Psychosocial Integrity

A nurse working with a chronically mentally ill client can be successful in dealing with a client crisis by taking which of the following actions? 1. Recognizing that rehospitalization is necessary in the event of crisis. 2. Involving the family to support the client whenever crisis occcurs. 3. Eliminating direct nursing interventions to allow the client to exercise problem-solving skills 4. Idnetifying strengths and the healthy aspects of functioning that may compensate for the weaknesses

4. Idnetifying strengths and the healthy aspects of functioning that may compensate for the weaknesses

An older client who has been in traction for several days is becoming disoriented. The nurse implements which appropriate interrvention? 1. Goes along with the disorientation to not upset the client 2. Lets the family reorient the client 3. Prescribes labortory tests to check for electrolyte imbalances 4. Uses environmental cues such as calendars and clocks along with gentle corrective reminders to reorient the client

4. Uses environmental cues such as calendars and clocks along with gentle corrective reminders to reorient the client

A nurse develops a plan of care for a 1-month old infant hospitalized for intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent--child relationship? 1. Provide educational materials. 2. Encourage the parents to room-in with their infant. 3. Inititate home nutritional support as early as possible. Encourage the parents to go home and get some sleep.

Encourage the parents to room-in with their infant.

A client with depression is considering treatment with cognitive therapy. The client says to the nurse, "How does this treatment work?" The nurse responds by telling the client that this type of treatment helps with which of the following? 1. Examining how thoughts and feelings contribute to difficulties 2. Examining how past life experiences contribute to problems 3. Confronting fears by gradually being exposed to them 4. Relaxing and developing new coping skills

Examining how thoughts and feelings contribute to difficulties

A nurse is preparing to do preoperative teaching with a client scheduled for radical neck dissection. The nurse should initially focus on which of the following subjects? 1. The client's usual coping behaviors 2. The client's dependable support systems 3. The client's postoperative communication techniques 4. Information already supplied by the surgeon.

Information already supplied by the surgeon.

A client wil Bell palsy is distressed about the change in facial appearance. The nurse educates the client about which characteristic of Bell palsy? 1. It usually resolves when treated with vasodilator medicaitons. 2. It is similar to stroke, but all symptoms will go away eventually. 3. The symptoms will completely go away once the stroke is treated. 4. It is not caused by stroke, and many clients receover in 3 to 5 weeks.

It is not caused by stroke, and many clients receover in 3 to 5 weeks.

A home care nurse visits a client who asks the nurse to buy some groceries for her because she is not feeling well today. Which of the following statements should the nurse make to respond to the client? 1. Let's discuss how we can solve this problem. 2. I am not allowed to buy groceries for clients. 3. Do you have any support systems for shopping? 4. Nurses are professionals and do not run errands.

Let's discuss how we can solve this problem.

A nurse is caring for a 25-year old single client who will undergo bilateral orchiectomy for testicular cancer. The nurse should make it a priority to explore which of the following potential psychological concerns with this client? 1. Postoperative pain 2. Postoperative swelling 3. Loss of reproductive ability 4. Length of recuperative period.

Loss of reproductive ability

A nurse is assigned to care for a client with paranoid personality disorder who is experiencing difficulty with diversional activity. THe nurse plans care, knowing that which of the following activities is appropriate for this client? 1. A crossword puzzle 2. PLaying bridge 3. Playing chess 4. Playing cards with another client

1. A crossword puzzle

When administering a liquid medication to an uncooperative toddler, a nurse should implement which of the following strategies? 1. Allow the parents to remain in the room 2. Remove the child to another room away from the parents. 3. Restrain the child in a highchair 4. Restrain the child in a papoose-type device

1. Allow the parents to remain in the room

A hospitalized client with a diagnosis of delirium becomes disoriented and confused in her room at night. THe nurse should take which action to assist in reducing the disorientation and confusion? 1. Ensure a low-stimulating environment at nighttime. 2. Keep the television on during the night 3. Maintain a well-lit room during the night 4. Keep the radio on during the night.

1. Ensure a low-stimulating environment at nighttime.

A client with a diagnosis of depression says to the nurse, I always make mistakes. I never do anything right! The best nursing action is to provide which of the following responses? 1. Tell the client that everyone makes mistakes 2. Tell the client that this is not true and that things will get better. 3. Reassure the client that you know how the client is feeling. 4. Identify recent client accomplishments that demonstrate skills and ability

4. Identify recent client accomplishments that demonstrate skills and ability

A manic client is placed in a seclusion room after an outburst of violent behavior that included a physical assault on another client. As the client is secluded, the nurse takes which of the following actions? 1. Remains silent because verbal interaction would be too stimulating. 2. Tells the client that he will be allowed to rejoin the others when he can behave. 3. Asks the client if he understands why the use of therapeutic seclusion is necessary. 4. Informs the client that he is being secluded for the purpose of helping him regain control of himself.

Informs the client that he is being secluded for the purpose of helping him regain control of himself.

The priority nursing action when caring for an older client who is a victim of physical abuse is which of the following? 1. Contact the social worker to report the abuse 2. Ensure that the client is safe 3. Call the clergy to meet the client's spiritual needs 4. Contact the appropriate state officials to report the abuse

2. Ensure that the client is safe

On the second day of hospitalization, a depressed client comes to the dayroom dressed neatly in slacks and a blouse, with hair combed back in a ponytail. The nurse should make which of the following statement to the client? 1. Wow, you look terrific! 2. You must be feeling better today. 3. This is a first-time event! 4. I notice that you are dressed and that your hair is combed.

4. I notice that you are dressed and that your hair is combed.

A client being mechanically ventilated after experiencing a fat embolus is visibily anxious. The nurse should take which appropriate action? 1. Remain with the client, speak calmly, and provide reassurance 2. Ask a family member to stay with the client at all times. 3. Ask the physician for a prescription for an antianxiety medication. 4. Encourage the client to sleep until arterial blood gas results improce

Remain with the client, speak calmly, and provide reassurance

A client with paranoia tells the nurse tht she will not attend the group therapy session because a student nurse has been sent to spy on her. The nurse makes which response to the client? 1. If you attend group therapy, I'll take you for a walk. 2. What makes you think the student is spying on you? 3. Student nurses attend group therapy as part of their education. 4. Come to therapy with me; I'll protect you.

Student nurses attend group therapy as part of their education.

A nurse is assigned to care for a client admitted to the mental health unit with a diagnosis of mania. Which activity should the nurse provide for the client initially? 1. Writing 2. PLaying cards with staff members 3. Playing checkers with other clients on the unit 4. PLaying a board game with family members.

1. Writing

A family of a client with Parkinson disease tells the nurse that the client is having difficulty adjusting to the disorder and that they do not know what to do to help. THe nurse advises the family that which of the following is most therapeutic in assisting the client to cope with the disease? 1. Encourage and praise client efforts to exercise and perform activities of daily living (ADLs). 2. Cluster activities at the end of the day when the client is restless and bored. 3. Plan only a few activities for the client during the day. 4. Assist the client with ADLs as much as possible

1. Encourage and praise client efforts to exercise and perform activities of daily living (ADLs).

A nurse is performing an assessment on a preshool child. To faciliate the cooperation of the child, the nurse should: 1. Have the child pretend to be a nurse 2. Have the parents leave the room 3. Offer information and answer questions 4. Explain in detail each part of the examination before doing it.

1. Have the child pretend to be a nurse

A client on the psychiatric unit is displaying manipulative behavior. The nurse should use which interventions in working with this client? (Select all that apply) 1. Identifying the manipulative behaviors exhibited by the client. 2. COmmunicating to the client the behaviors that are expected. 3. Describing clearly the consequences of not staying within identified limits related to behaviors 4. Making accusations regarding the clients behaviors. 5. Being prepared to argue with the client to ensure that views of a situation are shared.

1. Identifying the manipulative behaviors exhibited by the client. 2. COmmunicating to the client the behaviors that are expected. 3. Describing clearly the consequences of not staying within identified limits related to behaviors

The nurse prepares to implement suicide precautions for a suicidal client. Select the nursing interventions with regard to these precautions. (Select all that apply) 1. Maintain arms length distance with the client at all times. 2. Ensure that meal trays contain no glass or metal silverware. 3. Carefully watch the client swallow each dose of medication 4. Conduct one-on-one nursing observation and interaction 24 hours a day. 5. Document clients mood verbatim statements, and behaviors every 15 to 30 minutes per protocol. 6. Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.

1. Maintain arms length distance with the client at all times. 2. Ensure that meal trays contain no glass or metal silverware. 3. Carefully watch the client swallow each dose of medication 4. Conduct one-on-one nursing observation and interaction 24 hours a day. 5. Document clients mood verbatim statements, and behaviors every 15 to 30 minutes per protocol.

A nurse is caring for a client who is experiencing psychomotor agitation. Which of the following activities would be appropriate for the nurse to plan for the client? 1. Playing Ping-Pong 2. Playing chess 3. Playing simple card games 4. Reading magazines

1. Playing Ping-Pong

A nurse is planning care for a client who is experiencing psychomotor agitation. Which of the following activities would be appropriate for the nurse to plan for the client? 1. Working with clay 2. Playing chess 3. Playing simple card games 4. Reading magazines

1. Working with clay

A female prison client, who killed her abusive husband by shooting him six times, is eligible for parole and asks the nurse, "Do you think I have a chance of being paroled? Which nursing response is a therapeutic response? 1. You have promises of obtaining employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion. 2. Let me respond by telling you that most parole applications are denied the first time. NEvertheless, I have learned that your good conduct record will be seriously considered. 3. If I were you, I would not build up too much hope. Simply having a firm plan in place will not help your case. 4. Do you think you do?

1. You have promises of obtaining employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion.

A client is experiencing acute alcohol withdrawal, and 7.5 mg of diazepam (Valium) intravenously has been prescribed. The medication bottle indicates that there are 5 mg per millileter. The nurse draws how many milliliters into the syringe to administer the correct dose?

1.5 ml

A cleint is crying after receiving positive results on a tuberculin skin test and asks the nurse what this means. The nurse plans to reassure the client by sharing that the test result means which of the following? 1. Active tuberculosis is present 2. An exposure to tuberculosis has occurred. 3. A history of tuberculosis is indicated 4. Absolutely no tuberculosis is present.

2. An exposure to tuberculosis has occurred.

A child with croup is admitted to the hospital, and the physician prescribes a cool-mist tent. THe child is fearful and crying. Which of the following nursing interventions is appropriate? 1. Obtain a toy from the playroom for the child to bring into the tent. 2. Ask the mother to bring the child's favorite toy from home. 3. Ask the physician for a prescription for a mild sedative. 4. Ask the physician to change the prescription from the mist tent to oxygen via nasal cannula.

2. Ask the mother to bring the child's favorite toy from home.

To work with a woman victimized by physical abuse successfully and appropriately, the nurse should take which of the following steps first? 1. Agree with the woman that it is possible that she might have acted in a manner that provoked the abuse. 2. Carefully examine her own personal attitudes toward the victim and abuser before working with the client. 3. Establish firm timelines for the woman to make the necessary changes in her life situation. 4. Reinforce with the woman that dealing with the psychological and physical aspects is the priority.

2. Carefully examine her own personal attitudes toward the victim and abuser before working with the client.

A client with an anxiety disorder is also diagnosed with an acute inferior myocardial infarction and is placed on bed rest. THe nurse includes measures in the plan of care to avoid which of the following potential complications related to bed rest? 1. Increased chest pain 2. Constipation 3. Diarrhea 4. Arthritis

2. Constipation

A client is diagnosed with terminal carcinoma of the lung, and the nurse is assisting the client to plan for end-of-life issues. The appropriate nursing intervention is to assist the client to take which of the following actions? 1. Explore all treatments before death, even if they seem futile. 2. Gain control over the end-of-life issues through creation of advance directives. 3. Engage an attorney to make all decisions for the client. 4. Direct the insurance company to pay all expenses upon death.

2. Gain control over the end-of-life issues through creation of advance directives.

A young adult male client with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again. "The nurse replies in a realistic way by making which of the following statements to the client? 1. "It must feel horrible to know you can never have sex again. 2. It's still possible to have a sexual relationship, but it will be different. 3. "You're young, so you'll adapt to this more easily than if you were older." 4. "Because of body reflexes, sexual functioning will be no different than before.

2. It's still possible to have a sexual relationship, but it will be different.

When performing an admission assessment for a child, the nurse suspects physical abuse. The appropriate nuring action is which of the following? 1. File charges against the mother and father of the child 2. Report the case to legal authorities 3. Ask the mother to identify the individual who is physically abusing the child 4. Tell the child that she will need to go to a foster home until the situation is straightened out.

2. Report the case to legal authorities

A client is hospitalized with a diagnosis of severe depression. The client is withdrawn and exhibits poor motivation and concentration. The nurse plans to involve the client in which of the following activities at this time? 1. Small group discussions 2. Simple two-person card games 3. Cooking class 4. Dance therapy

2. Simple two-person card games

A nurse is caring for an anxious client who just had a chest tube inserted and an occlusive dressing placed over the insertion site. Which intervention would have the greatest overall immediate benefit to assist the client? 1. Encouraging the client to cough and take deep breaths 2. Staying with the client 3. Reviewing the arterial blood gas report 4. Distracting the client with television

2. Staying with the client

A mental health nurse reviews the activity schedule for the day and determines that the best activity that a manic client could participate in is which of the following? 1. Brown-bag luncheon and book review 2. Tetherball 3. Paint-by-number activity 4. Deep-breathing and progressive relaxation group

2. Tetherball

A nurse is caring for a depressed adult client who says to the nurse, What do you think I should do about my home? My son thinks I should sell it and move into something smaller now that I'm alone. Which of the following responses by the nurse is therapeutic? 1. Oh no, I'm not getting into the middle of this. This is something only you can decide. 2. What would you like to do? Do you feel you'd be happier in a smaller place? As your depression lifts, you'll be more able to decide what is best for you. 3. Why not wait until you're feeling less depressed to make such an important decision? You've only been on your medication for 4 months. 4. I agree with your son. As you age, you will find that smaller one-floor living is best.

2. What would you like to do? Do you feel you'd be happier in a smaller place? As your depression lifts, you'll be more able to decide what is best for you.

Which of the following actions must be taken for a client receiving tranylcpromine (Parnate) and sertraline (Zoloft) concurrently? 1. Teach the client how to take these two prescribed medications. 2. Ensure client understanding that it will take a week for the sertraline to exert its effects. 3. Consult with the physician and instruct the client to discontinue the sertraline for 2 weeks before starting tranylcpromine. 4. Instruct the client to limit alcohol to two glasses of wine daily.

3. Consult with the physician and instruct the client to discontinue the sertraline for 2 weeks before starting tranylcpromine.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares feelings of social isolation with the nurse. Which strategy does the nurse suggest to the client to decrease these feelings? 1. Using the Internet to faciliate communication 2. Using television and newspapers to maintain a feeling of being "in touch" with the world 3. Contacting any of the local support groups for clients with AIDS 4. Reinstituting contact with the client's family, who live in a distant city

3. Contacting any of the local support groups for clients with AIDS

A nurse assigned to care for a postpartum client plans to promote parent-infant bonding by encouraging the parents to take which of the following actions? 1. Use a low-pitched voice to speak to the infant 2. Allow the nursing staff to assume the infant care during hospitalization so they may rest. 3. Hold and cuddle the infant closely 4. Allow the infant to sleep in the parental bed between the parents.

3. Hold and cuddle the infant closely

After being on bed rest in a private room for 1 week, the client exhibits periods of confusion. The physician writes a prescription to start progressive crutch walking as tolerated. Which nursing intervention would decrease the client's confusion? 1. Ambulating in the room, increasing the distance by 5 feet each time 2. Ambulating to the bathroom in the client's room three times a day 3. Progressive ambulation in the hall three times a day 4. Range of motion three times a day to increase strength

3. Progressive ambulation in the hall three times a day

A nurse is caring for a child with osteosarcoma after amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. The initial nursing action is which of the following? 1. Request a referral for a psychiatric consultation. 2. Ask the physician for a prescription for a placebo. 3. Reassure the child that this is a temporary condition. 4. Tell the child that the prosthesis will relieve this sensation.

3. Reassure the child that this is a temporary condition.

A nurse is assigned to care for a client diagnosed with catatonic stupor. On entering the client's room, the nurse finds the client lying on the bed with the body pulled into a fetal position. The appropriate nursing action is which of the following? 1. Leave the client alone. 2. Move the client into the visitor's lounge 3. Sit beside the client in silence. 4. Ask the client direct questions to encourage talking.

3. Sit beside the client in silence.

A nurse is monitoring a client for complications following thyroidectomy. THe nurse notes that the client's voice is very hoarse, and the client is concerned about the hoarseness and asks the nurse about it. The nurse should make which of the following responses to alleviate the client's concern> 1. Hoarseness and a weak voice may indicate permanent damage to the nerves. 2. THis complication is expected 3. THis problem is temporary and will probably subside in a few days. 4. It is best that you not talk at all until the problem is further evaluated.

3. THis problem is temporary and will probably subside in a few days.

When assessing a client's psychosocial adjustment to a newly applied body cast, the nurse should collect data regarding which of the following? 1. Type of transportation available for discharge 2. Ability to perform activities of daily living 3. Usual coping techniques 4. The home environment

3. Usual coping techniques