Basic Psychological Needs
The nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors? effects of cigarette smoking responsible drinking patterns motor vehicle accidents preventative vaccinations
preventative vaccinations
On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate? "Are you having a great deal of uterine pain?" "Commonly spontaneous abortion means a defective embryo." "I am truly sorry you lost your baby." "You can try to get pregnant again after a normal period."
"I am truly sorry you lost your baby."
The nurse is caring for a client with a terminal illness who is awaiting transfer to hospice. The client states, "It is all out of my hands now." How should the nurse respond? "Are you feeling like you do not have control? Would you like to discuss the planned transfer to hospice?" "I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" "Change and transition can be challenging. We are here to support you. What can I do now to help?" "I hear you saying you do not feel in control. What coping technique do you usually use when feeling this way?"
"I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?"
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? "I will make an appointment with an addiction counselor for support." "I will invite my family to join me in psychotherapy." "I plan to attend Alcoholics Anonymous meetings regularly." "I will begin with inpatient treatment and participate in an aftercare program."
"I will begin with inpatient treatment and participate in an aftercare program."
A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse? "It's good to have something to believe in." "It sounds like that offers you a sense of security." "People with strong beliefs have better outcomes." "Think about your leader when you have moments of doubt."
"It sounds like that offers you a sense of security."
A client is 36 weeks' gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse? "Do you belong to any community groups that may be able to support you?" "It appears that you are concerned about where your friends and family are living right now." "Tell me more about how you are feeling." "Would you like to speak to the hospital social worker?"
"Tell me more about how you are feeling."
The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which statement by the nurse provides appropriate interpretation of the impact of stressors on the client's health? "You have a low risk of becoming ill in the near future." "These life stressors place you at moderate risk for illness." "The positive stressors will offset the impact of the negative ones." "Watch your health carefully for the next several months."
"These life stressors place you at moderate risk for illness."
A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. Which question would be appropriate for the nurse to ask to assist the client? "When is the best time of day to approach your boss?" "How is it best for you to approach your boss?" "What have you done so far to try to solve this problem?" "What are your alternative plans at this time?"
"What have you done so far to try to solve this problem?"
A client exhibits signs of increased anxiety. Which response by the nurse is most likely to reduce the client's anxiety? "There is nothing to worry about, really." "Anxiety is just the body's way of protecting itself." "Have you tried taking a few deep breaths?" "Would you like to talk about what's bothering you?"
"Would you like to talk about what's bothering you?"
A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be most therapeutic? "Tumors are not always cancerous." "Your healthcare provider can discuss this in more detail." "You sound concerned about what's happening." "You'll have to have some tests to rule out cancer."
"You sound concerned about what's happening."
Which factors should be the primary factor in a nurse's decision whether to pray with a client? the client's openness to being prayed for the nurse's familiarity with the prayer traditions of different faiths the nature and course of the client's current diagnosis the availability of a hospital chaplain or other spiritual counselor
the client's openness to being prayed for
A client who was involved in a motor vehicle accident is admitted to the hospital. The client's spouse arrives on the unit 6 hours after the accident, explaining that they have been out of town. The spouse is distraught because they were not with the client when the client needed them. What should the nurse do? Allow the spouse to verbalize their feelings and concerns. Describe the client's medical treatment since admission. Explain to the spouse that the client's condition is stable. Reassure the spouse that the important fact is that they are here now.
Allow the spouse to verbalize their feelings and concerns.
The nurse is caring for an adolescent client. What is the best way for the nurse to obtain data related to the client's spirituality? Ask the client's parents if the client attends religious services. Observe whether the client reads religious material. Ask the client if there are aspects of the client's life they consider spiritual. Interview the client about influential spiritual leaders in their life.
Ask the client if there are aspects of the client's life they consider spiritual.
The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person? Permit the roommate to cry alone. Change the roommate's assigned room. Console the roommate as grieving begins. Ask the facility chaplain to talk with the roommate.
Console the roommate as grieving begins.
The hospice nurse is caring for a client who has been diagnosed with terminal cancer. The client breaks down in tears and shares with the nurse "I should just end it now so my kids can start moving on with their lives. They will be better off without me. When they come to visit tomorrow, just tell them I'm not up for visitors." The nurse understands the client is in which stage of the grief process? Suicidal Denial Acceptance Depression
Depression
An adolescent presents to the emergency department after a motor vehicle accident. Police inform the parent that the client was thrown from the vehicle, was not wearing a seatbelt, and they believe the client was driving while under the influence of alcohol. The health care provider updates the parent that the adolescent has a cervical spine fracture and may be paralyzed. The parent becomes upset and agitated with the police officer and health care provider, and says "You are both wrong! My Johnny is a good boy! He would never do that - he plays basketball and is on the honor roll!" In which stage of the grief process is the parent? Anger Denial Acceptance Bargaining
Denial
A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which is most important for the nurse to include in the plan of care? Interview family members to determine the dynamics of the family relationships. Explore the client's obsessive thoughts that are resulting in high anxiety. Ask the client about plans for managing the financial obligations. Determine the client's ability to cope with the job loss and family obligations.
Determine the client's ability to cope with the job loss and family obligations.
A client who underwent cardiac surgery 2 days ago is recovering well. The client's spouse, who is assisting with care, says, "My spouse is doing too much. I want to help, but they won't let me." The nurse says to the spouse, "It sounds like you need to feel you can be more helpful." In order to make the nonverbal behavior complement the words, what should the nurse do? Direct the eyes at the client. Direct the body and eyes at the spouse and client. Avoid direct eye contact with the client and spouse. Shift the eyes back and forth between the client and spouse.
Direct the body and eyes at the spouse and client.
A nurse is caring for a client with advanced cancer. Based on the accompanying nursing progress notes, what should be the nurse's next intervention? 1/7/08 1545 Pt/s states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now/ I don't want to die in the hospital, I want to be in my own bed" R. Doly RN Reread the document on patient/client rights to the client. Call the client's spouse to discuss the client's statements. Tell the client that only in the hospital can there be adequate pain relief Explain the use of an advance directive to express the client's wishes.
Explain the use of an advance directive to express the client's wishes.
A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? Ask a child specialist to be present during treatment. Tell the infant that it will be over within a minute. Encourage parents to be present during the treatment. Provide the infant with soft toys or a feeding bottle.
Encourage parents to be present during the treatment.
The nurse is caring for a client with suicidal ideation on an inpatient unit. Which activity should the nurse recommend when the client has thoughts of suicide? keeping track of feelings in a journal engaging in physical activity talking with the nurse playing a card game with other clients
talking with the nurse
The nurse manager on the urology unit has employed three nurses from a culture that is different from that of most of the nurses and patients on this unit. Which strategy would help the newly employed nurses socialize into the team and promote the cultural competence of all of the nurses? Create a staffing plan, placing one of the newly employed nurses on each shift. Require newly employed nurses to speak English only when working. Hold a culture-sharing session at monthly meetings. Encourage the staff to invite the new nurses to meet their families.
Hold a culture-sharing session at monthly meetings.
The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client? Plan and implement care in a way that is sensitive to the needs of the client. Ask the client to explain the reasons for certain cultural preferences. Assure the client that all cultural preferences will be respected by staff. Introduce the client to other clients on the unit who share the same culture.
Plan and implement care in a way that is sensitive to the needs of the client.
The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply. Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body. Direct the family to the funeral home.
Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body.
Which statement about religion and spirituality is most accurate? Religion is an organized system of spiritual beliefs. Religion and spirituality are synonymous. Spirituality is the behavioral manifestation of religious beliefs. Spirituality is a recently developed alternative to traditional religious belief.
Religion is an organized system of spiritual beliefs.
A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply. Use the oldest child as the interpreter during the home visits. Request that a health related interpreter to come to the home. Ask the client's spouse to be the interpreter during each visit. Appeal to the client's best friend to stay and act as the interpreter. Utilize a trained telephone interpreter while providing care.
Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care.
A terminally ill client has a health care directive (advanced directive) that indicates "do not intubate" in the event of respiratory failure. The client is now unresponsive and the family requests that "everything be done" to support the client's breathing. What action(s) should the nurse take in this situation? Select all that apply. Arrange with the team to perform a "slow code" to alleviate the family's fears about nothing being done while still complying with the client's wishes. Request the health care provider speak with the family related to prognosis and realistic expectations should intubation be performed for the client. Show the health care directive to family members and explain that their wishes are not the team's concern. The client's wishes must be respected. Interview the family members about their wishes for spiritual and psychological supports related to the anticipated death and dying process.
Request the health care provider speak with the family related to prognosis and realistic expectations should intubation be performed for the client. Interview the family members about their wishes for spiritual and psychological supports related to the anticipated death and dying process.
Family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the patient's bedside to perform Anointing of the Sick. The nurse who is providing care for the client should recognize that the family is likely Roman Catholic. Christian Scientist. Jehovah's Witness. Jewish.
Roman Catholic
The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse? Support the implementation of the ideas of the majority. Seek input from all groups and strive for consensus on what would benefit most or all of these people. Seek to promote homogeneity and common views rather than focus on differences. Make decisions based on findings from the community assessment.
Seek input from all groups and strive for consensus on what would benefit most or all of these people.
An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is Spiritual need as evidenced by verbalization and distress at missing Methodist church services. Dysfunctional grieving related to inability to attend church services as a result of the client's medical condition. Potential for Enhanced spiritual well-being related to distress at missing Methodist church services.
Spiritual need as evidenced by verbalization and distress at missing Methodist church services.
A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest? Find ways to make work fun. Take stress-management classes. Spend more time with the family. Leave work at work.
Take stress-management classes.
A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure? The nurse should contact the person identified as the healthcare power of attorney. The attorney who prepared the client's last will and testament may sign the consent. The primary healthcare provider may act without consent to save the client's life. The client's do not resuscitate (DNR) order denies consent for the procedure.
The nurse should contact the person identified as the healthcare power of attorney.
A registered nurse (RN) suspects that another nurse on the unit is using controlled substances. The suspected nurse is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address their concerns? Select all that apply. Continue to document the behaviors, but wait until something happens to report. Talk compassionately to the suspected nurse and discuss the RN's concerns and observations. Report the behaviors to the unit manager for further investigation. Do nothing as the RN does not have proof of controlled substance abuse. Discuss the RN's concerns with another nurse on the unit to see what they think.
Talk compassionately to the suspected nurse and discuss the RN's concerns and observations. Report the behaviors to the unit manager for further investigation.
A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse? The nurse should listen attentively and provide realistic verbal reassurance. The nurse should report the client statements to the physician. The nurse should proceed with the assessment and preparation for surgery. The nurse should request an anti-anxiety medication from the anesthesiologist.
The nurse should listen attentively and provide realistic verbal reassurance.
A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. Which of these best describes a subculture? a cultural group with fewer than 5 million members in the United States a unique cultural group with unspecified geographic origins a cultural group with values that are incongruent with those of the dominant culture a unique cultural group that exists within the larger culture
a unique cultural group that exists within the larger culture
When a nurse reflects on questions such as "Why am I here?" the nurse is attempting to develop the concepts of holism and integration. become a more spiritual being for other people. develop a philosophical base for clearer thinking. strive toward unity with a higher power.
develop a philosophical base for clearer thinking.
Which is an important consideration when the nurse is providing culturally competent care in a community clinic? knowing about different cultural practices and generalizing when caring for clients from that culture asking about cultural beliefs related to health, illness, treatments, and dietary practices informing the client about preferred health interventions and making decisions for the client explaining that multiculturalism means all cultures melding to assimilate into one culture
asking about cultural beliefs related to health, illness, treatments, and dietary practices
Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy? the cause of death can be discovered rebirth is made impossible body ultimately decomposes into dust the continuation of society is prevented
the cause of death can be discovered
A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about a breast prosthesis and wigs. After answering the questions directly, the nurse should provide what additional information? contact information for the breast cancer support group a referral to the social worker how to contact a home health care agency when to contact a plastic surgeon
contact information for the breast cancer support group
The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply. discussion of pertinent information the client's agreement to the plan of care freedom from coercion caregiver preference and opinion verification from next of kin
discussion of pertinent information the client's agreement to the plan of care freedom from coercion
While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience? fear of the unknown fear of changes in body image fear of the effects of anesthesia fear of being in pain
fear of the unknown
A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time? ability to care for self feelings of anxiety barriers to effective communication experiences of powerlessness
feelings of anxiety
During the termination phase of a nurse-client relationship, which intervention may lead to client confusion? referring the client to support groups introducing new issues to the client reviewing what's been accomplished during the relationship responding with empathy when the client express sadness that the relationship is ending
introducing new issues to the client
A client with a fetal demise at 40 weeks asks the nurse, "How could God let this happen?" An appropriate goal for the client with a nursing diagnosis of Spiritual distress related to infant loss as verbalized by the client would be that the client will express feelings of anger and despair to God. meet with a minister daily. reflect on positive accomplishments in life. participate in supportive spiritual practices.
participate in supportive spiritual practices.
A client is admitted to the rehabilitation unit after a cerebrovascular accident (or brain attack). The client is bedridden and aphasic. When assessing the client's emotional response to the illness, what would the nurse most want to explore? past experiences and coping abilities frustration with changes in lifestyle willingness to participate in rehabilitation ability to understand the illness
past experiences and coping abilities
Arrangements are made for a member of the colostomy support group to meet with a client before bowel surgery. What is accomplished by having a representative from the group meet the client preoperatively? letting the client know that there are resources in the community that can help providing support for the health care provider's plan of therapy for the client providing the client with support and realistic information on the colostomy explaining that the surgery will not be disfiguring and that the client can lead a full life
providing the client with support and realistic information on the colostomy
A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. What best protects the client's right to self-determination? respecting the client's desire to have the uncle make choices on her behalf revisiting the decision when the uncle is not present at the bedside teaching the client about her right to autonomy holding a family meeting and encouraging the client to speak on her own behalf
respecting the client's desire to have the uncle make choices on her behalf
In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is clarification. reflection. restating. self-disclosure.
self-disclosure.
A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcohol use disorder. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? dietitian pharmacist social worker infection control nurse
social worker
A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling? the nurse's comfort and knowledge level related to the process of spiritual counselling the degree of alignment between the client's spiritual beliefs and those held by the nurse the family's wishes related to their involvement in the client's spiritual practices whether the client is receiving palliative care measures or is approaching end of life
the nurse's comfort and knowledge level related to the process of spiritual counselling
Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for chemotherapy. When the nurse enters the client's room, the client is sobbing and states, "I thought the chemotherapy would help, but now I feel worse." Which response by the nurse is most appropriate? "You sound discouraged. Chemotherapy commonly makes people feel worse." "Can you tell me more about how you are feeling right now about your treatment?" "Can you tell me what side effects of the chemotherapy are most troubling for you?" "It can be discouraging to feel worse after treatment. How can I help you feel better?"
"Can you tell me more about how you are feeling right now about your treatment?"
A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse? "Would you like me to call your spouse?" "This is a normal response to the loss of a loved one." "I would like to sit with you and talk about your child." "Could I call the health care provider for you?"
"I would like to sit with you and talk about your child."
The nurse is caring for a client who recently lost an infant to sudden unexplained infant death syndrome (SUIDS). The client talks about going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate? Denial Delusion Acceptance Bargaining
Acceptance
The healthcare provider has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family? Accommodate their grieving, explain what is happening, and encourage involvement in the care. Encourage realistic expectations of recovery and reinforce the reality of the prognosis. Reassure the family that it is normal to feel concerned after hearing such a prognosis. Encourage the family to stay positive and focus on the possibilities for the future.
Accommodate their grieving, explain what is happening, and encourage involvement in the care.
A client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, "I'm so frustrated with my doctors. The wound care doctor tells me this won't heal and I need to have my toes amputated, and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, what should the nurse do? Contact the client's case manager to set up a care conference. Assure the client that the health care providers (HCPs) know what they are doing. Remind the client of the responsibilities for health habits regarding diabetes. Review the HCPs' progress notes with the client.
Contact the client's case manager to set up a care conference.
A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What action should the nurse take? Explore their own feelings about the issues of anencephaly and organ donation. Contact the client's minister to discuss the client's options related to the pregnancy. Advise the client that the prolonged neonatal death will be very painful for them. Ask the client if their family agrees with the decision.
Explore their own feelings about the issues of anencephaly and organ donation.
A nurse has migrated to a different country and started working there. Which factor is important for effective functioning? stereotype ethnocentrism cultural habituation culture shock
cultural habituation
A client says to a nurse, "I know I am going to die." How should the nurse respond? "It sounds like you are worried about dying. This is common for people in hospital." "I hear you telling me you are afraid. What can I do to help you feel more secure?" "Tell me more about what you mean when you say you know you are going to die."' "I hear that you are afraid of dying. I can reassure you that your condition is stable now."
"Tell me more about what you mean when you say you know you are going to die."'
A client is admitted for an acute exacerbation of multiple sclerosis and says, "What is the point of all of this? I will never have a meaningful life." What is the nurse's best response? "It is common to feel hopeless when you have a terminal illness. Can you tell me more about how you feel?" "Things seem hopeless now because of the exacerbation. You will recover and go back to your life soon." "You sound very discouraged. Can you share with me your feelings about how this illness affects you?" "I have seen many visitors since you were admitted. It looks like you are important to many people."
"You sound very discouraged. Can you share with me your feelings about how this illness affects you?"
During the postoperative period after a modified radical mastectomy, the client confides in the nurse that they think they got breast cancer because they had an abortion and did not tell their spouse. What is the best response by the nurse? "Cancer is not a punishment; it's a disease." "You might feel better if you confided in your husband." "Tell me more about your feelings about this." "I can have the social worker talk to you if you would like."
"Tell me more about your feelings about this."
A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response? "You'll be okay after the physician gets the bleeding under control." "That's a difficult question to answer, and this must be very frightening for you." "What makes you think you're not going to make it?" "Chronic alcoholism has serious consequences, and you may have the same outcome as your friend."
"That's a difficult question to answer, and this must be very frightening for you."
A client gives birth to a neonate at 30 weeks' gestation. The neonate is stable on minimal ventilator settings. The client's previous infant, who was born at 24 weeks' gestation, did not survive. The family is Roman Catholic and requests that the neonate be baptized as soon as possible. What response by the nurse is most appropriate? "What would you like me to do to help arrange the baptism?" "Are you requesting the baptism because you are concerned that your infant might die?" "We have a unit chaplain who rounds daily and can perform the baptism." "Your baby is much older and much more stable than the baby you lost."
"What would you like me to do to help arrange the baptism?"
The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"? "This heart attack really saddens you." "I don't understand. You have survived this heart attack. Why do you think life will never be the same?" "Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack." "You're very concerned when you think about how this will change your life."
"You're very concerned when you think about how this will change your life."
Nurses are aware that variety and diversity occur both within and across groups. Which factor leads to cultural benefits as a result of diversity? Equal opportunity exists for various cultural perspectives. The dominant culture overpowers outward expressions of other cultures. Suppression occurs in people of differing cultural orientations. Other cultures experience the lasting effects of disempowerment.
Equal opportunity exists for various cultural perspectives.
A 17-year-old unmarried primigravida at 10 weeks' gestation tells the nurse that their family does not have much money and their parent just got laid off from work. What action should the nurse take? Instruct the client on methods for low-cost, highly nutritious meal preparation. Determine whether the client qualifies for local assistance programs. Refer the client to a social worker for enrollment in a food assistance program. Ask the client if they have a job and the amount of income earned.
Refer the client to a social worker for enrollment in a food assistance program.
The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family? Schedule time to visit the family at home. Contact the hospice agency to provide grief support for the family. Suggest the family engage in work and leisure activities. Ask the family to come to the facility to meet with the primary nurse caregiver.
Contact the hospice agency to provide grief support for the family.
An elderly client with primary degenerative dementia is slow in following simple directions and is indecisive selecting clothes to be worn for the day. What is the best approach for the nurse to take? Allow the client to select from the outfits and minimize other distractions in the environment. Give the client the opportunity to select from two outfits and cue follow-through instructions. Pick an outfit and assist with dressing because the client is too distracted to complete this activity without help. Time limit the indecision and let the client know that activities of daily living need to be completed faster.
Give the client the opportunity to select from two outfits and cue follow-through instructions.
A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse? "You have a right to withdraw consent. Can you share more about your decision?" "You have the right to refuse treatment. I'll let the healthcare provider know." "You can always change your mind afterwards. Did you want to try to see how it feels first?" "I respect your right to make that choice. However, do you think you may just be scared?"
"You have a right to withdraw consent. Can you share more about your decision?"
A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response? Assure the client that everything will work out fine. Explain that the condition is complicated and ask a physician to come speak with the client. Approach the client and ask if there are questions about the condition. Ask the client if calling the family would be helpful.
Approach the client and ask if there are questions about the condition.
A child with a nut allergy presents with a severe reaction for the third time in 3 months. The parent says, "I'm having trouble with the food labels." What should the nurse do first? Assess the parent's ability to read. Refer the client to the dietician. Notify the health care provider (HCP). Obtain a social service consult.
Assess the parent's ability to read.
The nurse is caring for a client with end-stage cancer whose health status is declining. A prescription is written by the attending health care provider (HCP) to withhold all fluid, but the health care team cannot locate a family member or guardian. The nurse requests an ethics consultation. Which information is true of an ethics consultation? Select all that apply. Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. Ethics consultations may prevent poor outcomes in cases involving ethical problems. The recommendations of ethics consultants are advisory only. Requests for ethics consultations may only be made by the HCP or nurse. An ethics consultation is intended to provide legal advice on client care.
Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. Ethics consultations may prevent poor outcomes in cases involving ethical problems. The recommendations of ethics consultants are advisory only.
The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket? The client states that the restraints are tight and uncomfortable. There is a medical need to maintain body alignment. The client is at risk for injury from fighting the restraints. Staff assessment reveals that the client will feel more secure under the blanket.
The client is at risk for injury from fighting the restraints.
A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? devising a bathing and dressing schedule for each morning drawing up a schedule and making certain that it is adhered to bathing and dressing the client each morning until the client is willing to perform self-care independently assisting the client with bathing and dressing by giving clear, simple directions
assisting the client with bathing and dressing by giving clear, simple directions
A nurse calls the unit manager to report that their purse has been stolen from the locked break room. The nurse says they think they know which staff member stole the purse. Which action(s) by the nurse manager would be appropriate? Select all that apply. Confront the person the nurse suspects stole the purse. Call hospital security to initiate an investigation. Ask the nurse to document all the facts related to the stolen purse. Alert nursing administration that a staff member's purse has been stolen. Ask other staff to report any suspicious activity they may have observed.
Call hospital security to initiate an investigation. Ask the nurse to document all the facts related to the stolen purse. Alert nursing administration that a staff member's purse has been stolen. Ask other staff to report any suspicious activity they may have observed.
The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation? Contact the chaplain to arrange a visit with the client. Perform a detailed spiritual assessment of the client. Organize a meeting between the chaplain, the adult child, and the client to achieve a resolution. Document the client's request and wait to see if the parent reiterates the request.
Contact the chaplain to arrange a visit with the client.
A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply. Explore the possibility of a female nurse being willing to swap clients. Explain that it is discriminatory to not accept male nursing care. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation. Explain that the unit is made up of mostly male nurses so it may not be possible.
Explore the possibility of a female nurse being willing to swap clients. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation.
Which approach would be the most therapeutic when working with the parent of a client presenting with quadriplegia as a result of a C-5 spinal cord injury? Reassure that given time and motivation prior level of functional ability will return. Advise that being this upset is not in the client's best interest. Explain the importance of moral support. Encourage the parent to express feelings and other fears about the injury.
Encourage the parent to express feelings and other fears about the injury.
A nurse is assessing available support systems for a client in the community mental health clinic. The client is divorced, has no siblings, and both parents died last year. The client has contact with once-supportive former in-laws; however, the client describes a strained relationship since the divorce. With regard to the relationship with the in-laws, what knowledge does the nurse use to plan care? The in-laws offer the only opportunity to obtain social support for the client. Low-quality support relationships often negatively affect coping in a crisis. The relationship with the in-laws can enhance the client's sense of control. Strong social support is of relatively little importance as a coping factor.
Low-quality support relationships often negatively affect coping in a crisis.
The nurse is developing a discharge plan with a client who has had an abdominal hysterectomy. Before implementing the plan, the nurse should perform which action first? Have the client watch an educational video. Assess the client's available social support system. Call the social worker to evaluate the client. Read the discharge instructions to the client.
Assess the client's available social support system.
A client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that they will have to wait to have their medication refilled. Which response by the nurse is most appropriate? "You are upsetting the other clients." "I'm sorry if you can't wait." "I won't continue to talk with you if you curse." "Come back tomorrow, and your medication will be ready."
"I won't continue to talk with you if you curse."
A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The most therapeutic nursing intervention would be to immediately call the chaplain because you realize symptoms may resolve with spiritual counseling. continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. ask a chaplain to meet with you and the client on the unit so you can monitor the exchange. tell the client you are not allowed to call the chaplain when a client is this disturbed.
continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis.
