to increase awareness nationwide of the need for ensuring client safety. These goals pertain to every type of healthcare agency. The focus is on solutions, not the person who made the error. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Remembering

An elderly client is dying and experiencing anxiety. The nurse makes which intervention a priority? 1) Allowing the client time alone to conduct a life review 2) Assisting the individual to identify fears 3) Explaining that anxiety is a common experience 4) Contacting the family to enlist their help

2: Rationale: People who are dying typically have many fears, including pain, being left alone, or being forgotten. Facilitating the client's identification of fears allows the nurse and client to work together to find ways to alleviate the concerns. Giving the client some time to be alone and contacting the family might be appropriate, but not until after the nurse has determined with the client that it would be helpful. Merely explaining that anxiety is common, without further intervention, is not the best action by the nurse. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

A very confused client on the unit is wandering. Which is an alternative to using a restraint for this client? 1) Wedging pillows against the side rails on the client's bed 2) Placing a rocking chair in the client's room 3) Assigning this client to the room farthest from the Nurses' station 4) Pulling up all the side rails on the client's bed

2: Rationale: Placing a rocking chair in the client's room will help the client to expend some energy so the client will be less inclined to walk and wander. Pulling up all the side rails is a restraint, so that action would not be an alternative. Assigning the client to the room farthest from the nurses' station would be an unsafe move for the client; closer would be safer than farther. Keeping pillows wedged against the side rails will not keep the client from wandering; the client is not in the bed. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse is caring for a client who is experiencing a major depressive episode. The nurse monitors the client for signs of urinary retention and constipation, which are possible due to: 1) Inadequate dietary and fluid intake 2) Psychomotor retardation and medication 3) Lack of exercise 4) Poor dietary choices

2: Rationale: The only option that can cause urinary retention and constipation is psychomotor retardation and medication. Medication therapy with tricyclic antidepressants is known to cause urinary retention and constipation. Psychomotor retardation is characterized by noticeably slowed body movements and a subsequent slowing of all body processes, which can lead to urinary retention and constipation. Inadequate dietary and fluid intake can lead to constipation. Lack of exercise and poor dietary choices also can cause constipation. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

An elderly client is grieving over the death of her spouse 7 months ago and tells the nurse that she is unable to walk down the street in her neighborhood because it reminds her of the loss. The priority nursing diagnosis is: 1) Disturbed self-image 2) Complicated grieving 3) Risk for situational low self-esteem 4) Grieving

2: Rationale: The patient is displaying symptoms of complicated grief. Complicated grief in older adults manifests in feelings of unrelenting preoccupation and yearning resulting from the loss, experienced over an increased duration of time (at least 6 months or more). All other nursing diagnoses do not apply. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse determines that a client with a phobia has not met goals when the client demonstrates which behavior? 1) Nausea and vomiting 2) Withdrawal 3) Complaining of a dry mouth 4) Fearfulness

2: Rationale: The phobic client who withdraws is not meeting the goal of demonstrating the absence of anxiety. Dry mouth and nausea are physical cues, and fearfulness is an emotional cue. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Applying

Which outcome is most realistic and appropriate when planning care for a client newly diagnosed with an anxiety disorder? 1) Within 2 months, the client will discuss the reasons for episodes with significant others. 2) Within 1 month, the client will experience decreased episodes. 3) Within 2 months, the client will be episode-free. 4) Within 2 months, the client will establish two new relationships.

2: Rationale: This outcome may not occur, but it is the most realistic outcome listed. Within 1 month, with intervention, the client may experience a decrease in episodes. Discussing the reasons for the episodes may not be realistic because the information may be repressed and may take years to get at, if ever. An anxiety disorder is not cured in 2 months. Establishing new relationships is not directly relevant to anxiety. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is admitting an older client to the hospital from a long-term care facility. In compliance with National Patient Safety Goals, the nurse plans to request: 1) When the client last ate 2) A list of the client's current medications 3) Documentation regarding restraints 4) Documentation of care at the agency

2: Rationale: When clients are transferred between agencies, their current list of medications, including when each was given last and when each is due, must be sent to the receiving agency to prevent medication errors. It is not necessary to know when the client last ate. Restraint documentation is not needed nor is documentation regarding care needed unless it affects the admission and ongoing care. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse is teaching a client and family, who all smoke, about health issues regarding smoking. Which statement indicates the need for further teaching? 1) "Cigarette smoking is the number one cause of preventable disease and death worldwide." 2) "Concentrations of many cancer-causing and toxic chemicals are lower in secondhand smoke than in the smoke inhaled by smokers." 3) "Smoking harms nearly every organ in the body, and is a main cause of lung cancer." 4) "Nonsmokers who are exposed to secondhand smoke at home or work increase their lung cancer risk by 20%-30%."

2: Rationale: Concentrations of many cancer-causing and toxic chemicals are higher in secondhand smoke than in the smoke inhaled by smokers. All the other statements are correct. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analyzing

The nurse is interviewing a client addicted to narcotics. During the assessment interview which question asked by the nurse would be inappropriate? 1) Have you had similar stresses/problems in the past? 2) Why do you think you need drugs? 3) Are you feeling as though you want to harm yourself or others? 4) What are your expectations and hopes concerning this problem?

2: Rationale: It is appropriate to ask questions in regards to past behaviors. It is also appropriate to ask if they want to harm themselves or someone else. Furthermore it is important to ask questions regarding their expectations. The nurse should not question why during an interview. This type of questioning does not promote a trusting relationship. Nursing Process: Assessment Client Need: Psychosoical Integrity Cognitive Level: Analysis

A client who has been physically abused asks the nurse, "What makes people so violent toward others?" Which is the best response to this question? 1) "If women were more agreeable, there wouldn't be any violence." 2) "It is difficult to give one specific reason for violent behavior." 3) "Hormones are the primary reason for violence in men." 4) "Violence is inherited from a person's family."

2: Rationale: Many theories exist concerning the motivation for violent behavior and abuse within families. Some of those theories propose that individuals are genetically predisposed to violence, while other theories discuss the influences of society and family structure. No definite causes of family violence have ever been agreed upon, but theories such as the psychopathology theory and the social learning theory lead into one another to help highlight some contributing factors to abusive behavior. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is aware that there are psychological factors of substance abuse. Which description best describes psychoanalytical theorists' views? 1) They see addition as a learned behavior. 2) They view substance abuse as a fixation at the oral stage of development. 3) They see addiction as a maladaptive behavior. 4) They focus on the dysfunctional pattern of family relationships.

2: Rationale: Psychoanalytical theorists do view substance abuse as a fixation at the oral stage of development, whereas behavioral theorists see addiction as a learned maladaptive behavior. Family system theory focuses on a dysfunctional pattern of family relationships throughout several generations. Nursing Process: Analysis Client Need: Psychosocial Integrity Cognitive Level: Comprehension

Which collaborative treatment option would be most appropriate for each of these alterations in violence, including abuse, assault, rape, and suicide? 1) Pharmacological therapy 2) Support groups 3) Sexually transmitted disease testing 4) Legal interventions

2: Rationale: Support groups would be an appropriate therapy for all alterations in violence mentioned above. Sexually transmitted disease testing would be appropriate for rape. Based on the information provided pharmacological therapy would primarily be appropriate for suicide and rape. Legal intervention would be for abuse, assault, and rape. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application

Which nursing diagnosis would be priority for a homosexual client who has been repeatedly physically assaulted by the partner? 1) Powerlessness related to feelings of dependence on significant other 2) Risk for injury related to history of abuse by significant other 3) Chronic low self-esteem related to guilt and shame for being a victim of abuse 4) Social isolation related to control by the significant other and feelings of inadequacy

2: Rationale: The safety of the client is the priority diagnosis. The greatest predictor of continued violence is the previous history of violence by the partner. Although powerlessness related to feelings of dependence on the significant other is an appropriate diagnosis, a concern for safety is the number-one priority. Chronic low self-esteem related to guilt and shame for being a victim of abuse may be appropriate for this client, but safety is the first concern. Social isolation related to control by the significant other and feelings of inadequacy may be an appropriate diagnosis for this client, but a threat to safety would supersede this diagnosis. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Applying

There are several non-modifiable factors that can be associated with the occurrence of violence. Which comment made by the student nurse indicates the need for further instruction? 1) "Patterns of violence evolve over a person's lifetime." 2) "Genetics plays a primary role in the manifestations of violence and anger." 3) "Some environmental factors increase the risk for violence in youth." 4) "Mental health alone is not a predictor of future violent behavior."

2: Rationale: While genetics is found to play a role in whether an individual becomes violent, environment is often a co-factor in its manifestation. Examples of environmental factors that may affect whether a person becomes violent include prior abuse and exposure to violence. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application

A client who has experienced the loss of a job and is depressed asks the nurse how cognitive-behavioral therapy can help return the client's good mental health. The best response by the nurse is which of the following? 1) "It trains you to be on 'automatic pilot' emotionally." 2) "The therapist figures out pleasurable activities." 3) "It will help you to explore new ways to react to negative situations." 4) "It will help you to sublimate negative reactions."

3: Rationale: A therapist helps the client identify habitual negative responses to stress and replace those with healthy responses. Sublimating negative reactions means they are still a part of the client and they will resurface. The client, not the therapist, learns to identify pleasurable activities. The client is trained to look at new ways of dealing with stressful situations so that the client is not on "automatic pilot." Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is taking care of a 46-year-old client status post angioplasty, who complains that he is still "having problems in the bedroom." The client states, "I think I might have to have another procedure done." What is the nurse's priority response? 1) "I think you need to see a sex therapist." 2) "Have you discussed this with your wife?" 3) "Are you taking Digoxin (Lanoxin)?" 4) "Let's call the doctor in now."

3: Rationale: Alteration in perfusion can cause erectile dysfunction due to arterial and/or venous flow. The client had an angioplasty to correct his perfusion issues; however, cardiotonics like digoxin, used to correct vascular supply, can cause decreased sexual desire, erectile dysfunction, and ejaculatory failure. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis

The nurse caring for a grieving client evaluates the client's plan of care. Which statement demonstrates an achieved outcome for this client? 1) The client will participate in group therapy or one-on-one therapy, depending preference. 2) The client will use healthy coping mechanisms. 3) The client employs healthy coping mechanisms. 4) The client will ask for help and support when needed.

3: Rationale: An achieved outcome for this client is "The client employs healthy coping mechanisms". The other options are acceptable but are anticipated outcomes, not achieved. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analyzing

A nurse in the emergency department is caring for a client who experiences recurrent panic attacks. The client states, "I want to know what causes these attacks so I can stop them from happening." Which response by the nurse would be most appropriate? 1) "No one really knows what causes panic attacks." 2) "Panic attacks are caused by low levels of epinephrine." 3) "One current theory is that panic attacks are caused by high levels of carbon dioxide." 4) "Some people believe that panic attacks are caused by an abnormal pathway in the brain."

3: Rationale: An increase of carbon dioxide in the brain stimulates the fight-or-flight physiological response. There are theories about what causes panic attacks, but the client is evaluated to help determine that client's probable cause. High levels of epinephrine would be associated with panic attacks. There is no proof that panic attacks are caused by abnormal pathways in the brain. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

A 63-year-old client with Alzheimer disease is brought to the emergency department (ED) with pressure sores and severe dehydration. Upon further assessment, the nurse notices bruises on the client's neck, arms, and legs. Which question could the nurse ask the client's spouse? 1) "How often do you turn your spouse while your spouse is in bed?" 2) "Have you considered placing your spouse in a nursing home?" 3) "What kind of support do you have at home to care for your spouse?" 4) "How long do you leave your spouse at home alone?"

3: Rationale: Asking about support at home will assess the support system and ability of the spouse to care for the client in a safe manner. This question also indicates that the nurse is aware of possible stress on the caregiver without accusing the spouse of abuse. Asking about placing the client in a nursing home subtly implies the spouse is abusing the client and is unable to care for the client properly. The nurse first assesses the client before planning interventions. Asking about turning the client in bed does not assess the possibility of caregiver strain nor does it offer support to the caregiver. Asking about the length of time the client is alone assumes that the client's injuries are signs of neglect or abuse. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

A client comes to the emergency department with multiple bruises on the face and head. The nurse suspects that domestic violence may be the cause of the injuries. What is the most appropriate initial action for the nurse to take? 1) Call a social worker to evaluate the client for domestic violence. 2) Refer the client to a shelter for battered partners. 3) Ask if the client is afraid of being hurt by someone at home. 4) Document the concern, but do nothing else.

3: Rationale: Asking if the client is being hurt is a critical step in a comprehensive assessment. Referring the client to a shelter without assessment may be a disservice; the nursing process requires assessment before intervention. After assessment and the determination of domestic violence, collaboration with social services is appropriate. Documenting the assessment does nothing to help the client resolve the issue. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analyzing

An 82-year-old client is seen in the clinic. While the nurse is palpating the client's breast, the client complains of tenderness in the left breast. The nurse knows what about this assessment finding? 1) This reflects enlarged axillary nodes. 2) This is a result of an infection in the pectoral nodes. 3) The client may have cancer; notify the physician. 4) This is a normal finding.

3: Rationale: Breasts should feel smooth, firm, and elastic. Many women have nodularity or lumpiness that is uniform in both breasts (fibrocystic changes related to cyclic hormones). Tenderness, in premenopausal women may be related to premenstrual fullness, fibrocystic changes, inflammation. Tenderness has also been associated with cancer in the older post-menopausal female. Tenderness, erythema, and heat may be seen with mastitis or inflammatory breast cancer. All other assessments are normal. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis

The nurse is visiting a family with two toddlers in their home. The nurse plans to educate the family when the nurse finds: 1) Electrical outlets containing safety plugs 2) Age-appropriate toys in the toy box 3) Cleaning fluids under the sink 4) Medications stored in a medicine cabinet

3: Rationale: Cleaning fluids are toxic to toddlers, who will explore all facets of their environment. The nurse would instruct the parents to make sure that the cabinet is locked at all times. Safety plugs, age-appropriate toys, and medications out of reach are all appropriate safety measures for toddlers. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Understanding

A nurse caring for a grieving family is aware that complicated grief may occur. A manifestation of complicated grief is: 1) Hiding grief from others as opposed to allowing support from friends and family 2) Not seeking support after a loss due to feelings of shame, guilt, or lack of recognition of the loss 3) Intense grieving for 6 months or more with little to no indication of grief resolution 4) More pronounced feelings of anger and depression due to resentment over the unacknowledged loss

3: Rationale: Complicated grief is an alteration in the grieving process defined as prolonged or intensified grief causing an individual to be unable to proceed with the grieving process. A manifestation of complicated grief is intense grieving for 6 months or more with little to no indication of grief resolution. All other manifestations are for disenfranchised grief, another alteration in the grieving process. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A nurse is caring for a pediatric client experiencing depression. The client's parents ask the nurse regarding the use of SSRI medications. The nurse will include which statement regarding SSRI's? 1) "Sertraline (Zoloft) is the only antidepressant that is FDA approved for use in children." 2) "The risks of antidepressant medications outweigh the benefits to children with major depression and anxiety disorders." 3) "Most prescribers will start children on a lower dose of antidepressant than is normally prescribed for adults." 4) "The FDA recommends paroxetine (Paxil) to treat depression in children and adolescents."

3: Rationale: Currently, fluoxetine (Prozac) is the only antidepressant that is FDA approved for use in children. Most prescribers will start children on a lower dose of antidepressant than is normally prescribed for adults. Recent studies suggest that the benefits of antidepressant medications outweigh the risks to children with major depression and anxiety disorders. The FDA does not recommend paroxetine (Paxil) to treat depression in children and adolescents. Nursing Process: Assessment Client Need: Safe and Effective Care Environment Cognitive Level: Applying

Which nursing diagnosis is a priority for the client who is depressed and expresses a lack of control? 1) Impaired home maintenance 2) Fatigue 3)Powerlessness 4) Disturbed body image

3: Rationale: Data indicate that the client perceives a lack of control over the situation. There is insufficient data to select any of the other nursing diagnoses. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Analyzing

The nurse is evaluating the efficacy of the family nursing care plan and identifies if the family members have achieved the outcomes relevant to each nursing diagnosis. These outcomes include all except the following: 1) Family members identify and demonstrate healthy coping strategies. 2) Family members demonstrate the ability to identify realistic personal and family goals. 3) Family members express the burden of caregiving. 4) Family members demonstrate support of the primary caregiver.

3: Rationale: During evaluation, the nurse also examines all aspects of the nursing care plan to determine the effectiveness of nursing interventions, as well as to evaluate the continued relevance of original nursing diagnoses. Based on evaluation, the nursing care plan is modified to meet the family's current needs. The outcome relevant to evaluating the efficacy of the family nursing care plan include: family members demonstrate the ability to identify realistic personal and family goals; family members identify and demonstrate healthy coping strategies; and family members demonstrate support of the primary caregiver. Family members who express the burden of caregiving is maladaptive. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analyzing

A psychiatric nurse is performing an assessment on a client diagnosed with a mood disorder. Which is not an example of effective assessment techniques for this client? 1) Establish a therapeutic relationship based on mutual trust. 2) Validate the client's feelings. 3) Ask frequent, direct questions in order to obtain as much information as needed. 4) Remain nonjudgmental

3: Rationale: Effective assessment techniques include establishing a therapeutic relationship based on mutual trust, asking open-ended questions and allowing time for the client to talk, remaining nonjudgmental, and validating he client's feelings. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A client has recently been diagnosed with terminal cancer. To help prevent alterations in family function, the nurse would do all actions except: 1) Encouraging talking about the illness as a family. 2) Informing the client and family of the challenges associated with the illness early in the process. 3) Referring the client and family to a psychologist 4) Connecting the family with the appropriate supportive resources

3: Rationale: Families who are made aware of the challenges associated with illness early in the process may benefit from having additional time to consider and plan for some of the upcoming circumstances. Successful coping with caregiver and family challenges comes as a result of accepting the illness, whether it is temporary or chronic, and then working to keep the family unit healthy. Talking about the illness as a family can be extremely beneficial, as can connecting the family with the appropriate supportive resources. Referring the client and family to a psychologist is not the nurse's role. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analyzing

A nurse caring for a client who has begun menopause selects the nursing diagnosis of deficient knowledge when the client makes which statement? 1) "I should increase my daily calcium intake to 1200 mg." 2) "I need to begin weight-bearing exercises such as walking." 3) "I must be coming down with the flu because I am having hot flashes." 4) "I need to obtain yearly mammograms."

3: Rationale: Hot flashes are a sign of menopause, not the flu. The nurse provides the client with education about symptoms and lifestyle changes for the woman entering menopause. Increasing calcium intake, weight-bearing exercises, and yearly mammograms are all recommendations for the perimenopausal woman. Nursing Process: Diagnosis Client Need: Physiological Integrity Cognitive Level: Applying

A 27-year-old client has missed a menstrual cycle and comes to the clinic. The client states, "I know I'm pregnant, I'm never late." The nurse performs which priority test to determine pregnancy? 1) A fasting hCG blood test 2) A CBC with differential 3) An HCG blood or urine test 4) A serum hormone study

3: Rationale: Laboratory tests for women related to the genitor reproductive system include laboratory tests for women include hCG (human chorionic gonadotropin) pregnancy tests (urine or blood) and Papanicolaou test (Pap test). Since the Pap test involves a pelvic examination, more teaching about the procedure and the test is required. The pregnancy tests and Pap test do not require that the woman be fasting. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Applying

Which of the following nursing interventions is appropriate when a client has a seizure? 1) Insert a tongue blade into the client's mouth. 2) Turn the client to the supine position if possible. 3) Loosen any clothing around the neck and chest. 4) Restrain the client.

3: Rationale: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. If possible, the client should be turned to the lateral position, not supine, to allow any secretions to drain out of the mouth. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A client reports to the nurse that the unlicensed assistive person (UAP) was violent toward the client during the client's bath and the client reveals a new bruise. The nurse knows that: 1) The incident must be reported when the nurse is finished with morning assessments of all patients. 2) The patient must report the incident to the nursing supervisor. 3) The incident must be reported immediately. 4) The patient is trying to retaliate against the UAP.

3: Rationale: Nurses themselves have a legal obligation to report conduct that is incompetent, unethical, and illegal. This includes reporting violence, abuse, or neglect toward clients by other nurses and extends to reporting conduct involving third parties, including family members and other health care providers. Nurses are in a position to identify and assess cases of violence, abuse, and neglect. Assuming the patient is trying to retaliate against the UAP is incorrect and punitive towards the victim. Nursing Process: Implementation Client Need: Safe and Effective Care Environment Cognitive Level: Applying

A 50-year-old client confides to the nurse that she is experiencing dyspareunia during sexual intercourse. The nurse recommends which therapy for this client? 1) Reduce sexual contact to once a month. 2) Tell the partner that sex is no longer desired. 3) Use a vaginal lubricant. 4) Consume alcohol to reduce inhibitions.

3: Rationale: Older women and those experiencing menopause may have decreased vaginal secretions, causing a dry entry that can be painful and irritating to the vagina. The nurse could suggest using a lubricant to replace normal secretions. Before assessing for the problem, it is not appropriate to advise the client to tell the partner that sex is not desired. Advising the client to reduce sexual contact or use alcohol does not address the client's problem. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

A client who has chosen to have a penile implant for erectile dysfunction is asking the nurse to explain the procedure to his spouse. What recommendation should the nurse make to help the couple adjust appropriately after surgery? 1) "Have sex once a week." 2) "Have sex once a day to facilitate adjustment." 3) "Seek counseling with a sex therapist." 4) "Return for follow-up care in 2 weeks."

3: Rationale: Penile implants are often uncomfortable for the partner, and the client may be able to sustain sex longer than the partner desires. The implant requires both partners to adapt, and a sex therapist can assist the couple. Frequency of sex does not facilitate adaptation, and follow-up care is needed if there are problems. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

Which should the nurse include when instructing a client about reasons for the development of phobias? 1) Physical response to disease 2) Result of severe trauma 3) Defense against anxiety 4) Result of poor nutrition

3: Rationale: Phobias develop as a defense against anxiety by objectifying underlying anxiety and displacing it. Poor nutrition, physical disease, and severe trauma do not usually promote the development of phobias. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is caring for an elderly client who has been admitted with a recent fall. The admission assessment revealed several bruised areas on the back and legs. During the interview with the caregiver, the caregiver states, "I don't know what to do with her when I go to work during the day so I leave her home alone." What is the most appropriate action for the nurse to take? 1) Encourage play therapy. 2) Threaten to contact the authorities. 3) Provide resource information on adult day cares. 4) Suggest art therapy.

3: Rationale: Providing resource information on adult day cares is most appropriate in this situation. The client's caregiver is expressing concern about leaving them home alone and an adult day care may give the caregiver a safe option for the times the caregiver is at work. Play therapy most commonly helps children play out traumatic themes, fears, and distorted beliefs. It is a nonthreatening way to process thoughts and feelings associated with the abuse, both symbolically and directly. Art therapy provides an opportunity to express feelings for which there are no words. While elder abuse is a reportable event, the lack of the caregiver's knowledge of resources has attributed to the safety issue. Nursing Process: Planning Client Need: Safe and Effective Care Environment Cognitive Level: Applying

The nurse understands that there are responsibilities related to mandatory reporting including all except: 1) Report conduct that is incompetent, unethical or illegal. 2) Report nurses suspected of being in violation of the nurse practice act. 3) The reporting individual agrees to assist in the investigation. 4) A legal obligation to report conduct that is incompetent, unethical, and illegal

3: Rationale: Responsibilities related to mandatory reporting includes reporting nurses suspected of being in violation of the nurse practice act. Also, nurses have a legal obligation to report conduct that is incompetent, unethical, and illegal. An immunity clause protects the reporter acting in good faith. The reporter is not involved in the investigation process of the claim. Nursing Process: Implementation Client Need: Safe and Effective Care Environment Cognitive Level: Applying

Seldenafil (Viagra) is prescribed for a client with erectile dysfunction. When reviewing the client's record and the nurse questions the prescription if which clinical manifestation is noted in the record? 1) Insomnia 2) Neuralgia 3) Use of nitroglycerin 4) Use of multivitamins

3: Rationale: Seldenafil enhances the vasodilation effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the medication's effect, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Neuralgia and insomnia are side effects of seldenafil. There is no contraindication when taking vitamins. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Applying

A client arrives in the emergency department with symptoms of a myocardial infarction that dissipated somewhat while talking with the nurse. The nurse learns that the client had recently been laid off from a job and was on the way to file for bankruptcy when the symptoms occurred. While developing the plan of care the nurse is aware that which nursing diagnosis would be priority? 1) Ineffective Coping. 2) Hopelessness 3) Anxiety 4) Ineffective Denial.

3: Rationale: Since the symptoms decreased as the client talked with the nurse and the client had experienced a recent job loss, the best diagnosis for the client is anxiety related to job loss and impending bankruptcy. There is no evidence that the client cannot cope, but there are physical signs of panic. There is no evidence of hopelessness since the client is acting on the job loss by filing bankruptcy. This client does not appear to be in denial. Nursing Process: Diagnosis Client Need: Physiological Integrity Cognitive Level: Analyzing

A psychiatric nurse is advising a client on how to utilize the Center for Epidemiological Studies Depression Scale-Revised (CESD-R). Which statement made by the nurse is incorrect? 1) "This is a self-rating scale." 2) "This scale will ask you how often during the past week you experienced symptoms associated with depression." 3) "This scale will ask you how often during the past month you experienced symptoms associated with depression." 4) "This scale is useful for a wide age range of populations including older adults."

3: Rationale: The Center for Epidemiological Studies Depression Scale-Revised (CESD-R) scale is a 20-item self-rating scale that asks people to rate how often during the past week they experienced symptoms associated with depression. A score of 16 or above indicates depression. This scale is useful for a wide age range of populations including older adults. Nursing Process: Assessment Client Need: Safe and Effective Care Environment Cognitive Level: Applying

The nurse is explaining to a client with erectile dysfunction (ED) about nocturnal penile tumescence and rigidity (NPTR) monitoring. The nurse knows that which test will help determine if the client's ED is psychogenic or organic in nature? 1) In his own home 2) At the hospital 3) At a sleep study lab 4) At the clinic

3: Rationale: The NPTR test is conducted in a sleep study lab, as the number and quality of erections during REM sleep are what is being measured. The home, hospital, or clinic is not equipped for sleep studies. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

Which intervention would help prevent falls in the older client? 1) Check vision every five years. 2) Turn the light on after getting out of bed. 3) Exercise regularly. 4) Place socks on feet.

3: Rationale: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Vision can be a cause of falls, but it should be checked at least once a year; every five years is not often enough. Older clients should have something on their feet when walking but not regular socks that will allow them to fall; a nonskid-type sock or shoe will help prevent falls. The client should be able to turn the light on before getting out of bed since inadequate lighting is another cause for falls. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse is planning care for a client who is experiencing erectile dysfunction. The nurse selects which nursing diagnosis as most appropriate for this client after the initial assessment? 1) Risk for Impaired Attachment 2) Defensive Coping 3) Situational Low Self-Esteem 4) Autonomic Dysreflexia

3: Rationale: The client with erectile dysfunction often thinks of himself as being less of a man due to the dysfunction. The nurse plans care to help restore self-esteem. Defensive coping may exist in some clients, but low self-esteem is more common. Autonomic dysreflexia is a complication of spinal shock. Risk for impaired attachment does not impact the client's ability to have an erection. Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive Level: Applying

A nurse is conducting research on the relationship between the neurological system and mood disorders. The nurse learns that the neurotransmission hypothesis explains this relationship and also: 1) hypothesizes that an increase in all neurotransmitters lead to mood disorders. 2) during the depressive state, receptors may be sub sensitive, resulting in a decrease in the transmission of impulses. 3) provides an explanation for the higher incidence of depression in women and older adults. 4) describes an increase in neurotransmission during depression.

3: Rationale: The neurotransmission hypothesis is specifically concerned with the levels of serotonin, dopamine, norepinephrine, and acetylcholine in the central nervous system (CNS). It is believed that there is a functional deficiency of these neurotransmitters during a depressive episode and a functional excess during a manic episode. The theory provides an explanation for the higher incidence of depression in women and older adults. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Understanding

A nurse is educating a client on the goals and expected outcomes regarding nicotine use. Which response by the client indicates the need for further teaching? 1) The client describes methods of coping without the use of nicotine. 2) The client expresses true feelings associated with nicotine use. 3) The client does not wish to consider smoking cessation and verbalizes the positive effects of nicotine use. 4) The client describes strategies that will be useful when beginning a program to quit smoking.

3: Rationale: The nurse would need to further educate if the client voiced they do not wish to consider smoking cessation and they verbalize the positive effects of nicotine use because an expected outcome would be for the client to consider smoking cessation and verbalizes the negative effects of nicotine use. It is appropriate for the client to describe methods of coping without the use of nicotine, expresses true feelings associated with nicotine use, and to describe strategies that will be useful when beginning a program to quit smoking. Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Evaluating

The nurse is teaching an adolescent who was injured in a car accident. When providing education about car safety, the nurse determines that the teen should understand that: 1) Electrical equipment should be check for frayed wires before using. 2) Medications should be kept in a locked cabinet. 3) Using a cell phone while driving is hazardous. 4) Excessive drinking can cause falls in the home.

3: Rationale: The nurse would want the teen to understand that using a cell phone while driving increases the risk of injury from an accident. Electrical safety is an issue but not for the person who is driving. Keeping medications locked is appropriate for children. Educating about excessive drinking in the home is an appropriate caution but is not appropriate teaching for car safety. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A spouse and his client who is perimenopausal is questioning the nurse regarding self-care during this process. The nurse plans to focus teaching for this client on which priority of care? 1) Referring the client to a support group 2) Recommending hormonal therapy 3) Reducing the risks associated with menopause 4) Stressing the importance of foot care

3: Rationale: The priority of care is teaching the client lifestyle changes that can help reduce the risks associated with menopause. Referring the client to a support group may be a consideration, but is not the priority. The nurse can offer information regarding hormonal therapy, but it is the physician who makes the recommendation. Foot care is important to the woman who has diabetes. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Applying

The mental health nurse conducting an educational group on stress and stress management is aware that further teaching is needed when a client makes which statement? 1) "An increase in oxygen delivery is intended to meet the increased metabolic demands associated with facing a stressor (fight) or escaping the stressor (flight)." 2) "Epinephrine causes bronchial dilation and an increase in heart rate and blood pressure." 3) "Epinephrine causes bronchial constriction and a decrease in heart rate and blood pressure." 4) "When the sympathetic nervous system is activated it causes a release of hormones such as epinephrine."

3: Rationale: The sympathetic nervous system triggers the body's "fight or flight" response, which is necessary for survival. Activation of the sympathetic nervous system causes release of hormones such as epinephrine, increasing heart rate and blood pressure to assist in the delivery of oxygen to tissues and organs. Epinephrine also causes bronchial dilation, which allows for increased oxygen uptake. This increased oxygen uptake and delivery is intended to meet the increased metabolic demands associated with facing a stressor (fight) or escaping the stressor (flight). Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Evaluation

The nurse is caring for a toddler and determines that the best nursing diagnosis for the safety of the client is: 1) Risk for Injury 2) Risk for Suffocation 3) Risk for Poisoning 4) Risk for Disuse Syndrome

3: Rationale: Toddlers are active and like to explore, and they do not have discretion about what they put into their mouths. Suffocation is more likely to occur with an infant. Risk for injury fits any age group and is too vague to be applied to any specific age group. Disuse syndrome is seen more in older adults. Nursing Process: Diagnosis Client Need: Safe, Effective Care Environment Cognitive Level: Analyzing

Which nursing intervention should be performed first when removing gloves? 1) Drop the gloves into the appropriate waste receptacle. 2) Ease the fingers into the gloves. 3) Grasp the outside of the nondominant glove. 4) Hook the bare thumb inside the other glove.

3: Rationale: When removing gloves after use, one must grasp the outside of the nondominant glove in order not to contaminate the hands and spread infection. Hooking the bare thumb inside the other glove, and dropping the gloves into the appropriate waste receptacle will come after the gloves are removed. Easing the fingers into the gloves is an intervention used when applying gloves. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Applying

The nurse caring for a client with a 5-year history of chewing tobacco. The nurse is educating the client on risks associated with this type of tobacco use. Which is the greatest risk associated with this habit? 1) Lung cancer 2) COPD 3) Oral cancer 4) Wrinkling of the skin

3: Rationale: Because the tobacco is chewed, the greatest risk is oral cancer. Smoking tobacco is associated with the other risk factors listed. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Understanding

The nurse conducting a group therapy session on a mental health unit is aware that which curative factor is demonstrated when a client openly speaks in group about what is bothering them? 1) Altruism 2) Universality 3) Catharsis 4) Instillation of hope

3: Rationale: Catharsis is a curative factor of group therapy in which clients learn how to express their own feelings in a goal-directed way, speak openly about what is bothering them, and express strong feelings about other members in a responsible way. The curative factor altruism suggests that through the group process, clients recognize that they have something to give to the other group members. Universality suggests that through interaction with other group members, clients realize they are not alone in their problems or pain and instillation of hope refers to clients beginning to feel a sense of hope for themselves. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The nurse is aware that which statement best describes peritoneal lavage? 1) A scan done to determine if there are injuries to the brain and spinal cord. 2) Measures the amount of alcohol in a client's blood stream. 3) A catheter is placed into the peritoneal cavity to determine if there is a presence of blood. 4) Measures the amount of cocaine in a client's blood stream.

3: Rationale: Diagnostic peritoneal lavage determines the presence of blood in the peritoneal cavity, which may indicate abdominal injury. A local anesthetic (such as lidocaine) is injected subcutaneously, and a small incision is made in the lower abdomen. A catheter is placed into the peritoneal cavity, and any free blood is aspirated. If 10 mL of blood is found, the client is taken to the operating room for exploratory surgery. If no free blood is aspirated, 1 L of a warm isotonic solution (Ringer's solution or normal saline) is rapidly infused into the peritoneal cavity and then allowed to drain by gravity. If the solution returns pink and is found to have a red blood cell count of 100,000 mm3, a white blood cell count of >500, or bile, food, or feces, the test is considered positive and the client is taken to the operating room for exploratory surgery. A blood alcohol level is used to measure the amount of alcohol in a client's blood stream. A drug screen is used to measure the amount of cocaine in a client's blood stream. Magnetic resonance imaging (MRI) is a scan that can determine if there are injuries to the brain and spinal cord. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The nurse caring for a client admitted with drug addiction is aware that which diagnostic test can provide information in regards to organ damage caused by substance abuse? 1) Chest x-ray 2) Hair testing 3) Organ biopsies 4) Serum drug levels

3: Rationale: Diagnostic tests required for clients with addiction will be ordered based on the type of addiction they display. Organ biopsies are able to identify damage to organs caused by substance abuse. Serum drug levels identify types of drugs used. Chest x-rays are used for inhaled substances and hair testing is used to determine substance use in the past 90 days. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension

The nurse is caring for a severely battered woman. Which action taken by the nurse would be inappropriate? 1) Support the victim's choice to return to the unsafe situation. 2) Determine the immediacy of danger. 3) Convey that the victim and the abuser are to blame. 4) Provide information regarding available resources.

3: Rationale: It is inappropriate to suggest that the victim is to blame for the abuse. It is appropriate for the nurse to determine the immediacy of danger, provide information regarding available resources, and to support the victim's choice to return to the unsafe situation. The nurse should avoid being judgmental and support the individual's choice about whether to leave the unsafe situation or return to the abusive relationship. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application

The nurse is preparing a support group session for those clients admitted with a process addiction. Which clients should attend this therapy session? 1) A client with a diagnosis of anxiety who"s addiction is nicotine 2) A client with a diagnosis of depression who is an alcoholic 3) A client with a diagnosis of depression who is addicted to gambling. 4) A client with a diagnosis of anxiety who abuses prescription medications

3: Rationale: Process addictions are those behaviors compulsively performed to reduce anxiety; they are considered by some to be a form of obsessive compulsive disorder. Some examples of process addictions are gambling, sex addiction, and an addiction to shopping. The others are specific addictions to a substance, such as, alcohol, drugs, or nicotine. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application

The nurse is preparing to educate a group of adolescents on violence and violence prevention. The nurse is aware that violence results from a combination of factors. Which are considered protective factors? 1) Living in an impoverished community 2) A childhood history of abuse 3) Involvement in the community 4) Continually being bullied by a student at school

3: Rationale: Protective factors decrease the risk of violence perpetration and victimization; therefore involvement in the community is considered a factor that would reduce the risk associated with violence. Living in an impoverished community is considered a predisposing factor. A childhood history of abuse is an influential factor and continually being bullied by a student at school is a precipitating factor. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Comprehension

While caring for a 70-year-old client with a history of coronary artery disease, the nurse explains the negative health effects of smoking. The client asks what effect nicotine has on coronary arteries. Which response by the nurse would be most appropriate? 1) "Nicotine can cause the vessels to dilate." 2) "Nicotine causes vasospasm, reducing oxygen available for the tissues." 3) "Tissue oxygenation can be impaired in areas where vessels are already narrowed by atherosclerosis." 4) "Nicotine causes loss of potassium ions needed for contraction of the cardiac muscle."

3: Rationale: Smokers can develop tolerance to nausea and dizziness, which may be experienced with initial use of nicotine, but not to the cardiovascular effects. Furthermore, because of the vasoconstriction, tissue oxygenation can be impaired in areas where vessels are already narrowed by atherosclerosis. Nicotine can cause vasoconstriction. It is not linked to vasospasm or potassium ion loss. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Understanding

An oncology nurse is admitting a client to the unit. Which factor is not of concern when assessing a client with a history of smoking? 1) History of the client's past substance use 2) The presence of psychosocial concerns 3) The frequency and brand of tobacco the client uses 4) Medical and psychiatric history

3: Rationale: The brand of tobacco the client uses is not of concern when assessing the client. Three important areas to assess are a history of the client's past substance use, medical and psychiatric history, and the presence of psychosocial concerns. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analyzing

The nurse is caring for a client who wishes to quit smoking. Which nursing diagnosis would be most appropriate for this client? 1) Readiness for enhanced parenting 2) Impaired gas exchange 3) Readiness for enhanced self health management 4) Readiness for enhanced coping

3: Rationale: The client is expressing an interest in making better lifestyle choices, so readiness for enhanced self health management would be most appropriate. More information would be required to determine if gas exchange has been compromised, if the client is a parent, or if the client needs improved coping skills. Nursing Process: Diagnosis Client Need: Health Promotion and Maintenance Cognitive Level: Analyzing

A nurse is conducting a grief and loss assessment interview and understands that the current loss, the history of previous losses, and lifestyle are all a part of this assessment. What question will the nurse ask the client to assess the current loss? 1) "What types of coping mechanisms have you employed to work through your grief? 2) "Do you drink on a regular basis?" 3) "Do you have an active support system?" 4) "Are you having trouble carrying on with your normal activities?"

4: Rationale: A question that the nurse will ask the client to assess the current loss is: "Are you having trouble carrying on with your normal activities?" All other questions are appropriate questions to ask during the grief and loss assessment, however, are part of the lifestyle area of the assessment, not the current loss. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse is caring for an elderly client who is experiencing complicated grief after the sudden death of her son. The physician has ordered an antidepressant for the client. The nurse understands that antidepressant therapy in complicated grief is: 1) Not an effective treatment method for complicated grief. 2) More effective by itself than in combination with Complicated Grief Treatment (CGT). 3) Contraindicated in older adults. 4) Used with caution in older adults.

4: Rationale: Antidepressants should be used with caution in older adults, as various other medications have adverse reactions with some forms of antidepressants. Similarly, some conditions that are particularly prevalent in older adults—such as diabetes, dementia, and heart problems—can be made worse by antidepressants. Antidepressants are used in combination with Complicated Grief Treatment, as they have not proved effective when used alone to treat complicated grief. Older adults who are prescribed antidepressants for grief should be monitored closely for any side effects or complications. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analyzing

When conducting a health assessment, which question or statement would the nurse most likely use to elicit information about sexual concerns? 1) "Why do you think you should be sexually active at your age?" 2) "Following your prostate surgery, when did you first notice you had problems with sexual intercourse?" 3) "Do you miss having sex?" 4) "Tell me about your experience with sexual function since you developed prostate enlargement."

4: Rationale: Asking the client for his experiences facilitates the client's ability to feel comfortable discussing erectile dysfunction or other sexual concerns. Asking the client when he first noticed problems is assuming that there are problems. Asking the client if he misses sex or suggesting that he is too old for sex is judgmental. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

The home health nurse is working with a family who will be bringing home their older parent, who has dementia. The nurse assists the family with preparations by suggesting that: 1) A bedside commode be obtained. 2) Scatter rugs be kept in the kitchen only. 3) Medications can be kept in the kitchen. 4) Dead bolt locks should have a key for opening.

4: Rationale: Clients with dementia can become confused and wander away from home. Dead bolt locks that need keys are a safe method of preventing the confused client from getting outside the house. There should be no scatter rugs in the home. Medications should be locked to prevent an accidental overdose. A bedside commode is not necessary unless the client has urgency. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Applying

A client who is a victim of elder abuse has been attending counseling sessions with their family. The nurse evaluates that an abusive family member has learned positive coping skills when which statement is made? 1) "I will make sure that my parent's needs are met." 2) "I will need to change my behavior when my parent moves in with us." 3) "I am sorry for the abuse; it won't happen again." 4) "Now that I know what my resources are, I think I can do a better job of caring for my parent."

4: Rationale: Elder abuse can occur when family are expected to care for the aging parent. This causes frustration, overextension, and sometimes is a financial burden. Stating that the abuser will use assistance from resources is a positive action toward behavior change. Stating that they will meet the needs of the client, that they are sorry, or that they need to change behavior are not demonstration of a positive change; it is simply lip service and a hallmark response by habitual abusers. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analyzing

A charge nurse on the unit is asking nurses to stay for another shift because a nurse scheduled to work the next shift is ill. One nurse, who has worked extra this week, tells the charge nurse that it would not be safe for the nurse to work extra because: 1) The lighting on the unit is distracting. 2) There are too many interruptions. 3) Human memory causes errors. 4) Stress and anxiety can cause mistakes.

4: Rationale: Many nurses feel that they should accede to requests to work extra to ensure that clients are cared for. The reality is that the nurse should evaluate the stress this will add because stress causes anxiety, which causes errors. Nurses should examine their own situations and assess their own safe practice. Lighting, interruptions, and memory do not apply to this situation. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Understanding

The nurse concludes that a client has understood teaching about menopause when the client states the following: 1) "I am depressed about having this disease." 2) "I will experience symptoms of menopause for 2 weeks." 3) "I have missed two periods now and am grateful I will have no more." 4) "I know I have begun menopause and it will take a while to finish."

4: Rationale: Menopause is a lengthy process since estrogen levels decrease gradually. The process may take years. Menopause is not a disease, but a normal physiological process. The client may miss several menstrual periods only to have one at a later time. Symptoms of menopause can last years, but do gradually decline with time. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analyzing

The nurse is preparing to assist the physician, who is performing a procedure on a client in the client's room. When everything is ready, the nurse's next action to reduce errors is: 1) Checking the client's vital signs 2) Maintaining a sterile field 3) Making sure all supplies are open 4) Asking for a time out

4: Rationale: Prior to any procedure, the nurse asks for a time out to identify that this is the right client and that the correct procedure is being performed on the right body part. All supplies should be opened before the time out. The sterile field and the client's vital signs are a part of preparation prior to the time out. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Understanding

A nurse working in the emergency department is caring for a child with ligature markings on his arms and legs and multiple unexplained bruises. The nurse's next action should be: 1) Report the findings to the child's parents at the bedside. 2) Ask the parents what happened to the child. 3) Ask the child, with parents at bedside, what caused the suspicious markings. 4) Report the findings to the physician and the charge nurse.

4: Rationale: Reporting of abuse or suspected abuse of vulnerable individuals is mandated in most states. As a general rule, the nurse reports the required information through the administrative chain of the institution, beginning with the nurse's immediate supervisor and the primary health care provider. All information reported is documented in the client record. In most states, mandatory reporters are required only to have a good faith suspicion, based on information disclosed by the client and/or on physical symptoms manifested by the client. All other responses are incorrect and jeopardize the child's safety. Nursing Process: Implementation Client Need: Safe and Effective Care Environment Cognitive Level: Applying

A client who is a victim of intimate partner abuse attends a group therapy session. Which comment by the client indicates a desired outcome? 1) "I am not afraid to be alone with my significant other even though he is the reason I am here." 2) "I should have kept my mouth shut and none of this would have happened." 3) "I can't leave the situation. There is nowhere for me to go." 4) "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way."

4: Rationale: The client is demonstrating a desired outcome by stating, "I realize now that I am not responsible for the abuse and I do not deserve to be treated this way." The desired goal is for the client to verbalize awareness that they are not responsible for the abuse and that they do not deserve it. The other responses demonstrate negative outcomes. Desired outcomes would include the client openly communicating fears in regards to the abuse and demonstrating knowledge of available resources to those in abusive situations. Nursing Process: Evaluating Client Need: Health Promotion and Maintenance Cognitive Level: Evaluating

The nurse determines that a client with depression is meeting a short-term goal when the client makes which statement? 1) "I will not harm myself during hospitalization." 2) "I wish I was really good at enjoying myself at parties." 3) "I do not have much hope of getting my job back." 4) "I made friends with another client and talked about my problems."

4: Rationale: The client with depression must learn alternative ways of dealing with stress such as talking. The client has demonstrated that goal by discussing problems with another client. Refraining from self-harm during hospitalization is not a goal for discharge. The other statements demonstrate hopelessness or unrealistic assessments of personal strengths. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analyzing

The nurse is working with a family who has just experienced a theft of most of their furniture and electronics from their home. Which of the following priority interventions will the nurse initiate for this family? 1) Help the family develop psychosocial skills. 2) Help the family develop spiritual skills. 3) Suggest the family engage in denial temporarily. 4) Focus on managing the feelings provoked by the theft.

4: Rationale: The nurse would assist the family best by helping them manage the feelings associated with the theft, to allow for the emotional discharge of anger, despair, and frustration. Psychosocial skills and denial will not benefit the family at this time. Spiritual skills may be helpful if the family is so inclined, but managing the emotions would be the priority. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

A nurse has obtained a new position in a psychiatric facility and is reviewing the facilities policies and procedures regarding preventing client suicide. Which policy will not be included? 1) Let suicidal clients know that the environment is safe for them. 2) Examine items brought by visitors and monitor for safety. 3) Family members cannot substitute for staff in performing one-to-one observation. 4) Establish a predictable pattern of observation during the day and night.

4: Rationale: The nurse's first priority in all situations is client safety. All policies and procedures regarding preventing client suicide should focus on the client's safety. In a client at risk for suicide, the nurse will let suicidal clients know that the environment is safe for them. The nurse will also examine items brought by visitors and monitor for safety. Family members cannot substitute for staff in performing one-to-one observation of a suicidal client. Also, the nurse will establish an unpredictable pattern of observation in order to let suicidal clients know that the environment is safe. Nursing Process: Assessment Client Need: Safe and Effective Care Environment Cognitive Level: Applying

During an assessment, a client responds "yes" to the question, "Have you ever felt a sudden, intense fear for no apparent reason?" The nurse is aware that this statement may be reflective of which disorder? 1) Agoraphobia 2) Obsessive-compulsive disorder 3) Post-traumatic stress disorder 4) Panic disorder

4: Rationale: The onset of a panic attack is sudden, and the client may not be aware of the precipitating factor. Agoraphobia is fear of leaving the home. Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive behaviors. Post-traumatic stress disorder is associated with a traumatic event. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Applying

A recently widowed elderly client tells the nurse, "I just can't even get out of bed in the morning anymore." What response by the nurse would be most helpful? 1) "Why do you think you feel this way?" 2) "I don't know why you feel that way." 3) "After you get up, you will feel better." 4) "This must be a difficult time for you."

4: Rationale: The open-ended statement of acknowledgment is the best choice for validating the client's feelings and facilitating further discussion. The other statements close off the possibility of discussion, ignore the client's feelings, and belittle the client. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Applying

The nurse caring for a client with alterations in coping is aware that which intervention is an independent nursing intervention? 1) Psychotherapy 2) Cognitive-Behavioral Therapy 3) Pharmacological therapy 4) Teaching relaxation techniques

4: Rationale: The process of teaching relaxation techniques is an independent nursing intervention. Psychotherapy, cognitive-behavioral therapy, and pharmacological therapy are all considered collaborative interventions. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application

A nurse came to work with a black eye and a swollen lip. Coworkers have noticed that the partner calls the nurse at least 10 times during a 12-hour shift. The nurse has refused all invitations to go out with coworkers, saying that the partner will be there after work and doesn't like to wait. Which action taken by the coworkers would be most helpful? 1) Convince the nurse to leave the partner. 2) Encourage the nurse to get a restraining order against the partner. 3) Enlist the parents' aid in getting the nurse away from the partner. 4) Encourage the nurse to talk to a professional.

4: Rationale: Encourage the nurse to talk to a professional. Nurses encourage the client to accept help in seeking an abuse-free living situation, but the decision ultimately lies with the client. Some individuals will not be ready to seek help, and while the nurse may disagree with this decision, he must refrain from judgment and be respectful of the client's decision. All nurses can do in these situations is offer assistance and resources, the victim will then know that help will be available if it is needed in the future. Trying to convince abused adults to leave their abuser does not empower the adult. Friends and coworkers should provide support without telling the nurse what to do. Encouraging the nurse to get a restraining order against the partner is inappropriate because a restraining order may actually increase the violent behavior of the partner. Involving the parents may complicate the situation and result in more abuse, which further isolates the nurse from family and friends. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analyzing

A client is prescribed amitriptyline (Elavil) for major depressive disorder. When educating the client about this medication, the nurse will include the following statement: 1) "The herb St. John's Wort improves the efficacy of this medication and may improve your outcome." 2) "This medication may take up to 5 days to achieve full therapeutic effect." 3) "If difficulty in urination occurs, increase fluid intake." 4) "Dry mouth, constipation, blurred vision, and increased heart rate may occur."

Rationale: Amitriptyline is a tricyclic antidepressant (TCA). Significant drug interactions may occur with TCA's. The herb St. John's Wort may cause serotonin syndrome, a life-threatening condition. Dry mouth, constipation, blurred vision, and increased heart rate may occur due to the medication's anticholinergic effects. However, if a client taking a TCA has difficulty in urination, this is a life-threatening emergency and increasing fluid intake is incorrect. The therapeutic effect from this type of medication takes a week or more to achieve. Nursing Process: Assessment Client Need: Safe and Effective Care Environment Cognitive Level: Applying