exam 6

What is Kübler-Ross's third stage of grief?

Bargaining Explanation: Her proposed stages of grief are denial, anger, bargaining, depression, and acceptance.

The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group?

skin-to-skin contact can spread herpes and genital warts

urinary irrigation

a flushing or washing out with a specified solution types: -bladder irrigation-catheter irrigation -open vs. closed irrigation (closed= more effective in preventing infections)

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone." Explanation: The clinical definition of depression is anxiety and hostility turned inward. The statement asking the nurse to go away and a desire to be "left alone" indicates withdrawal, which is a characteristic of depression. "This does not seem real to me" indicates the client is in denial. Blaming oneself for the loss is an expression of guilt that may occur in the anger phase of grieving.

A woman age 49 years has sought care from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes her significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing?

Dyspareunia Explanation: Dyspareunia is painful intercourse. Vaginismus is characterized by difficult penetration rather than acute pain during intercourse. Vulvodynia is associated with pain that is not limited to intercourse. Sexually transmitted infections (or STIs) are infections that can be caught or passed on from unprotected sex, or close sexual contact. An STI may or may not be contributing to the woman's problem, though most cases of dyspareunia are unrelated to infections.

The nurse is preparing to counsel a couple on their sexual relationship. The nurse prepares for the session by reviewing the sexual response cycle. The nurse recalls the order of the four phases of the cycle. Place the phases in correct order as they occur. Use all options.

Excitement Plateau Orgasm Resolution

A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?

Have you gone through and donated your spouse's clothing?" Explanation: Abnormal grief responses present beyond 3 years after a loss. Remembering good times and keeping photos of loved ones are part of reminiscing and a healthy form of grieving. Crying on the anniversary of a loved one's death is part of the normal grieving response.

A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase?

Headache Explanation: Premenstruation is characterized by the appearance of one or more of the following symptoms several days before the onset of menstruation: (1) emotional symptoms such as depression, irritability, anxiety, changes in sleep habits, changes in sexual desire, poor concentration, crying, anger, and social withdrawal; and (2) physical symptoms such as appetite changes, breast tenderness, bloating and weight gain, aches and pains, swelling, acne, gastrointestinal issues, and fatigue. Blurred vision may be an ominous sign that is unrelated to premenstrual syndrome.

A client comes to the women's clinic and reports to the nurse that she is having a foul-smelling, thin, grayish-white vaginal discharge. What testing will the nurse prepare the client for?

Nonspecific vaginitis Explanation: Nonspecific vaginitis is characterized by foul-smelling, thin, grayish-white vaginal discharge. Herpes simplex virus type 1 and 2 are characterized by lesions. Trichomoniasis is characterized by thin, foamy, greenish vaginal discharge that causes itching of the vulva and vagina; it is often asymptomatic in males.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness. Explanation: Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, may be given at any time during a client's illness, from diagnosis to end of life. Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers.

When the mother of a 2-year-old tells the pediatric nurse that the child masturbates, the nurse informs the mother that the child:

is exhibiting normal behavior.

The nurse is caring for a client diagnosed with vaginismus. When reviewing the client's history, what would the nurse would expect to find?

past history of a rape Explanation: Vaginismus usually results from psychological problems, namely fear of penetration due to a negative association such as rape, sexual abuse, or fear of sexual intercourse.

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?

"It must be very difficult for you." Explanation: Use statements with broad openings such as "It must be difficult for you" and "Do you want to talk about it?" Such language encourages communication and allows the client to choose the topic or manner of response. Accept the client's behavior. Anger is part of the grieving process. Indicating that this is "awful" is not an appropriate way to promote coping. It is not the nurse's role to tell the client to make things right with the family. While this may be desired, the client should initiate it.

After the physician has discussed euthanasia with a terminal client and family, the nurse assesses their understanding of the topic. Which statement by the family indicates that learning has occurred?

"It is all right to stop dialysis."

The nurse is discussing contraception with an adolescent client who asks the nurse: "What if I can't have an orgasm?" What is the nurse's best response?

"A mature sexual relationship does not require a man and woman to achieve simultaneous orgasm Explanation: Simultaneous orgasms, or both people attaining orgasm at the same moment, are difficult to achieve. A preoccupation with attaining simultaneous orgasms might disrupt the ultimate intimacy and satisfaction possible during coitus. Multiple orgasms are not abnormal. The size of the penis does not affect whether an orgasm will occur. Having an orgasm is not the only indicator of sexual responsiveness; some individuals may have a pleasurable sexual experience without orgasm.."

The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family?

"All efforts will be taken to make sure your loved one is comfortable and out of pain." Explanation: A common and valid concern of families during terminal weaning is to make sure the client is not suffering. As such, the nurse's role is to educate the family regarding comfort measures, such as pain medication and additional sedation. The nurse must be honest with the family, as the client may be aware of loved ones in the room and talking to the client is encouraged.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?" Explanation: Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings.

A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction?

"Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?" Explanation: Common causes of impotence (which may be physiologic or psychological) include various illnesses, treatments for these illnesses, and personal anxieties. Antihypertensive medication and antidepressant medications are a leading cause of impotence in male clients and it is possible to switch medications to help the client with this problem.

A nurse practitioner is teaching the student about sexual health and is evaluating the student's knowledge of sexual identity. The practitioner knows that the student understands when the student says which of the following?

"Gender role behavior is the behavior a person conveys about being male or female."

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend?

"Get the human papillomavirus vaccine."

A client presents to the office with concerns of low testosterone and feels it is due to a pituitary gland disorder. Which teaching would the nurse provide to educate this client on how testosterone is produced?

"Gonads are the reproductive organs of the male and are responsible for the production of testosterone and spermatozoa."

Which assessment question is most likely to yield data about a female client's sexual identity?

"How do you feel about yourself as a woman?" Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships or if their health allows for a meaningful sex life. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

A nurse is conducting a health history on a 45-year-old client. The nurse is preparing to address the client's sexual history. Which statement by the nurse would be most appropriate at this time?

"I am going to ask you some questions about your sexual health."

Which statement by the client indicates acceptance of dying?

"I have finalized all my financial arrangements for my family." Explanation: The statement, "I need to take out a life insurance policy right now" may represent the client in the anger phase of death and dying, as anxiety is expressed. The client is in the bargaining stage when indicating, "I just want to live long enough to see my child get married." The client could be in the anger stage when stating, "Everyone dies; death is a part of life and I have to accept it," as the client is expressing frustration with the situation.

A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse?

"I have noticed I have less lubrication with sexual intercourse."

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

"I will contact the health care provider to extend services since your family member meets the criteria." Explanation: Hospice care is generally provided to clients that have 6 months or less to live, although they are not automatically discharged when they reach 6 months after having been admitted to hospice care. The client may still receive care as long as the health care provider certifies that the client continues to meet the criteria for hospice services. The client should not be admitted to the hospital since the acceptance of palliative comfort care is required to qualify for hospice services. Based on the provided information, there is no need to admit the client to the hospital, and hospital admission may result in termination from the program due to the provision of non-palliative care.

A client diagnosed with a terminal illness is displaying periods of depression and anger alternating with acceptance. The client's spouse is concerned about the client's labile mood. When talking with the client's spouse, which statement made by the nurse best addresses principles of loss and grieving?

"Not everyone experiences grief in the same way and your loved one needs our support." Explanation: Some people may not experience each stage.

A nurse reads in a client's chart that he or she has gender dysphoria. The nurse determines that the client understands the diagnosis when making what statement?

"People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria." Explanation: Heterosexuals experience sexual fulfillment with a person of the opposite sex. People who find pleasure with both opposite-sex and same-sex partners are bisexual. An intersex condition occurs in about 1 in every 2000 babies in which there are contradictions among chromosomal sex, internal organs, and external genital appearance, resulting in ambiguous gender.

The hospice nurse is visiting a new client. Which assessment questions are appropriate for the nurse to ask a client who has a terminal illness?

"Please describe what you have been told about your condition." "What community resources might be of help to you?" "How well do you think those around you are coping?" "Have you had any previous experiences with the death of someone you love?" Explanation: Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the client's and family's knowledge, perceptions, coping strategies, and resources. Interview questions for these areas would include the following: adequacy of knowledge base ("describe your condition"), perceptions ("previous experience with death of someone you loved"), adequacy of resources ("community resources"), and adequacy of coping ("those around you coping"). Determining if a client has a will to distribute personal property is not a priority assessment for the nurse.

The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief?

"Please, let me live long enough to see my grandchild." Explanation: Bargaining occurs as a client seeks to delay a dreaded event. For example, the client bargains with a higher power for enough time to see the grandchild. The statement, "Why is this happening now? I will never see my grandchild" indicates frustration and anger. Depression is evident in the statement, "I do not care about anything. Just let me sleep." Acceptance occurs when the client comes to terms with the loss and begins to detach from supportive people. As such, the statement, "I may not see my grandchild here on Earth, but I will in the afterlife" shows acceptance.

The nurse has provided information to a client about oral contraceptives. Which statement by the client would indicate a need for further education?

"Some oral contraceptives protect against STIs."

Which response will the nurse provide to a 13-year-old female client who says to the nurse, "My parents said masturbation is wrong. Is that true?"

"Tell me more about what you know of masturbation."

A young client tells the nurse, "I am gay, and my family will not accept me." What is the nurse's best response?

"That must be very distressing. Let's talk more about it."

While teaching sexual education to a group of high school students, the nurse talks about forms of birth control and when a woman can become pregnant. Which explanation by the nurse about the chance of the woman becoming pregnant is accurate?

"The intrauterine device is a highly effective and reversible contraceptive."

The nurse assessing an adolescent's need for further information regarding sexual health should ask which question?

"What questions or concerns do you have about your sexual health?" Explanation: An open-ended, nonthreatening question related to the client's need for further information should be included while obtaining a sexual history. "Are you involved in an intimate relationship at this time?" and "Have you ever been diagnosed with a sexually transmitted disease? "are closed ended questions requiring a yes or no response. Asking how many sexual partners, while open ended, is threatening and assumes that the adolescent has had multiple partners.

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states:

"Why did this have to happen to me?" Explanation: The client is expressing anger when displaying a "why me" attitude. The other statements are reflective of other stages of grief

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death?

-Gurgling sounds emanating from the client's throat with each breath -Distended abdomen with last bowel movement documented 7 days ago -Cyanotic nail beds in hands and feet bilaterally Explanation: Signs of an impending death include noisy respirations, abdominal distention, constipation, and cyanosis of the extremities.

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

'In hospice care, the nurses make most of the care decisions for the clients." Explanation: The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life. Reference:

Which nursing interventions would be anticipated with hospice care?

-Administer prescribed morphine for pain control. -Ease respiratory function by providing oxygen via nasal cannula. -Administer prescribed antiemetics to control nausea. -Insert a Foley catheter to prevent incontinence.

The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.

-Encourage expression of feelings. -Provide for stability and safety. -Talk openly about death and the feelings associated with it. Explanation: In preparing children for death, encourage expression of feelings, provide for stability and safety, talk openly about death, and encourage expression of feelings. Do not praise stoicism, nor encourage forgetting of the deceased, nor force the child to participate in mourning rituals.

A nurse is conducting a seminar for a group of young adult women about the menstrual cycle. When discussing the hormones involved during the various phases, the nurse explains that estrogen is dominant during which phases of the cycle?

-Follicular phase -Proliferative phase Explanation: Estrogen is the dominant hormone during the follicular phase of the ovarian cycle and during the proliferative phase of the endometrial cycle. Progesterone is the dominant hormone during the luteal phase and during the secretory phase. The follicle ruptures during the ovulatory phase.

When preparing for the death of a client, the nurse should provide the client's family with which interventions?

-Listen to concerns, fears, and worries. -Encourage rest and proper nutrition. -Explain the dying process and allow grieving. -Utilize therapeutic communication techniques.

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal?

-Listen to expressions of grief. -Include significant others in discussions and decisions as appropriate. -Communicate acceptance of discussing the loss.

The nurse is advising an adolescent male about sexual myths that have him concerned. Which client education accurately describe these concerns?

-Masturbation or self-stimulation is a natural and healthy outlet for sexual urges. -No male or female should feel pressured into sexual activity at any age. -Nocturnal emissions are normal in men of all ages.

The female reproductive system is made up of both external and internal organs. Which are external organs in this system? Select all that apply.

-Mons pubis -Labia majora -Clitoris -Skene glands Explanation: The mons pubis, labia majora, clitoris, and Skene glands are external organs. The ovaries are internal organs.

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying?

-Pale, cool skin -Decreased urine output -Irregular heart rate Explanation: Signs of dying include extremely pale, cyanotic, jaundiced, mottled or cool skin; irregular heart rate; weak, rapid, irregular pulse; shallow, labored, faster, slower, or irregular respirations; and decreased urine output.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind?

-People vary widely in their responses to loss. -Stages occur at varying rates among peoPle -Some people actually skip some stages of grief altogether Explanation: In reality, the stages of the grief cycle model are not as discrete as the model indicates. However, it is helpful to use the model as a general guide, while keeping in mind that people may vary greatly in their responses to loss and still fall within the normal response range. Grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages.

Which are signs of a "good death"?

-The person dies with dignity. -The person is prepared for death. -The person has a sense of completion of life. Explanation: A good death is one that allows a person to die on their own terms, relatively free of pain, and with dignity. It is free from avoidable distress and suffering for clients, families, and caregivers; in general accord with clients' families wishes; and reasonably consistent with clinical, cultural, and ethical standards.The definition of a good death varies for each client, but there are factors-control of symptoms, preparation for death, opportunity to have a sense of completion of one's life, and a good relationship with health care professionals.

A nurse is conducting a program for a local community support group about grieving. The nurse would describe grief as fulfilling which function?

-allowing the outer reality of loss to become internally accepted -altering the emotional attachment to that which was lost Explanation: Grief has several important functions: to make the outer reality of the loss into an internally accepted reality; to alter the emotional attachment to the lost person or object; and to make it possible for the bereaved person to become attached to other people or objects. Grief does not prepare the client for the loss nor does it allow the person to avoid the experience the loss more fully. Grief is a necessary and normal reaction to loss.

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.

-expression of feelings -management of pain -use of coping strategies Explanation: Nursing care for the dying client should be directed toward the achievement of several goals, including demonstration of the ability to express feelings, fears, and concerns. The client's pain should be managed effectively to allow the client to interact meaningfully with family. The client should also be able to identify and utilize effective coping strategies such as deep breathing, talking with family members, and rest periods. Nutritional therapy and urinary elimination are not specific to the dying client, and more assessment would be needed to determine if these are viable needs for the client.

Which assessment finding would best support a nursing diagnosis of Dysfunctional Grieving?

A man is unable to return to work after his sister's death 18 months ago. Explanation: Crying and having difficulties sleeping are not unusual and will often accompany healthy grieving. A feeling of "not doing enough" is common during grief and would only be considered dysfunctional if this became a long-term and all-encompassing belief.

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which scenario would be an example of assisted suicide?

Administering a lethal dose of medication Explanation: Assisted suicide refers to providing another person the means to end his or her own life, such as administering a lethal dose of a medication. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual. Administering a morphine infusion may be used to assist with a client's pain near the end of life. Granting a client's request not to initiate enteral feeding when the client is unable to eat is an example of wishes of a terminally ill client, and the agreed-upon measures near the end of life. Neglecting to resuscitate a client with a "do not resuscitate" status is following the prescribed, mutually agreed-upon decisions about care.

The nurse is caring for a client who has just expired. Which action will the nurse perform?

Allow the client's family to see the client's body before it is discharged. Explanation: After the client has been pronounced dead, the nurse is responsible for preparing the body. Family members may need to see the client's body to accept the death fully; allow them to see the client's body before discharging to the mortician. The body is placed in normal anatomic position (flat) to avoid pooling of blood. In most cases it is unnecessary to wash the body, and some religions strictly forbid it. The nurse is legally responsible for placing identification tags on either the shroud or garment that the body is clothed in, and on the ankle to ensure that the body can be identified even if separated from its shroud.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?

Anger Explanation: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept death

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible. Explanation: the child's concept of death matures, and the child perceives death realistically as irreversible, universal, inevitable, and natural.

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Call a code and begin resuscitating the client. Explanation: If there is no DNR order to the contrary, the standard of care obligates professionals to attempt resuscitation if a client stops breathing or his or her heart stops. It is important for nurses to clarify a client's code status if the nurse has reason to believe a client would not want to be resuscitated. It is imperative that the client's wishes are documented in a formal document in the health record for all to view. Slow-codes are never good practice, and the nurse could be charged with negligence in the event of a slow-code and resultant client death. Calling the charge nurse or nurse manager is not appropriate because it can delay emergency care, which could result in negligence and client death.

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care?

Cleanse drainage from the skin. Explanation: The nurse should cleanse secretions and drainage from the skin to ensure delivery of a hygienic body. The dentures should be replaced in the mouth, as they maintain the natural contour of the face. A small rolled towel is placed beneath the chin of the client to close the mouth; it is not placed under the head.

In the female reproductive system, what corresponds with the male penis?

Clitoris Explanation: The clitoris corresponds to the penis in the male in that both organs respond to stimulation that can result in orgasm.

A nurse is conducting a healthy living workshop with a group of female college students. Which information will the nurse include in the teaching plan about condoms?

Condoms can protect the client from pregnancy. Explanation: Condoms should be used during every sexual encounter to provide significant (but imperfect) protection against both pregnancy and sexually transmitted infections. Condoms are worn by male and female partners. Condoms are 98% effective in preventing pregnancy. Each individual will determine which method of contraception is the best method to personally use. Condoms should never be reused.

A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?

Contact the organ procurement team to discuss organ donation with the spouse. Explanation: The organ procurement team should be contacted as soon as possible to talk with the client's spouse. This discussion cannot wait, as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined. The organ procurement team is specially trained to have these kinds of conversations.

A female nurse is giving a complete bed bath to a young male client. The nurse notices the client has an erection. Which action will the nurse take?

Continue bathing the client. Explanation: An erection may occur in response to a full bladder, fantasy, or touch. Exposure of the male client by the nurse may cause an erection during a bed bath. An erection is a normal physiological response and not something the man can voluntarily control. It does not mean the client is attracted to the nurse. By continuing on with the bath the nurse creates a sense of normalcy. There is no need to tell the client's parents about this normal reaction.

An adolescent female is in the community health clinic seeking contraception since becoming sexually active. The community health nurse demonstrates effective health promotion and prevention with the client when what is included in the health education teaching plan?

Contraception plans prior to initiation of sexual activity. Explanation: The prevention of unwanted pregnancy must be a conscious decision. Anyone who is unprepared for pregnancy should refrain from intercourse or obtain a contraceptive method from a healthcare provider or from the pharmacy; it is too late to think about contraception during sexual intercourse. To practice responsible sexuality, the contraceptive method must be used consistently and according to instructions.

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

Durable power of attorney form Explanation: The nurse would review the durable power of attorney (DPA) for health care form identifying the client's chosen proxy for health care decision-making. The DPA for health care is a person legally designated by the client to make health care decisions if the client becomes physically or mentally unable to do so. A living will is a legal document detailing the client's wishes for end-of-life care and usually includes specifics such as resuscitation in the event of cardiopulmonary arrest and wishes regarding feeding tubes. An advance directive is a legal form filled out by the client or client's DPA for health care that identifies wishes regarding lifesaving treatment. The health care provider's progress notes are drafted by the health care provider regarding the client's current status and medical treatment plan.

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

I feel like I have absolutely no idea what to do next." Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, decreased resistance to illness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, neglect of appearance, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased, and return to previous level of ability. Reference:

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

Ineffective coping related to failure of previously used coping mechanisms Explanation: The nursing diagnosis best supported by the data is Ineffective coping. Defining characteristics include poor coping skills with activities of daily living as evidenced by unkempt appearance, eating poorly and losing weight, and client statement. Death anxiety refers to an impending death or thoughts of death. Ineffective denial refers to denying the reality of the situation. Decisional conflict refers to inability to make decisions

The school nurse is educating a group of 5th and 6th grade girls on menstruation. One girl asks if there is a name for having her first menstrual period. The nurse replies with which of the following terms?

Menarche

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs

The nurse is preparing a 15-year-old adolescent for the first gynecological examination to evaluate heavy menstruation. Which intervention by the nurse will help the client feel less anxious during the gynecological examination?

Offer to remain with the client during the examination. Explanation: Offering to remain with the client during the examination would help the client feel less anxious. Providing privacy while donning the gown is not addressing anxiety that may occur during the gynecological examination. Showing and explaining the examination instruments may heighten the client's anxiety. Telling the client that the nurse will leave once the assessment begins may cause anxiety if the client is not familiar with the health care provider.

During the menstrual cycle, when does ovulation typically take place?

On day 14 Explanation: Ovulation generally occurs on day 14 when the mature ovum ruptures from the follicle and the surface of the ovary and is swept into the fallopian tube. From day 15 to day 28, the phase in the ovaries is called the luteal phase. On day 1 of a new cycle begins the new menstrual cycle. Menstrual flow might occur every 21 to 35 days or the last two to seven days. Ovulation does not begin when sperm is present. If ovulation and sperm engage, then pregnancy occurs.

A nurse caring for a client with a terminal illness understands which statement to be true?

Recovery is not expected. Explanation: Clients with terminal illness do not recover from the illness; they may be treated symptomatically and be provided care and comfort. Recovery cannot be based on a time frame such as 3 months. Recovery is not dependent on the selected treatment as it is not expected.

A school nurse is providing a class on sexually transmitted infections (STIs). Which statement is correct regarding STIs?

STIs are most prevalent among adolescents and young adults.

A 19-year-old client scheduled for a vaginal exam is visibly upset and cancels the appointment when learning the clinic provider is a man. Which factor should the nurse prioritize when assisting this client?

Taught to avoid exposing herself to strangers Explanation: Some cultures forbid the woman from exposing herself to a man who is not her spouse. The nurse should ask about cultural practice and alert the health care provider to the situation. The other factors can be explored after the nurse determines the cultural aspect is clarified. Reference:

The community health nurse is aware that many factors influence a client's decision for contraception. Which of the following is the most likely reason a client would select permanent contraception?

The choice not to start a family. Explanation: Some people choose a permanent method to prevent pregnancy from ever occurring. Factors that affect a person's choice of a contraceptive method include age, marital status, desire for future pregnancy, religious beliefs, level of education, cost, and ease of use. Permanent contraception offers no protection against sexually transmitted infections.

Traditionally, the male sexual response is thought to be broken up into three phases. Which occurrence is part of the plateau phase?

The circumference of the penis thickens at the coronal ridge and a few drops of fluid appear at the urethral meatus. Explanation: During the plateau phase, the circumference of the penis thickens at the coronal ridge. The size of the testes also increase by 50% and a few drops of fluid appear at the urethral meatus.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

The client's breathing becomes noisy. Explanation: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first. Explanation: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.

A client that has been shot in the chest is now deceased, and the nurse is delegated to provide postmortem care. In which situation should the delegating charge nurse intervene while the nurse is providing postmortem care?

The nurse is preparing to remove the IV lines from the deceased. Explanation: Because the client is deceased due to an unnatural or suspicious cause, an autopsy will be performed. All IV needles and lines, endotracheal, gastrointestinal tubes, drains, and airways must remain with the body. They should be firmly taped or secured so that they will not be inadvertently removed or leak. The body is not washed, even if it is soiled, to avoid removing evidence. The deceased should always be treated with dignity by providing privacy and treating the body with respect. Tags should always be used to identify the body.

When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response?

This must be very difficult for you." Explanation: The nurse should use statements with broad openings, such as "This must be difficult for you," to allow the client to continue expressing concerns and to acknowledge the client's feelings. This facilitates communication and allows the client to choose the topic or manner of response during this stage of the grieving process.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief Explanation: In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited grief occurs when a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death).

A male client comes to the clinic because he thinks that he has syphilis. Which test would the nurse expect the client to have done?

VDRL

The nurse is assessing the sexual health of a female client age 20 years. During the interview, the client says, "I feel that my vaginal opening constricts whenever I am about to have intercourse. I seem to have no control over it." What would the nurse use when documenting the client's report?

Vaginismus

The nurse is caring for several clients in the home care setting. Which client, when found deceased, will the nurse report as a case for the medical examiner?

a client found with an empty bottle for a newly-prescribed opioid by the bedside Explanation: A death that is reportable to the medical examiner would include one that is suspicious for suicide (in this instance, as demonstrated by an empty prescription bottle for an opioid). The deaths of the other clients described are not suspicious. The client with end-stage kidney disease is under the regular care of a health care provider since receiving dialysis at home. A client with cancer is not suspicious. Even with the refusal of hospice care, the client has been diagnosed with an end-stage disease, thus not qualifying for a medical examiner case. A client who was recently discharged after a myocardial infarction who had also been receiving care from a primary care provider is not considered suspicious. Other indications for reporting to a medical examiner include a death that occurs when a client is otherwise in good health and not under the care of a provider, a client who was involved in a violent crime such as a homicide, a client who dies while in police custody or in prison, a client who has had a criminal abortion, or if the deceased poses a potential threat to public health (such as a client who had an infectious disease).

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms Explanation: The goal of palliative care is to provide clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. There is no treatment goal for the life-threatening illness for palliative care. Aggressive management of symptoms includes medical and nursing care for the client. Providing counseling related to the stages of death and dying is pursued after aggressive management of symptoms.

The spouse of a recently deceased client states, "I just can't believe he left me. He swore he would never leave me and I feel betrayed!" Using Kübler-Ross stages of grief, what stage does the nurse identify the client is experiencing?

anger Explanation: The client has accepted the fact that the spouse is gone but is angry and betrayed at the departure from life. The client has yet to accept this death and may have some overlapping with depression as well.

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement. Explanation: Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people.

A client has a diagnosis of bladder cancer with metastasis. The client asks the nurse about the characteristics of hospice care. The nurse should explain that:

care is premised on the fact that dying is a normal process. Explanation: Symptoms are treated aggressively in order to preserve comfort. Care is interdisciplinary and admission usually requires a 6-month life expectancy or less.

During a routine physical exam, a male client informs the nurse that he frequently participates in anal intercourse with his new girlfriend. The nurse discusses this practice with the client by informing him that:

condoms are recommended for anal intercourse.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies Explanation: Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed. Reference:

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing?

denial Explanation: By making this statement, the client denies the seriousness of the malignant tumor diagnosis. Denial is often the first emotion the client will experience, as initially it helps in coping with the reality of impending death. There is nothing in the client's statement to indicate anger or acceptance. Bargaining would be indicated by the client negotiating with a higher power to extend life or delay the inevitable.

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan?

difficulty swallowing Explanation: People who are dying do not experience decreased pain. They may not be in a position to report pain; therefore, the caregiver should observe the client closely. Urinary output decreases when a person is approaching death due to system failure and limited intake. The client approaching death has decreased sensory stimulation.

When a man cannot achieve an erection, the phase of the sexual response in which the man is experiencing difficulty is:

excitement phase.

A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

grief reaction Explanation: The anticipatory grief occurs prior to the death. The client's spouse has not had enough of a length of time to determine if the grief is pathologic. The spouse is experiencing the denial stage of grief and not the bargaining stage.

A client is being discharged from the hospital with terminal brain cancer and a life expectancy of 1 month. When planning this client's discharge, it is most important for the nurse to include a referral to which agency?

hospice Explanation: Hospice is care provided for people with limited life expectancy, often in the home. A support group would be appropriate, but not as high in priority as hospice. Home health and outpatient rehab would not be appropriate for this client, as both of these facilities promote care toward independence.

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

leaving the wife's room and belongings intact Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond 3 years.

A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome." This is an example of:

maturational loss. Explanation: Maturational loss is experienced as a result of natural developmental processes, such as sending children off to kindergarten or away to college. A situational loss occurs as a result of an unpredictable event. Physical loss is a loss such as a body part (amputation). Anticipatory loss involves a display of loss, and grief behaviors for a loss that has yet to take place.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility?

placing ID tags on the shroud and ankle Explanation: Although the nurse may place the body in a normal anatomic position and remove tubes and soiled dressings, the only legal action is placing ID tags on the shroud and ankle. The body is not usually washed by the nurse, as different cultures and religions have specific guidelines concerning cleansing the body.

When a 19-year-old male client tells the nurse that he has never been able to achieve an erection, the nurse recognizes that the client is experiencing:

primary impotence.

The Surgeon General's Call To Action To Promote Sexual Health and Responsible Sexual Behavior was released in 2001. The goal of this document is to:

promote general health and wellness.

The nurse is talking with the son of a client with end-stage renal failure and late-stage dementia. The client can no longer live at home, and the son states, "I live 500 miles away. I don't know what to do." Which type of living arrangement will the nurse teach the son about?

residential care Explanation: Nursing homes or long-term care facilities can provide around-the-clock nursing care for clients who cannot live independently or do not have family that can provide in-home care. Acute care is not appropriate, as the client's condition is known and is not unstable. The client needs more monitoring than home care can provide. Respite care is used to provide rest for caregivers.

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

shock Explanation: In the shock and disbelief stage, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies the emotional impact.

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life Explanation: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. A separate plan of care developed by the client with each discipline of the health care team is not the goal of palliative care.

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering Explanation: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.