NUR 190 EAQ - Psychosocial Integrity

A client who underwent mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." What is the nurse's best response?

"Losing power seems important to you."

A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean birth. What should the nurse tell the client to expect?

"We'll be encouraging you to walk early after surgery."

A husband sits in the waiting room while his wife is getting her infertility prescription refilled by the clinic pharmacist. As the nurse sits down beside him, he blurts, "It's like there are three of us in bed - my wife, me, and the doctor." What feeling is reflected by this statement?

Anger.

A client describes his delusions in minute detail to the nurse. How should the nurse respond?

By changing the topic to reality-based events.

What is the greatest difficulty for nurses caring for the severely depressed client?

Contagious quality of depression.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?

Impulsive.

The significant other of a client who is dying of acquired immunodeficiency syndrome (AIDS) tells the nurse, "Life is not worth living without my partner." What should the nurse plan to do to help the significant other cope with the impending death?

Involve the significant other's support system.

A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder?

Loose association.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate?

Loosening of associations.

A caregiver fails to give medications on time to an older adult. Which type of abuse is this?

Neglect.

A client has just awakened from her first electroconvulsive therapy (ECT) treatment. What is the most appropriate initial intervention by the nurse?

Orienting the client to time and place and explaining that the treatment is over.

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts what studies?

Parent-child attachment.

Which toddler behavior should the nurse identify as global organization, a characteristic of preoperational thought?

Refusal to sleep in bedroom because the bed has been moved.

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?

Regression.

After three months of rehabilitation following a craniotomy, a client still is having some motor speech difficulty. What should the nurse do to promote the client's use of speech?

Respond to the client's efforts of speaking.

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days?

Seek out the client frequently to spend short periods of time together.

Which statement regarding abuse is true?

Sexual abuse is nonconsensual sexual contact with another individual.

A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?

Supporting the parents.

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction made by the client leads the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image?

The client recognizes the reality and becomes anxious.

A client with a massive head injury was admitted to emergency department. The trauma team leader notifies the family that the client is expected to die and asks the family about donating the client's organs. The family members agree to proceed with the donation. To which religious group does the family belong?

Unitarian Universalist Association.

A homosexual client is diagnosed with human immunodeficiency virus (HIV). The primary nurse informed the nursing team that the client wept when told of the diagnosis. A health care team member responded by saying, "I don't feel sorry for people like that. My philosophy is that you made your bed and now you can sleep in it." What is the basis of the team member's comment?

Values and beliefs about sexual lifestyles.

A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply.

-Apathy -Flatness

A client with renal colic is scheduled for extracorporeal shock-wave lithotripsy. The night before the procedure, the client puts the call light on frequently and has many demands. Which would be an appropriate statement for the nurse to make?

"You are facing a new experience tomorrow, tell me what concerns you have."

A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do?

Continue the prescribed methadone to prevent withdrawal symptoms.

A nursing student is learning about cultural competence. Which statement by the nurse reflects ethnocentrism?

"I sincerely believe that the beliefs and practices of the culture I was born into are the best."

A 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. Two hours later, the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." How should the nurse respond?

"I will stay with your child while you leave."

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower?

"I'll help you take your shower now."

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do. What is the nurse's most appropriate response?

"You seem concerned about managing your time. Let's talk about it."

A nursing instructor explains to a nursing student that the nursing student is using ethnic stereotyping in her beliefs about a particular culture. Which of these beliefs are likely held by the nursing student? Select all that apply.

-"All the people who belong to this ethnic group are violent and have criminal tendencies." -"I feel that clients who are originally from a certain part of the world usually aren't compliant with the norms of the biomedical health system."

A client is telling a nurse what she does to maintain her health. Which statements made by the client indicate she adheres primarily to an alternative or complementary health belief system? Select all that apply.

-"I often use topic essential oils to promote relaxation." -"I believe acupuncture is most effective in relieving pain." -"I frequently practice meditation to keep myself from becoming depressed."

What should a nurse do if a 2-year-old child insists on drinking milk from a cup without assistance? Select all that apply.

-Give the child a cup with two handles. -Put a plastic bib around the child.

Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during the time following an episode of binge eating? Select all that apply. 1

-Hopelessness -Powerlessness

What are the similarities between the teaching methods for a toddler compared to a preschooler? Select all that apply.

-In both cases, play is used to teach a method or procedure. -In both cases, learning is accompanied with pictures and short stories.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate?

Dehydration.

Which interventions should the nurse recommend for a toddler who is biting other children at daycare? Select all that apply.

-Separating the child from the situation. -Enquiring whether the child is getting enough sleep. -Telling the child it is not okay to hurt another person. -Using a time-out form of discipline for the child's behavior.

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.

-Weak pulse -Difficulty swallowing -Loss of bladder control