Basic Psychosocial Needs - ML8

The nurse provides care to a verbally unresponsive client diagnosed with terminal cancer. The client's family refuses palliation on religious grounds. The nurse experiences great anxiety and distress when caring for the client due to the level of suffering perceived. What action should the nurse take? Accept that this is the client's and family's wish. Discuss the plan of care with the client's healthcare provider. File a complaint with the facility's client advocate. Speak to the charge nurse about the nurse's moral conflict.

Speak to the charge nurse about the nurse's moral conflict. The nurse is experiencing moral conflict and needs to discuss this with the charge nurse. The nurse is not able to simply ignore the feelings being experienced and accept the family's wish; if that were the case, there would be no issue to begin with. If there is an ethical breach related to the client's care, the nurse's first action is to speak with the healthcare team, not with the client advocate. In this case, a true ethical issue is not established. The goal is to strike a balance between the religious freedom of the client and family, the moral autonomy of the nurse, and the delivery of care that exhibits non-malfeasance. After consulting with the charge nurse, it may be decided to excuse the nurse from working with the client on moral grounds, or that the ethical committee needs to be consulted.

The family of a client receiving hospice care takes a dinner break only to learn that the client died while they were absent from the bedside. What should the nurse do to console the family at this time? Stay with the family while they view the body. Explain that the time of death could not be predicted. Allow the family to feel guilty for leaving the client to die alone. Discuss how the client is no longer in pain and is now at rest.

Stay with the family while they view the body. The family may go to great lengths to ensure that their loved one will not die alone. However, despite the best intentions and efforts of the family and clinicians, the client may die at a time when no one is present. If the client dies while family members are not present, the family may express feelings of guilt and will need emotional support. This would be provided by staying with the family while they view the body. Even though the time of death cannot be predicted, some clients appear to "wait" until family members are away from the bedside to die. The family does not need to hear how the client is no longer in pain and at rest. The family needs emotional support. The family should not be permitted to feel guilty for leaving the client. The family should take rest periods away from the bedside in order to provide the best support to the client.

A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN 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 her concerns? Select all that apply. Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. Do nothing as the RN does not have proof of controlled substance abuse. Continue to document the behaviors, but wait until something happens to report. Discuss the RN's concerns with another nurse on the unit to see what they think. Report the behaviors to the unit manager for further investigation.

Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. Report the behaviors to the unit manager for further investigation. ANA Code of Ethics for Nurses provision 3 states that nurses have a duty to protect the patient, the public, and the integrity of the nursing profession when they observe physical or mental impairment in a nurse or other healthcare professional. Substance abuse is treatable and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; she is still liable for her actions. The nurse should talk to the suspected nurse and report to management. It should not be discussed with others on the unit. It is not appropriate to wait until something happens.

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 primary healthcare provider may act without consent to save the client's life. The nurse should contact the person identified as the healthcare power of attorney. The client's do not resuscitate (DNR) order denies consent for the procedure. The attorney who prepared the client's last will and testament may sign the consent.

The nurse should contact the person identified as the healthcare power of attorney. Clients may have several types of legal documents regarding healthcare decisions. A healthcare power of attorney is a document that authorizes a person to make healthcare decisions if the client is unable. A DNR order designates when to withhold life support but does not include food or fluids. A client may have a living will to state what sort of treatment is wanted at the end of life, but it may not be legally binding in all states, provinces, or territories. A last will and testament allocates the client's possessions but does not address healthcare needs.

An older adult client is speaking to the nurse about the expected death of a spouse due to cancer 3 weeks ago. The client says, "My spouse is in a better place now, and I'm happy my spouse is not hurting anymore. But I just miss my spouse!" How should the nurse respond? Validate the client's statement as evidence of a normal grieving process. Explore the client's expression of denial about the death of the spouse. Commend the client's faith and reinforce the belief that the spouse is at peace. Refer the client to a counselor to work through the complicated grief.

Validate the client's statement as evidence of a normal grieving process. This client is experiencing the uncomplicated grief that normally follows a significant loss. Nothing about this scenario leads the nurse to believe the client is experiencing abnormal grieving or denial. The nurse should refrain from expressing personal beliefs about spirituality and focus on the grieving process while providing room for the client to share the client's own beliefs.

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. The nurse should: describe her husband's medical treatment since admission. allow her to verbalize her feelings and concerns. reassure her that the important fact is that she is here now. explain to her that her husband's condition is stable.

allow her to verbalize her feelings and concerns. Verbalizing feelings and concerns helps decrease anxiety and allows the wife to move on to understanding the current situation. Describing events or explaining condition or treatment is appropriate when the person is not distraught and is ready to learn. Explaining the client's medical status is appropriate when the person is not distraught.

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which is a characteristic of rituals? common and observable expressions of culture preconceived and untested beliefs about people viewing one's own culture as the only correct standard belief system held to varying degrees as absolute truth

common and observable expressions of culture Rituals are common and observable expressions of culture. A preconceived and untested belief about people is called a stereotype. Viewing one's own culture as the only correct standard is ethnocentrism. A belief system held to varying degrees as absolute truth is referred to as culture.

A client from Pakistan informs the nurse of cultural dietary requests. The nurse responds to the special dietary needs by stating, "You are now living in the United States and you should try to start eating those foods common to an American diet." This inappropriate response is an example of cultural blindness. cultural imposition. cultural diversity. cultural assimilation.

cultural imposition. The nurse's response is an example of cultural imposition, which is defined as the belief that everyone should conform to the majority belief system. Cultural blindness is the result of ignoring differences and proceeding as though they do not exist. In this situation, the nurse did not ignore the request but inappropriately responded to it. Cultural diversity is defined as a diverse group in society, with varying racial classifications and national origins, religious affiliations, languages, physical sizes, genders, sexual orientations, ages, disabilities, socioeconomic statuses, occupational statuses, and geographic locations. Cultural assimilation occurs when members of a minority group live within a dominant group and lose the cultural characteristics that make them different.

When a nurse reflects on questions such as "Why am I here?" the nurse is attempting to develop the concepts of holism and integration. strive toward unity with a higher power. develop a philosophical base for clearer thinking. become a more spiritual being for other people.

develop a philosophical base for clearer thinking. In terms of spiritual care, the nurse's background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining one's own spirituality, values, and beliefs is essential to develop clearer thinking and have unbiased reactions to clients' points of view. The question "Why am I here?" is philosophical but may or may not have a religious or spiritual dimension, depending on the nurse's beliefs. The question tends to lead to thinking about purpose in life but does not seek answers that lead to holism (the treating of the whole person, including mental, social, and physical factors) and integration (assimilation of life experiences such as illness into the self and activities of daily living).

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority? offering to disregard the client's plan if he does not go through with it warning the client that his telephone privileges will be taken away if he abuses them notifying the proper authorities after saying nothing until the client has actually completed the call explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)

explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP) The priority is to explain to the client that this information has to be shared immediately with the staff and the HCP because of its serious nature. Safety of all is crucial regardless of whether the client follows through on his plan. It is possible that the client is asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining with the client, such as warning him that his telephone privileges will be taken away if he abuses them, or offering to disregard his plan if he does not go through with it, is inappropriate. Saying nothing to anyone until the client has actually completed the call and then notifying the proper authorities represent serious negligence on the part of the nurse.

Which activity would be most appropriate to include in a playroom that will be used by children aged 13 months to 6 years? drawing and painting projects a group sing-along free play with adult supervision viewing cartoon videos

free play with adult supervision Planning any single activity that will appeal to children from ages 13 months to 6 years is next to impossible because of the developmental differences found in such a wide age group. It would be best to allow these children to participate in free play with adult supervision.A group sing-along would be appropriate for preschoolers and school-aged children. However, toddlers have short attention spans and would most likely find it difficult to participate in a group activity, such as a sing-along.Although drawing and painting projects would be appropriate for preschoolers and school-aged children, toddlers have a tendency to put objects into their mouths. Therefore, drawing and painting projects would be inappropriate for this age group.Viewing cartoon videos would be inappropriate for young toddlers, who typically have short attention spans. Additionally, young toddlers may not understand the videos.

A client requests that the nurse assist with spiritual counseling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counseling? 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 the degree of alignment between the client's spiritual beliefs and those held by the nurse

the nurse's comfort and knowledge level related to the process of spiritual counselling A nurse who feels competent to counsel the client may assist the client in achieving spiritual goals through spiritual counselling. The level of ability of the nurse to perform in this role is not directly related to the level of congruence between the nurse's beliefs and that of the client; people of all faiths are permitted to counsel those of others. The nurse would consider the client's condition when offering counselling, but this is not the most important factor--the nurse's abilities are. Family involvement may be necessary, but this would be determined by the nurse asking the client's preference rather than being based on the family's preference.

In which situation can a client's confidentiality be breached legally? in a student nurse's clinical paper about a client when a client near discharge is threatening to harm an ex-partner to answer a request from a client's spouse about the client's medication when a client's employer requests the client's diagnosis to initiate medical claims

when a client near discharge is threatening to harm an ex-partner Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.

A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? Determine whether the client qualifies for local assistance programs. Ask the client if she has a job and the amount of income earned. Instruct the client in methods for low-cost, highly nutritious meal preparation. Refer the client to a social worker for enrollment in a food assistance program.

Refer the client to a social worker for enrollment in a food assistance program. The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program.Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's needs for additional funds for food.Determining whether the client qualifies for government assistance is part of the role of the social worker, not the nurse.Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.

The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." What should the nurse do next? Inform the health care provider (HCP) of the client's statement. Ask the client whether a family member could help. Ask the social worker to find financial assistance for the client. Schedule a follow-up appointment in 48 hours.

Ask the social worker to find financial assistance for the client. The client needs to continue the medication without interruption to minimize the chance of decompensation. Because the client is in danger of noncompliance with the medication due to financial concerns, the nurse should contact the social worker to assist with locating resources for the client. Although the HCP is responsible for prescribing the client's medication, the HCP is not routinely involved in finding financial assistance for a client's medication needs. Scheduling a follow-up appointment in 48 hours does not address the client's immediate need for the medication; the client could stop the medication before being seen and become severely depressed. A family member's assistance may not be a sufficient, a permanent, or an appropriate means of financial help for this client.

A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do? Contact the relative to determine their capacity to be an adequate care provider. Gather more information about the client's feelings about the childcare arrangements. Reassure the client that her children will be fine and she should stop worrying. Encourage the client to call the children to make sure they are doing well.

Gather more information about the client's feelings about the childcare arrangements. The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs.

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 you do not feel in control. What coping technique do you usually use when 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 things are out of your hands. Can you tell me more about what has you 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?" The client has a complex situation involving both a transfer to a new area of care and facing a terminal illness. While the nurse may have the focus of preparing the client for transfer to a new care area, this may not be the client's primary concern. Assuming the client's comment is related to the transfer could impede exploration of the client's actual reason for the comment. The priority is to clarify the comment's meaning before offering to explore coping strategies or how the nurse can help.

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? "People with strong beliefs have better outcomes." "It sounds like that offers you a sense of security." "Think about your leader when you have moments of doubt." "It's good to have something to believe in."

"It sounds like that offers you a sense of security." Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.

The wife of a terminally ill client asks the nurse, "Why is my husband having frequent bowel movements if he is not eating?" What should the nurse tell the wife? "I don't know when the bowels will shut down, but they will eventually." "The pain medication will eventually help to slow the process of bowel function." "I know he's having frequent loose stools and it's distressing for you, but that's just the way it is." "The intestines still produce some waste products even when a person is not eating."

"The intestines still produce some waste products even when a person is not eating." It is important to give factual information to answer a loved one's questions and concerns. Stating "That's just the way it is" is unprofessional and uncaring. Saying "I don't know when the bowels will shut down, but they will eventually" projects an uncaring attitude and does not address the wife's concern for her husband or her need for information. Although it may be true that the pain medication will slow bowel function, this does not provide the wife with the information she is seeking.

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client? "You may want to have an abortion if you find out you are pregnant." "You handled the attack as well as you could because you survived." "You didn't do anything to cause the attack, and it's not your fault that you were raped." "You may feel anger, guilt, fear, or embarrassment, but these are very normal reactions."

"You may want to have an abortion if you find out you are pregnant." This statement hinders the therapeutic relationship because it advises the client to make a personal choice that may be against the client's values and beliefs. This statement would block further communication about the options that are available to the client. The other statements appropriately respond to feelings a victim may have following sexual assault or violent attack and provide reassurance that the victim acted as rationally and appropriately as anyone could in a life-threatening situation and let the client know that the nurse understands the emotions one commonly feels following a violent attack.

A client admitted for investigation of a tumor asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic? "Your healthcare provider can tell you more about that." "You sound concerned about what the tests results might be." "We won't know for sure until you undergo some tests." "Tumors are very common and not always cancerous."

"You sound concerned about what the tests results might be." This response allows the client to express the client's feelings and promotes further discussion. Referring the client to the healthcare provider ends the discussion and prevents exploration of the client's feelings. Generalizing about tumors shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

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"? "You're very concerned when you think about how this will change your life." "Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack." "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?"

"You're very concerned when you think about how this will change your life." The response should be attuned to the feelings of sadness and dejection the client is experiencing and should allow concerns to be shared. This response also addresses the content of the client's statement, namely how life will change. "This really saddens you." addresses the feelings but does not attend to the feelings about life. "Why" questions are nontherapeutic, and telling the client to be more hopeful negates what the feelings are.

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? Encourage the family to stay positive and focus on the possibilities for the future. Encourage realistic expectations of recovery and reinforce the reality of the prognosis. Accommodate their grieving, explain what is happening, and encourage involvement in the care. Reassure the family that it is normal to feel concerned after hearing such a prognosis.

Accommodate their grieving, explain what is happening, and encourage involvement in the care. The family is grieving, and it is important to acknowledge and listen to them. They need to know what is happening. They also need to be encouraged to be involved in the client's care to give them an opportunity to connect and feel actively involved. It is difficult for them to give up hope and be realistic regarding the prognosis; they need to have time. Reassuring the family that it is normal to feel concerned is not therapeutic. Encouraging the family to stay positive is not realistic at this time.

Which nursing action would be most beneficial to a client and her spouse who state they wish to go through labor without the use of analgesics or anesthetic agents? Encourage the use of drugs if the client has difficulty maintaining control during labor. Act as an advocate for the couple and verbalize their wishes to nurses and physicians. Provide privacy for the couple and respect their wishes for being left alone during labor. Provide information about the nature and availability of drugs for the client.

Act as an advocate for the couple and verbalize their wishes to nurses and physicians. Nurses are ethically responsible for giving childbearing families the autonomy to make informed choices about the care they receive. This also fosters a collaborative relationship with the family. Nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct. A client should never be left alone in labor. Providing information about or encouraging the use of drugs may leave the client and family feeling as though the nurse is not supportive of the couple's choices by encouraging actions that are contradictory to the family's birth plan.

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do? Allow the client to see the baby through the nursery window. Allow the client to see and hold the baby for as long as she desires. Contact the health care provider for advice related to the client's visitation. Tell the client that it would be best if she did not see the baby.

Allow the client to see and hold the baby for as long as she desires. The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the health care provider and social worker.Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client.Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby.Contacting the health care provider for advice related to the client's visitation is not necessary.

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. Approach the client and ask if there are questions about the condition. Explain that the condition is complicated and ask a physician to come speak with the client. Ask the client if calling the family would be helpful.

Approach the client and ask if there are questions about the condition. This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.

The nurse cares for a client with a sports-related concussion. What is the best way for the nurse to assess the client's orientation? Ask the if the client knows where they are and what time it is. Ask the client to describe the events leading up to the injury. Ask if the client knows their name and their spouse's name. Ask the client if they know the date, including year, day, and month.

Ask the if the client knows where they are and what time it is. To help assess orientation, the nurse asks the client direct questions about various spheres of orientation such as time, place, and person. Asking about place and time assesses two different spheres. Asking a client their name and their spouse's name only assess person. Also, in many cases, person is the least likely sphere to be affected in more minor injuries. Asking the client for the year, day, and month assesses only one sphere--that of time. Asking the client to recall the events of the day assesses memory, not orientation.

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. What is the nurse's role in this situation? Encourage the client to pray for clarity on the matter and offer support. Provide examples of ways clients handle spiritual and care planning conflicts. Inform the client's healthcare provider of the client's concerns. Assist the client in obtaining information to make an informed decision.

Assist the client in obtaining information to make an informed decision. The nurse's role in resolving conflicts between spiritual beliefs and treatments is to assist the client in obtaining the information needed to make an informed decision and to support the client's decision making. Telling the client to pray does not assist the client in the decision-making process. The healthcare provider does not manage client decisions when it comes to spiritual beliefs. Offering examples of other clients does not help this client.

A client with an infected abdominal wound must be placed on contact precautions for 10 days. What should the nurse do to help meet the client's emotional needs? Tell the client to bring in whatever personal items they want while on contact precautions. Gently explain that the client's movements must be limited while on contact precautions. Describe why the client is on contact precautions and what will occur there, and reassure the client. Tell the client that family members and significant others can't visit but may telephone at any time.

Describe why the client is on contact precautions and what will occur there, and reassure the client. To meet the client's need for information and help reduce the client's anxiety, the nurse should describe the reasons for contact precautions and how they are carried out and should also provide reassurance and empathy. To reduce the client's feelings of isolation, visitors should be allowed to spend time with the client or telephone. The client needn't limit movements while on contact precautions. Unnecessary personal items usually aren't permitted when a client is on contact isolation.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He's doing too much. I told him to let me help, but he won't let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, what should the nurse do? Avoid direct eye contact with the client and wife. Direct the eyes at the client. Shift the eyes back and forth between the client and wife. Direct the body and eyes at the wife and client.

Direct the body and eyes at the wife and client. Assuming cultural appropriateness of eye contact with the client and his wife, this body language would make the nurse's nonverbal message congruent with the nurse's verbal message and demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and wife conveys a lack of assurance about the nurse's focus and comments.

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. Explain that it is discriminatory to not accept male nursing care. Notify the facility patient-advocate to make them aware of the situation. Report to the charge nurse to make them aware of the situation. Explore the possibility of a female nurse being willing to swap clients. 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. The nurse should do whatever is necessary to ensure the client's health and well-being, as well as respect the integrity of all of the participants involved per the ANA Code of Ethics for Nurses. Best practice would be to talk with the charge nurse or unit manager about the situation and see if there is a possibility of a female nurse that could swap client assignments. Telling them that it is discriminatory or making excuses for providing male nurses will not ensure the nurse's obligation to provide culturally competent care to this client.

The nurse manager has employed three nurses from a culture that is different from that of most of the nurses who currently work 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? Require newly employed nurses to speak English only when working. Create a staffing plan placing one of the newly employed nurses on each shift. 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. Cultural competence is necessary for all nurses to provide culturally appropriate care and meet the needs of a diverse client population. Allowing staff time to share individual culturally specific information provides the opportunity to learn from each other and form relationships. This strategy also facilitates nurse identification with personal cultural attributes. It is important to provide support to the nurses from different cultures. Assigning one nurse to each shift may undermine the initial goal and result in attrition. Restricting language to only English could decrease client satisfaction for those who also speak a similar language. Asking staff to invite new staff to after-work activities is not appropriate because not all staff may have time to participate in these activities and could result in decreased staff morale.

A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary healthcare facility with symptoms of fever, cough, and running nose. While interviewing the client, which points should the nurse keep in mind? Sit at the other corner of the room. Do not probe into emotional issues. Maintain eye contact while talking. Do not ask very personal questions.

Maintain eye contact while talking. While interviewing a client of Anglo descent, the nurse should maintain eye contact because it indicates openness and sincerity. Such clients freely express positive and negative feelings; therefore, the nurse may probe into emotional issues. Anglo culture is an open culture and members of this culture don't mind providing personal information. Also, clients of Anglo descent are not threatened by closeness so the nurse does not have to sit in another corner of the room.

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? 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.

Plan and implement care in a way that is sensitive to the needs of the client. Providing culturally competent nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations within society. To provide culturally competent care, the nurse does not need to ask the client to explain the reasons for the client's beliefs. Assuring the client that the client's cultural preferences will be respected is dismissive and presumes the behavior of others instead of actively creating culturally competent interventions in the plan of care. Introducing the client to other clients makes the assumption that clients of similar cultural backgrounds will share interests and a desire to interact with each other. Making such an assumption is not a culturally competent approach.

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. Expect the family to express grief. Serve as an attentive listener. Arrange for the family to view the body. Provide emotional support. 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. Postmortem care of a client includes care of the family. When a client dies, the family needs emotional support. The nurse serves as an attentive listener and should expect the family to express grief. Part of this care is preparing the client so the family can view the body. The nurse should not direct the family to the funeral home. The family should not have to wait to view the body; plans can be made for the viewing to occur in the care facility.

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: "My name is Mary, and I'm your nurse for today." "I'm sorry. I was busy with another client." "You seem upset this morning." "You've had your light on for 20 minutes?"

"You seem upset this morning." To be therapeutic, the nurse should respond to the content of the client's statements. This client is obviously angry. A restatement or summary of what the nurse heard the client say is appropriate. By making an introduction or apologizing, the nurse would ignore the client's expressed feelings. Repeating the client's statement as a question indicates either skepticism about the client's statement or ignorance of the client's needs and would likely fuel the client's anger.

A 30-year-old client shares with the nurse that he or she has had a really hard time since the divorce 1 year ago, struggling with depression and anxiety. The client had a makeover and will be going on vacation with a best friend next month. The client has started thinking about dating again. The nurse understands that this client is in which stage of the grief process? Acceptance Depression Bargaining Ongoing

Acceptance The client is in the acceptance stage of grief regarding the divorce. The client has come to terms with the new reality, accepted the new reality, and is focusing on the positives and living life to the fullest. The bargaining stage of grief is characterized by making deals or promises of doing things differently if only there could be a different outcome. Depression would appear as intense sadness, feelings of hopelessness and often crying, and the client has most likely already worked through this stage, as the client reported struggling with depression over the last year since the divorce. Ongoing is not one of the stages of grief, and this client appears to be dealing with the grief well at this point.

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest? Take stress-management classes. Spend more time with the family. Find ways to make work fun. Leave work at work.

Take stress-management classes. The nurse would suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach how to manage stress more effectively. The client may not be able to make the job fun. The information provided by the client does not indicate that spending too little time with the family and taking the job home contribute to the client's stress.

Which interaction is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client? Equal sharing of time for discussion of problems so there is mutuality in the relationship Considering the verbal and nonverbal messages and meaning expressed by a client An interaction that involves facilitative qualities of caregivers, including empathy, respect, and empowerment An interaction used to assess the coping abilities of the person and views regarding health

Equal sharing of time for discussion of problems so there is mutuality in the relationship With a therapeutic relationship, there needs to be a client-centered approach, with the focus being on the client. A social relationship involves more equal sharing of concerns.

Which would be most helpful when coaching a client to stop smoking? Discuss the effects of passive smoking on environmental pollution. Establish the client's daily smoking pattern. Review the negative effects of smoking on the body. Explain how smoking worsens high blood pressure.

Establish the client's daily smoking pattern. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs? "I'll stay with you in case you would like to share your feelings with me." "Accidents can result in all kinds of feelings. It must have been scary." "It must have been a frightening experience to be in an accident." "There is nothing physically wrong with you. You need to stop breathing so rapidly."

"There is nothing physically wrong with you. You need to stop breathing so rapidly." In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person? Ask the facility chaplain to talk with the roommate. Permit the roommate to cry alone. Console the roommate as grieving begins. Change the roommate's assigned room.

Console the roommate as grieving begins. In a health care facility, other clients are often aware of a death and may need to be consoled. Other clients may have a grief reaction and should be supported through the grief process. The client's roommate should not be left alone. The room should not be changed without first discussing it with the client. The facility chaplain should not be notified without the client's permission or request.

A client tells the nurse about experiencing "spiritual distress." What should the nurse do first? Ask the client if having prayers would be helpful. Make a referral to a member of the clergy. Determine what spiritual distress means to the client. Refer the client to a support group.

Determine what spiritual distress means to the client. The nurse must first allow the client to clarify the meaning of spiritual distress and explore his or her own beliefs and values before making referrals to clergy or a support group. The nurse should allow the client to indicate if praying would be helpful after helping the client clarify the meaning of spiritual distress.

While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, "I want to leave him because I am afraid he will hurt the baby." Which action is the nurse's most appropriate response? Report the incident to the unit nursing supervisor. Tell the client to leave the boyfriend immediately. Refer the client to a social worker for possible options. Ask the client when she last felt the baby move.

Refer the client to a social worker for possible options. In an abusive situation, the client's safety is the priority. The nurse should refer the client to a social worker who can provide the client with options such as a safe shelter. Commonly clients who are battered feel powerless and fear that the batterer will kill them. As a result, they remain in the abusive situation. Telling the client to leave the boyfriend immediately is not helpful and reflects the values of the nurse. Although asking about fetal movement is important and is part of a routine assessment, a sonogram can be performed to confirm fetal well-being. The referral is more important at this time. Although it may be part of the unit's policies and procedures to report any incidents such as this one to the unit supervisor, the client's immediate need for safety must be addressed first.

The nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors? preventative vaccinations responsible drinking patterns effects of cigarette smoking motor vehicle accidents

preventative vaccinations Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults.

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. verification from next of kin discussion of pertinent information freedom from coercion caregiver preference and opinion the client's agreement to the plan of care

discussion of pertinent information the client's agreement to the plan of care freedom from coercion Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin.

Which beliefs of traditional Chinese medicine found in Asian culture should the nurse consider when planning care for a follower of traditional Chinese medicine? Illness is caused by an imbalance of the yin and yang. Illness is caused by a change in eating habits. Health is described as harmony between family members. Exercise to the point of overexertion can improve health.

Illness is caused by an imbalance of the yin and yang. Traditional Chinese medicine describes health as the balance of yin and yang. It describes health as harmony between the mind, body, and soul.

Which statement about religion and spirituality is most accurate? Religion is an organized system of spiritual beliefs. Spirituality is the behavioral manifestation of religious beliefs. Spirituality is a recently developed alternative to traditional religious belief. Religion and spirituality are synonymous.

Religion is an organized system of spiritual beliefs. Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion nor is it a recent development.

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." "What makes you think you're not going to make it?" "That's a difficult question to answer, and this must be very frightening for you." "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." This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? pharmacist social worker dietitian infection control nurse

social worker The social worker is the most essential team member to be involved in discharge planning to meet the client's needs and offer suggestions for the best community resources.There is no indication that the client should follow a special diet, so a dietitian is not needed at this time.The pharmacist may be consulted to teach the client about taking medications, but the focus of the care conference is planning for discharge to the community.The infection control nurse should follow up with teaching about preventing the spread of the disease after discharge.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time? Send flowers. Avoid phoning the family to permit the family to grieve. Remove the client's name from the care list. Attend the funeral.

Attend the funeral. It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

A client expresses a desire to discuss spiritual and religious beliefs with someone. What is the best nursing intervention at this point? Ask if the client would like to speak with the nurse daily. Tell the client to speak with family members or friends. Begin meeting as often as the client likes to discuss spirituality. Interview the client further to gather more details.

Interview the client further to gather more details. A thorough assessment is the initial step in providing nursing care of any type. Asking if the client wants to speak to the nurse daily or discussing spirituality with the client are not forms of assessment. Telling the client to speak to family members or friends about spirituality shifts the focus and removes the nurse's responsibility to the client.

A nurse has attended an in-service workshop to address the phenomenon of ageism in the healthcare system. Which practice is indicative of ageism? implementing falls prevention measures in a setting where older adults receive care speaking to older adults in a way one would with clients who have mild cognitive deficits providing slightly smaller servings of food for clients who are elderly assessing the skin turgor of older adults differently than for younger adults

speaking to older adults in a way one would with clients who have mild cognitive deficits Accommodation of normal, age-related changes such as decreased skin turgor and slightly decreased nutritional needs is not an indication of ageism. Similarly, safety measures are unlikely to be motivated by ageist beliefs. Assuming that all older adults have cognitively deficits, however, is an indication of ageism.

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 Bargaining Denial Acceptance

Denial The parent is in the denial stage, which is characterized by feelings of shock and numbness, and disbelief that this is real. The parent is in denial of the information provided by the police and health care provider. Acceptance is accepting the new reality, focusing on living life to the fullest and recovering from the grief. Bargaining is making deals or promises of doing things differently if only there could be a different outcome, such as promising to never curse again, if only God will let the adolescent not be paralyzed. Anger would be characterized by being mad at someone or something, even yelling or hitting something possibly.

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by: Teaching through religious-based schools. Teaching the child about God. Teaching through parental behaviors. Teaching the child about religion.

Teaching through parental behaviors. A child's parents play a key role in the development of the child's spirituality. What is important is not so much what parents teach a child about God and religion, but rather what the child learns about God, life, and self from the parent's behavior.

A Malaysian client is admitted to the healthcare facility with reports of cramping pain in the abdomen and loose stools. Where would the nurse be seated when interviewing the client? behind the client in the corner of the room alongside the client at more than one arm's distance

at more than one arm's distance While interviewing the Malaysian client, the nurse would sit at a distance of more than one arm's length from the client. The nurse would not sit alongside the client because the client may feel uncomfortable. If the nurse sits at the back of the client the nurse may not be able to observe the client's body language. If the nurse sits in a corner of the room communication may not be effective.

When discussing spirituality with a parent of an 8-year-old child, the nurse instructs the parent that children of this age may question religious authority. enjoy lore and legends of religious groups. are influenced by their peer groups. are moved deeply by spirituality.

enjoy lore and legends of religious groups. Childhood is the period when lore, legends, language, and symbols of a particular religious group are best presented.

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? revisiting the decision when the uncle is not present at the bedside respecting the client's desire to have the uncle make choices on her behalf holding a family meeting and encouraging the client to speak on her own behalf teaching the client about her right to autonomy

respecting the client's desire to have the uncle make choices on her behalf The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of what? slander assault negligence libel

slander Slander involves words communicated verbally to a third party that harm or injure the personal or professional reputation of another person. The other options do not define the situation described in the question.

A client is admitted with glomerulonephritis. Which psychosocial problems could likely affect this client? impaired physical mobility related to bone reabsorption altered breathing patterns related to dehydration altered sexuality patterns related to prolonged hospitalization anxiety related to poorly functioning kidneys and body image disturbance

anxiety related to poorly functioning kidneys and body image disturbance Developing a problem with the kidneys may cause anxiety about poor kidney function, especially if the condition becomes a chronic one. Altered sexuality is not a primary concern at this time, impaired physical mobility and altered breathing patterns are physical problems, not psychosocial.

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion? reviewing what's been accomplished during the relationship referring the client to support groups introducing new issues to the client responding with empathy when the client express sadness that the relationship is ending

introducing new issues to the client The nurse shouldn't introduce new issues during the termination phase, because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups or other resources. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, and this is a normal response to which the nurse should respond therapeutically.

A nurse is preparing a client for chemotherapy to treat colon cancer. The client says, "I don't know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway." Which response by the nurse is most therapeutic? "Everyone who has cancer worries, but you have every reason to be hopeful." "Colon cancer can now be cured in many cases. Let's hope you'll be one of the lucky ones." "You're wondering whether you've made the right decision about your treatment." "Many people beat cancer. You need to keep a positive attitude."

"You're wondering whether you've made the right decision about your treatment." By rephrasing the client's statement and focusing on their concerns, the nurse encourages further discussion of the client's feelings. Telling the client to keep a positive attitude incorrectly implies that the nurse knows the best way to deal with the situation. Saying that cancer of the colon may be cured ignores the client's feelings. Mentioning that everyone who has cancer worries disregards the uniqueness of the client's feelings and implies that the client's concerns aren't acceptable.

A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? telling the client not to be afraid. reassuring the client by telling her that surgery is a common procedure providing the client with information about what to expect postoperatively stressing the importance of following the health care provider's (HCP's) instructions after surgery

providing the client with information about what to expect postoperatively Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.

A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. Which community resource is appropriate for this client? a meal delivery service an association for retirees a hospice/palliative care association a home care/visiting nurses group

a meal delivery service A meal delivery service would be the most helpful to this client. There are a variety of services, some of them at no cost to the client in which a volunteer brings the meal and visits with the client, and is a means to check on elderly persons who live alone. Hospice care involves daily needs for the terminally ill at home, and this client does not need this type of service. Home nursing services typically provide skilled nursing care to clients at home, and this client does not need this level of care. Associations for retired persons advocate for care and services for retirees, but they do not provide services or care.

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 experiences of powerlessness barriers to effective communication feelings of anxiety

feelings of anxiety Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority.

Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness? expecting the worst and being grateful when it does not happen reliving the pleasant memories of days gone by planning ahead for the remaining good times that will be spent together living each day as it comes as fully as possible

living each day as it comes as fully as possible When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.

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? 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. The in-laws offer the only opportunity to obtain social support for the client. Strong social support is of relatively little importance as a coping factor.

Low-quality support relationships often negatively affect coping in a crisis. Strong social support enhances mental and physical health, providing a significant buffer against distress. Relationships of low-quality support are known to impact a person's coping effectiveness negatively.

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? Staff assessment reveals that the client will feel more secure under the blanket. The client states that the restraints are tight and uncomfortable. The staff want extra protection for themselves. The client is at risk for injury from fighting the restraints.

The client is at risk for injury from fighting the restraints. A full-length restraint blanket is added when the client is at risk for injury from fighting the restraints. The increased degree of restriction is justified only when the risk of client injury increases. Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate protection for the staff.

A nurse has migrated to a different country and started working there. Which factor is important for effective functioning? cultural habituation culture shock stereotype ethnocentrism

cultural habituation Cultural habituation reduces the extent to which people must take environmental cues into account; a predictable environment and being able to perceive the world as coherent are essential for human functioning. Assigning people to specific categories because of their culture, race, or ethnic emblems is stereotypical thinking; it is misleading and denies individuality. Ethnocentrism reflects a fear of difference from one's belief system, and consequent derision or disqualification of people and practices that do not conform to one's own view. Cultural shock is the acute experience of not comprehending the culture in which one is situated.

The son of an older adult client who has cognitive impairments approaches the nurse and says, "I'm so upset. The health care provider says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? "Boy, I have a lot to think about before I see the social worker tomorrow." "I think I can handle most of Dad's needs with the help of some home health care." "I want the social worker to make this decision so Dad won't blame me." "I'm so afraid of making the wrong decision, but I can move him later if I need to."

"I want the social worker to make this decision so Dad won't blame me." Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

The health care provider (HCP) recommends that a client have a partial bowel resection and an ileostomy. Later, the client says to the nurse, "That doctor of mine surely likes to play big. I will bet the more he can cut, the better he likes it." Which reply by the nurse is most therapeutic? "Does that remark have something to do with the operation he wants you to have?" "Why don't you think about getting a second opinion?" "I can tell you more about the surgery if you like." "What do you mean by that statement?"

"What do you mean by that statement?" When the client seems to be questioning the HCP's goals, it is best for the nurse to present an open statement and ask what the client means. This technique helps the client express feelings. Telling the client about the surgery is less therapeutic when the client is upset. While it is the client's right to get a second opinion, this suggestion does not address the client's feelings. Making assumptions can also interfere with communication, especially if the assumption is incorrect.

A client's friend is visibly distressed by the client's condition and lack of improvement. The friend says they feel powerless and unable to help the friend. How should the nurse respond? Tell the client's friend that there's nothing they can do. Agree with the client's friend. The nurse states understanding of how the friend must feel. Ask the client's friend if they would like to help with comfort measures.

Ask the client's friend if they would like to help with comfort measures. The client's friend expressed a need to help. The nurse should encourage the friend to do whatever they feel comfortable doing, such as applying lubricant to the client's lips, placing a moist cloth on the forehead, or applying lotion to the client's skin. Agreeing with the client's friend or stating that the nurse understands how the friend feels doesn't diminish the friend's sense of powerlessness. There are many ways the client's friend can help if they choose to do so.

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. Make decisions based on findings from the community assessment. Seek to promote homogeneity and common views rather than focus on differences.

Seek input from all groups and strive for consensus on what would benefit most or all of these people. The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.

Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what? stereotyping cultural assimilation cultural imposition cultural blindness

cultural blindness Cultural blindness is characterized by ignoring cultural differences or considerations and proceeding as if they do not exist. This phenomenon may underlie the failure to incorporate cultural considerations into dietary choices. Stereotyping assumes homogeneity of members of other cultures while cultural assimilation involves the replacement of values with those of a dominant culture. Cultural imposition presumes that everyone should conform to a majority belief system.

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action would the nurse include in the care plan? removing all personal belongings from the bedside allowing the family to visit only when the client asks to see them providing the client with detailed explanations of condition and treatment involving the client and family in planning care

involving the client and family in planning care For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse would provide simple, not detailed, explanations to the client and family because stress may have diminished their comprehension. The nurse would encourage the family to visit as often as the client's condition permits.

For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep? encouraging the client to be less active during the day playing soft or soothing music increasing the client's activity 2 hours before bedtime serving the client a cup of coffee and a snack in the evening

playing soft or soothing music Playing soft or soothing music promotes relaxation, which fosters rest and sleep. To promote sleep, the nurse should also encourage the client to increase activity during the day, avoid providing stimulating beverages (such as caffeinated coffee) in the evening, and offer an evening snack with warm milk. The nurse should also encourage the client to decrease activity 2 hours before bedtime to promote sleep.

An older adult client shares with the nurse having never gotten over the grief of losing a parent 22 years ago. The client states that the parent completed suicide and the client found the parent and called for emergency assistance. The nurse assesses that the client is experiencing which type of grief? Disenfranchised Uncomplicated Dysfunctional Anticipatory

Dysfunctional Dysfunctional grief is intense grief that does not result in reconciliation of feelings, such as this client is experiencing. Anticipatory grieving is grief before the actual loss occurs. Uncomplicated grief is a grief reaction that normally follows a significant loss and proceeds normally. Disenfranchised grief is grief that is not openly acknowledged, socially sanctioned, or publicly shared.

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 tell the client you are not allowed to call the chaplain when a client is this disturbed. 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.

continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. Safety is the nurse's first priority. The client is experiencing altered thought processes and is unlikely to be able to distinguish his spiritual beliefs at this time.

A nurse is working in the emergency department when a woman comes in reporting that she was notified that her husband was just admitted following an accident. The woman is pacing, tearful, and her attention span seems poor. The nurse recognizes that the woman is having moderate anxiety. What should be the nurse's first response? "You seem really nervous about all of this. Maybe you should complete the admission paperwork before seeing your husband." "Your husband had an X-ray, and he might have a fractured femur. His hemoglobin and hematocrit are stable. He is diaphoretic. He has had an analgesic while awaiting an orthopedic consultation." "Hi! I'm really glad you are here. I work on this unit and was here when your husband came in. He was in really bad shape." "Your husband is awake and stable right now. I'll take you to his room."

"Your husband is awake and stable right now. I'll take you to his room." When people are experiencing moderate anxiety, their attention span is limited and they are only able to focus on immediate concerns, so being brief and concise with communication initially is best. Giving the client too many details, or using medical terms prior to her knowing the immediate condition of her husband, will just increase her anxiety. At this point she is also unable to focus on details such as paperwork as her immediate concern is her husband.

A woman employed full-time wants to request a leave of absence to care for her father who is being treated for colon cancer 300 miles (480 km) away. What should the nurse advise the client to do first? Contact her employee resources department about policies guiding leaves of absence. Make a plan to see how long she can be out of work without financial concerns. Ask her father if he can afford a caregiver. Find someone to do her work while she is away.

Contact her employee resources department about policies guiding leaves of absence. The nurse should advise the client to check with her employer to determine the policies and legislation followed there regarding leaves of absence. While the client can consider the other options, the first step is to obtain information from her employer.

The nurse is caring for a young adult with hepatitis A. The client is crying and saying that they hate the way they look with yellow skin. Which response is most appropriate? "I'll leave you alone for awhile until you feel better." "Try covering your face with a little make-up. The discoloration will be hardly noticeable." "If you start to get well and feel better, the skin will return to its normal color." "Don't cry. It doesn't look as bad as you think."

"If you start to get well and feel better, the skin will return to its normal color." The nurse must communicate honestly and give the client factual information about their appearance. Leaving the client alone or telling them not to cry ignores the client's feelings and needs. Make-up wouldn't conceal the jaundiced appearance, so using it might upset the client more.

An older adult has few health problems, performs self-care, plays cards, and talks about "the good old days." The client wants to make "final" arrangements, such as completing an advance directive and planning and paying for a funeral and burial. What interpretation does the nurse make about the client? The client is depressed and should be watched for further signs of depression. The client should be placed on suicide precautions and seen by a psychiatrist. The request is age appropriate and should be honored. The request suggests that the client has a premonition about dying soon and needs to talk about it.

The request is age appropriate and should be honored. Given the client's age, making final plans is age appropriate. The absence of any signs of ill health, depression, or suicidal ideation makes the other options inappropriate.

A client with physical deficits related to a recent cerebral vascular accident states tearfully, "I no longer can take care of myself." Which statement by the nurse is most therapeutic? "You will get back to normal after you have some physical therapy." "Let's focus on the positive things that you can still do." "It is hard not to be able to care for yourself." "Let me help you dress, and then we can get some breakfast."

"It is hard not to be able to care for yourself." Therapeutic communication is client centered, meaning that it is focused on supporting the client's physical and emotional well-being. The client is in control of the topic and supported in expressing feelings of concern. Responding with open-ended questions or validating statements allows the client an opportunity to explore the ideas and feelings they wish to discuss. The nurse would not offer the condescending or potentially untrue statement that the client will be back to normal. It is also not appropriate to deflect the client's feelings by changing the topic to breakfast or focusing on "positive things."

What short-term goal for a client hospitalized with a stress related disorder is most realistic? The client will write a list of strengths and needs. The client will describe plans for how to get back into school. The client will practice assertiveness skills in confronting his mother. The client will demonstrate a positive self-image.

The client will write a list of strengths and needs. Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self-assessment.

During a physical examination, the nurse observes a copper bracelet on a client's wrist. The client states that she is wearing it to treat her arthritis. What should the nurse do? Encourage the client to continue wearing the copper bracelet because this is a medically supported treatment for arthritis. Tell the client that wearing the bracelet is a form of quackery and not to use the bracelet as a treatment. Recognize that the client is wearing a protective object she believes prevents illness. Inform the client that this is a not a helpful practice and ask her to remove the bracelet.

Recognize that the client is wearing a protective object she believes prevents illness. The client might wear objects as a protection against specific medical disorders. Typically, these practices bring no harm to the client and should not be discouraged. The client should continue to be encouraged to follow the medical guidance of her health care provider (HCP). If the practice is not harming the client, it is inappropriate to label it quackery and demand that the client discontinue it. There is no medical evidence to support the wearing of a copper bracelet.

A client is experiencing stress in a change of role from married to divorced. The client states that the in-laws blame the client's drinking for the divorce. The client states, "These days, a couple of glasses of wine in the evenings helps calm my nerves." What is the best coping strategy for the nurse to offer the client? Practice deep breathing and muscle relaxation. Rely on the support of work colleagues. Use assertiveness training techniques. Cease all contact with the in-laws.

Practice deep breathing and muscle relaxation. The client is experiencing stress due to a role change subsequent to the recent divorce. Using previously learned relaxation techniques would be an appropriate way of decreasing stress without using alcohol as a temporary fix. Ceasing contact with significant others is extreme and would not be recommended. Similarly, suggestions to rely on work colleagues would not be appropriate. While assertiveness techniques may be helpful in the long term, short term stress is well managed with relaxation techniques.

A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply. identifying current or past spiritual supports asking the client about original spiritual beliefs offering to pray with the client to help resolve the conflict exploring factors that are creating conflict with client's beliefs reading aloud Bible passages that relate to the client's needs

asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonable for the nurse to explore the client's faith origins as well as what the usual sources of spiritual support were or are. Commonly, a hospitalized client is separated from those of common faith practices so this should be explored. The nurse can also carefully explore what is contributing the challenges to faith the client is expressing. The scenario does not state that the client is Christian so reading from the Bible is an assumption by the reader, first. Second, the nurse would not take the step of reading to the client from a religious text unless this was a direct request by the client. Nurses should also not offer to pray with the client but should only engage in this if directly asked and if this is something the nurse is comfortable with.

The nurse provides care to a client with severe burns. During the recuperation phase, the client becomes withdrawn. For what potential contributor to the client's change in demeanor should the nurse assess? dependence and unwillingness to be discharged decrease in coping abilities pressure from family and friends to be more social changes in body image and self-esteem

changes in body image and self-esteem During the recuperation phase, the client is likely to consider the body image implications of this injury. Sensitivity to body image and self-esteem issues are anticipated concerns. The client has suffered through the most difficult part. There are fewer concerns regarding dependence and coping abilities in the recuperation phase. The pressure from family and friends to be more social would be a reaction to the client's withdrawing from social interactions rather than a causative factor of the withdrawal.

Which factors should be the primary factor in a nurse's decision whether to pray with a client? the nature and course of the client's current diagnosis the nurse's familiarity with the prayer traditions of different faiths the availability of a hospital chaplain or other spiritual counselor the client's openness to being prayed for

the client's openness to being prayed for Many factors influence the nurse's decision to pray with a client. Central among these, however, is the question of whether the client is open to this possibility. This factor is more important than the nurse's familiarity with specific prayer traditions, the patient's medical condition, or the presence or absence of a chaplain.

To decrease a female client's anxiety about being placed in the lithotomy position for surgery, what should the nurse do? Pad the stirrups for comfort. Determine what the client is concerned about. Explain in detail what will occur in the operating room. Reassure the client that an all-female surgical team will be present.

Determine what the client is concerned about. The nurse should first attempt to find out what the client's concerns are and address them. Providing too much information with details can increase the client's anxiety and does not address specific concerns. Padding the stirrups will provide comfort, but does not address concerns. Having an all-female team may or may not be the source of the client's concerns, and probably is not possible.

An older adult with end-stage cancer needs assistance with arranging the finances for end-of-life home care. The nurse should refer the client to which person? a social worker the executor of the client's will the business manager of the health care agency the health care provider (HCP)

a social worker A social worker can provide information for supportive services and can help the client determine which resources are necessary at this time. The business office of the health care agency does not provide advice about managing finances. The HCP will be part of the team, but will focus on managing the client's health and end-of-life care. The client may or may not have a will; it is not the role of an executor to make financial decisions about health care.

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? Provide the infant with soft toys or a feeding bottle. Encourage parents to be present during the treatment. Tell the infant that it will be over within a minute. Ask a child specialist to be present during treatment.

Encourage parents to be present during the treatment. When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child.

The client states, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is most therapeutic? "You sound very lonely. Is there a friend or relative I could call for you?" "You must be feeling lonely at this time. Would you like to talk about your loss?" "I am sorry for your loss. Would you like to share some stories about your loved ones?" "I understand you are feeling lonely. Would you like me to arrange for a volunteer visitor?"

"You must be feeling lonely at this time. Would you like to talk about your loss?" The client is experiencing loss and is feeling hopeless. The most therapeutic response by the nurse is the one that attempts to translate feelings into words. This means focusing on the client's feelings of loss rather than reminiscing about lost loved ones. Offering to call someone after the client says they have no one is insensitive, as is offering a volunteer visitor before exploring the client's wishes or feelings.

The client is Asian and non-English speaking. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom? constipation pain hunger depression

pain The client may be describing symptoms of pain. Culture specific symptoms for "feeling bad" include numbness, thinking too much, feeling hot under the skin. Asian clients may describe pain in terms of Yin and Yang (hot and cold). Nurse's knowledge of pain associated with health problems is necessary to assist this client manage pain. Clients from some cultures may associate mental health symptoms with evil spirits and will not report them as being unusual. Clients from Asian cultures may not describe symptoms locally but in a diffuse fashion.

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? 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 providing support for the health care provider's (HCP's) plan of therapy for the client letting the client know that there are resources in the community that can help

providing the client with support and realistic information on the colostomy Preoperative visits and talks with others who have made successful adjustments to colostomies are helpful and tend to make the client less fearful of the operation and its consequences. Knowing about resources in the community will be helpful as the client approaches discharge. Supporting the HCP is less important than supporting the client and giving the client information. The client will have a change in body image, with disfigurement due to the creation of a colostomy. However, the client should be able to lead a full life.

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 neonate be baptized as soon as possible. What response by the nurse is most appropriate? "Your baby is much older and much more stable than the baby you lost." "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." "What would you like me to do to help arrange the baptism?"

"What would you like me to do to help arrange the baptism?" Patient-centered care involves honoring client preferences. It is common practice to baptize infants who are at risk of death in the Roman Catholic faith. While a 30-week gestation infant on minimal ventilator settings would be expected to survive, the family has had real experiences with neonatal death, and spiritual practices can provide comfort. The nurse should ask the family about their preferences and try to honor them. The family may indeed be requesting the baptism because they are fearful their infant might die. The nurse can reassure the family that the infant is doing well but must also respect the client's spiritual preferences. After the family shares their preferences, the nurse can offer the local chaplain as a resource.

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? Depression Suicidal Denial Acceptance

Depression The client is in the depression stage of the grief process, which is characterized by withdrawal from life and loved ones, feelings of intense sadness, and feeling like there is no reason to go on. The denial stage is characterized by feeling of shock and numbness, disbelief that this is real. Acceptance is accepting the new reality, focusing on what time is left and trying to make the most of it. This client may be suicidal; however, this is not one of the five stages of grief.

After the spouse has visited, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels incapable of handling the situation. What should the nurse do at this time? Instruct the client to stop pounding on the overbed table. Tell the client that the spouse is probably under a lot of stress. Call facility security to control the situation. Use the call system to request assistance.

Use the call system to request assistance. A nurse who feels unable to handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client the spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

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 unique cultural group that exists within the larger culture a cultural group with values that are incongruent with those of the dominant culture a cultural group with fewer than 5 million members in the United States a unique cultural group with unspecified geographic origins

a unique cultural group that exists within the larger culture Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture but this is not their defining characteristic.

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 explaining that multiculturalism means all cultures melding to assimilate into one culture informing the client about preferred health interventions and making decisions for the client asking about cultural beliefs related to health, illness, treatments, and dietary practices

asking about cultural beliefs related to health, illness, treatments, and dietary practices It is a nursing obligation to practice in a culturally sensitive and competent manner. This answer elicits key information regarding the client's beliefs, values, and cultural practices. This also indicates willingness to learn and be respectful of different beliefs and practices. Knowledge is important, but individualizing rather than generalizing is critical. The other choices are inaccurate because they involve making decisions for the client and explaining that the aim is for all cultures to become one.