PASSPOINT: Psychosocial Integrity
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which response by the nurse would be most appropriate?
"I understand, but feel free to visit or call anytime to see how your child is doing."
A client has been admitted with depression and asks to speak with the hospital chaplain. What is your most therapeutic nursing intervention?"I will try my best to have the chaplain visit you as soon as possible."
"I will try my best to have the chaplain visit you as soon as possible."
The client with bipolar disorder, manic phase, states to the nurse, "You're looking good. I'm taking you out to dinner." What reply by the nurse is most therapeutic?
"I'm Chris, a nurse working on this unit."
In a mental health interview, a client who has returned from military service reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response?
"Many people who've been in your situation experience similar emotions and behaviors."
A 15-year-old client with a urinary tract infection is admitted to the facility. The adolescent tells the nurse she hopes she's pregnant. How should the nurse respond?
"Tell me what being pregnant would mean to you."
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?
"Tell me what you are feeling."
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which would be the most helpful statement to make to the daughter?
"The health care provider will prescribe tests to find out what's causing her condition."
A 20-year-old client with paranoid schizophrenia is in the 4th day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic?
"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease."
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."
A client with schizophrenia states "I can't stay here. I have to get away." The nurse observes that the client is very agitated. What should be the nurse's first action?
Approach the client in a calm, nonthreatening manner.
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?
Assist the client in obtaining information to make an informed decision.
The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients?
Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors.
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, "My boyfriend has been beating me up once in a while since I became pregnant, but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children." What is the priority action by the nurse at this time?
Help the client make concrete plans for the safety of herself and her children.
A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.
Provide an early opportunity for the couple to see the child if desired. Offer to stay with the grieving parents. Answer the parents' questions accurately.
An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober?
Provide the client with a quiet room to sleep in.
A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child?
Remain silent after asking a question.
An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is
Spiritual distress related to inability to attend church services evidenced by verbal states of guilt.
A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which response?
a stage of grief reaction
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 client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:
consistently enforcing unit rules and facility policy.
Which behavior exhibited by the parents of an infant with pyloric stenosis should the nurse correctly interpret as a positive indication of parental coping?
discussing the infant's care realistically
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?
encouraging them to ask questions
A child is being seen at the clinic for an attention deficit hyperactivity disorder (ADHD) assessment. What symptoms the nurse would expect to find? Select all that apply.
excessive climbing and running excessive fidgeting cannot wait to take turns easily distracted
The client states he washes his feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling?
intolerable anxiety
A 3-year-old is seen in the well child clinic. The parent is concerned that the child may be autistic. Which assessment data would indicate a concern to the nurse? Select all that apply.
lack of communication abilities withdrawing into a private world inability to develop social skills
After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor?
lacking understanding of body integrity
Which group of characteristics should a nurse expect to see in the client with schizophrenia?
loose associations, grandiose delusions, and auditory hallucinations
A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first?
medication compliance
A 22-year-old client is admitted to room 13. He states that he does not want to remain in the room because the number will bring him bad luck. The nurse should:
move the client; his fears, even when unfounded, can impede recovery.
A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
paranoid thoughts
A client with schizophrenia is withdrawn and suspicious of others, and projects blame. The client's behavior reflects problems in which stage of development as identified by Erikson?
trust versus mistrust
During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response?
"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."
When a client expresses feelings of unworthiness, the nurse should respond by saying:
"As you begin to feel better, your feelings of unworthiness will begin to disappear."
A client's husband expresses concern that his dying wife keeps saying, "I have to go to the store." Which statement by the nurse will be most effective in assisting the husband to understand the dying process?
"Comments related to going somewhere or leaving on a trip are common in dying clients."
A nurse counsels a mother with young children after leaving her abusive husband 6 months ago. The mother says, "My 6-year-old is starting to act just like his father. I just don't know how to handle this." Which response by the nurse is most appropriate?
"Counseling for your son would be helpful."
A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?
"During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."
A client with an anxiety disorder is admitted to the psychiatric unit because of panic attacks. What statement by the nurse is the most appropriate?
"I am going to ask you some questions to help me understand the anxiety you are experiencing."
The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate?
"I do not hear any voices. What are you hearing?"
The nurse is assigned to care for a client admitted with depression as well as a dependent personality disorder. Which statement by the client is indicative of this personality disorder?
"Please don't forget to wait for me to go to dinner. I don't want to go by myself."
A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. What is the best response by the nurse?
"Please help me to understand this practice."
A client had a cesarean section with her first pregnancy and is hoping to have a vaginal birth with this pregnancy. She begins to cry at her 38-week visit when she realizes that her baby is a breech presentation. She says, "I just know it's going to be horrible again. I won't be able to breastfeed my baby. It will be painful." What response from the nurse is appropriate?
"Tell me about your previous baby's birth."
A client is admitted to the hospital for a recent suicide attempt. While on the unit, the client has been taking antidepressants as prescribed, attending group therapy, and engaging with other clients and staff. The client states, "I have lots of things to do when I get home, and I don't really need to be in the hospital anymore." Which response by the nurse would be most appropriate?
"Tell me how you feel about killing yourself."
The nurse leading a group session for parents of children diagnosed with oppositional defiant disorder. The nurse should give which recommendation for discipline?
Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration.
The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse tell them?
Dehydration is expected during the dying process.
A child is newly diagnosed with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first to help the parents?
Evaluate and assess parents' stress and anxiety levels.
Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse?
a person who says, "I've found a solution for this mess
In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?
health habits, family relationships, affect, and thought patterns
Which nursing action is most appropriate when trying to defuse a client's impending violent behavior?
helping the client identify and express feelings of anxiety and anger
A community health nurse working with a group of 5th grade girls is planning a primary prevention to help the girls avoid developing eating disorders during their teen years. The nurse should focus on which factor?
helping the girls accept and appreciate their bodies and feel good about themselves
Which activity by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip?
holding and cuddling the child
The nurse is admitting a client with a history of bipolar mania. Which assessment finding is the priority when developing a plan of care?
hyperactivity, ignoring eating, and sleeping
Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness?
repression
A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. On the way to the radiology department, the client looks around anxiously and tells the nurse, "The Interpol is coming to kill me." What is the nurse's best response?
"It sounds like you're frightened."
A client hospitalized for preterm labor tells the nurse her mother-in-law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse?
"Let's talk about how preterm labor occurs to help you understand what causes it."
The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process?
"You cannot have any visitors while you're here involuntarily."
A school-age child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, "It's that school nurse again. She's done nothing but try to make trouble for our family since my son started school. And now you're in on it." What is the nurse's most appropriate response?
"You sound pretty angry with the school nurse. Tell me what's happened."
The nurse is caring for a severely depressed client. Which statement by the nurse is best when talking to the client on the patient care unit?
"You're wearing a new shirt today."
Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?
"I understand my pain will feel worse when I am worried about my divorce."
The home health nurse attends to a terminally ill client whose older adult spouse is the primary caregiver. The spouse states, "I am so ashamed to admit that sometimes I wish it would all just end. I am so tired." How should the nurse respond?
"It sounds like you are overwhelmed. How can we better support you through this process?"
A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate:
aggreassion.
In a family with a 7-year-old child with a chronic illness, which family members feel jealousy, resentment, embarrassment, shame, fear of becoming ill, and guilt at causing the illness?
siblings
Which approach is the best way for the nurse to begin the preoperative interview? Walk in the client's room:
sit down, maintain eye contact, and make an introduction.
Which factors should be the primary factor in a nurse's decision whether to pray with a client?
the client's openness to being prayed for
A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply.
"I need to have consistent limits." "Living in a critical environment is not good for me." "I need to have healthy boundaries."
While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the most therapeutic response by the nurse?
"You are concerned that the client is receiving too much narcotic medication?"
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 must be feeling lonely at this time. Would you like to talk about your loss?"
The client was admitted to the psychiatric unit yesterday evening. In the morning, the client approaches the nurse and states, "The psychiatrist and all of you nurses are conspiring against me. I've been warned and I know it's true. You know what I mean." Which response by the nurse would be most therapeutic?
"You must feel very frightened. You're safe here."
The nurse is educating parents of first graders about child sexual abuse. What is the most critical information the nurse should convey to the parents?
An adult who sexually abuses a child is usually known to the child.
A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client?
Discuss secondary gains that are unconsciously driving the client's behavior.
When a client with croup is admitted to the facility, a physician orders treatment with a mist tent. As the caregiver attempts to put the client in the crib, the client cries and clings to the caregiver. What should the nurse do to gain the client's cooperation with the treatment?
Encourage the caregiver to stand next to the crib and stay with the client.
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.
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?
Slow movements.
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
continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis.
A nurse is admitting a client with possible borderline personality disorder. The client has called the nurse every 15 minutes with one request or another. Which behavior should the nurse give priority to when planning care?
regression Explanation: The client is exhibiting the defense mechanism of regression, a return to behavior characteristic of an earlier developmental level. Dependent, attention-seeking behavior is an attempt to relieve anxiety. Repression manifests as a denial of the symptoms. In planning care for this client, the staff will need to cooperate with one another because the client may try to manipulate them along with exhibiting regressive attention-seeking behavior. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Functional neurologic symptom disorder involves the transfer of a mental conflict into a physical symptom to relieve anxiety.
A nurse is counseling a client with cancer who is experiencing anxiety. Which goal will provide the best long-term client outcome?
Solve problems independently. Explanation: The ultimate outcome is to have clients solve problems by themselves, collaborating in their own care. Client follow-up with mental health providers, while desirable, does not ensure that the client will fully comply with treatment or medication. Knowledge of the medication's effects and adverse effects and compliance can help the client, but it will not ensure success unless the client knows how to address and solve problems independently.
A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet. The client repeatedly checks to see if the clothing is arranged in the proper order. What term is commonly used to describe this behavior?
compulsion Explanation: Compulsion is present when a client performs recurrent, persistent, repetitive actions and behaviors that the client feels driven to perform. This behavior interferes with the client's activities of daily living and disrupts the lifestyle. These compulsions relieve the intense anxiety experienced when the client doesn't act on them. Obsession is a recurrent, persistent, and intrusive thought. Exhibitionism is the compulsive need to expose a part of one's body, especially the genitals, to an unsuspecting stranger. Transference is the process of projecting one's feelings and thoughts onto the therapist, who symbolically represents a significant person in the client's past.
A nurse cares for a client who states that they believe that God can be seen in everything and every action. The nurse recognizes this as what characteristic of spirituality?
self-reflective Explanation: The client is referring to self-reflection. Spirituality is based on self-reflection and not group-oriented like religion is. Spirituality is unorganized and subjective; it differs from person to person. There are no universal beliefs on spirituality. Rather, spirituality is based on experience and not rituals.
A client with major depression states, "Life is not worth living anymore. Nothing matters." Which response by the nurse is best?
"Are you thinking about killing yourself?"
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
"Family members should continue to talk to the client."
The nurse cares for a middle-aged client with a below-the-knee amputation. What statement indicates the need for further assessment of the client's body image?
"I hope I can handle having a prosthesis, but I'm really wondering what my wife will think."
The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been effective?
"It's a way to express anger and rage."
A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate?
"It's okay to cry when something hurts."
The nurse observes an unlicensed assistive personnel (UAP) sharing extensive stories of her own mother's death with a dying client's husband. Which statement demonstrates appropriate feedback for the nurse to offer to the UAP?
"It's probably best to avoid talking about your personal experience very much; keep communication client centered."
A client is a 25-year-old pregnant mother of two children under the age of 6. She is a very protective mother and will not allow her children play outdoors for fear of tick bites. She tells the nurse that she feels "worn out" from cleaning the house from top to bottom every day. She asks the nurse how she can stop worrying so much. What is the most appropriate response from the nurse?
"Tell me your concerns about the children playing in your backyard."
A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic?
"That must be frightening to you. Can you tell me how you feel about it?"
The decision maker for a dying client on hospice care expresses to the nurse that all treatment, including pain medication, should be stopped to allow for natural death to occur. Based on the principles of palliative care, what is the nurse's best explanation about the plan of care for this client?
"The reason for providing pain medication is to alleviate pain and suffering."
A client was admitted to an inpatient psychiatric unit with a diagnosis of major depression. The client expresses feelings of worthlessness and of being abandoned by significant persons in their life. Which response by the nurse would convey empathy to the client?
"This must be a difficult time for you."
A client states, "I feel so sad. I don't think I can go on anymore." Which is the most therapeutic response the nurse can offer the client?
"You feel like you can't go on anymore?"
A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which way should the hospital admission process be modified for the client?
Allow her sufficient extra time in which to gain an understanding of what is happening to her.
The nurse is meeting weekly with an adolescent recently diagnosed with depression to monitor progress with therapy and antidepressant medication. The nurse should be most concerned when the client reports what information?
An acquaintance hanged herself two days ago.
After learning that a roommate is HIV-positive, a client asks a nurse about moving to another room on the psychiatric unit because the client no longer feels "safe." What should the nurse do first?
Ask the client to describe the fears. Explanation: To intervene effectively, the nurse must first understand the client's fears. After exploring the fears, the nurse may move the client or roommate or explain why such a move wouldn't be therapeutic, as needed.
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?
Ask the client's friend if they would like to help with comfort measures. Explanation: 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.
A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first?
Assess the physical problems.
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 Explanation: 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.
The nurse is caring for a 4-year-old child who is admitted for minor elective surgery. The child is frightened and anxious. Which intervention is most appropriate?
Encourage parental reinforcement. Explanation: Positive parental reinforcement has the greatest impact on a child of this age and provides reassurance and comfort to face potentially frightening experiences. The other options would be more useful in calming an older child.
An 18-month-old child is admitted to the pediatric unit. Which of the following can the nurse do to reduce the stress on the client during this hospitalization?
Encourage the client's caregivers to be with the client as much as possible
Which would be most helpful when coaching a client to stop smoking?
Establish the client's daily smoking pattern.
When providing nursing care to a client of African origin, which cultural factors should the nurse consider?
Making eye contact may be considered rude. Explanation: Cultural factors that should be considered when providing care to a client of African origin include a tendency for eye contact to be viewed as disrespectful or presumptuous, for families to feel close-knit and for family members to cooperate, and for individuals to be highly religious and hold the clergy in high esteem. Families may be matriarchal or patriarchal depending on the culture of origin, so assumptions should not be made about gender roles in the family based only on the information that the client is of African origin.
Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?
Offer the client nutritious finger foods.
A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first?
Reassure the client that her feelings are typical reactions to serious trauma. Explanation: The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.
A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding?
exhaustion
Prior to surgery for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which approach offers the best guide for the nurse to answer these questions?
Tell the client as much as she wants to know and is able to understand.
In addressing health promotion for a patient who is a member of another culture, the nurse should be guided by which principle?
The client may have a very different understanding of health promotion.
A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of:
halucination
A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?
The nurse should listen attentively and provide realistic verbal reassurance.
While teaching a group of parents whose children have Tourette syndrome, a nurse is asked about factors associated with its development. Which factor should the nurse include in the response?
abnormalities in brain neurotransmitters and the caudate nucleus, and genetics
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused?
absence of crying during the examination
The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?
acquisition of new coping skills
A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior?
avolition Explanation: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.
A nurse is assessing a client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is:
diarrhea
A nurse must assess a client's judgment to determine the client's mental status. To best accomplish this, the nurse should have the client:
discuss hypothetical ethical situations.
The family of a client with a terminal illness tells the hospice nurse supervisor that they have lost hope for a peaceful death for their loved one. While talking to this family about their concerns, the nurse would immediately explore their concerns about which health care issue?
effective management of the client's physical discomfort
A nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which nursing actions would take first priority for this client?
engaging the client in reality-based conversations
The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse?
ensuring relevance to, and quickly refocusing upon, the client's experience
A client hospitalized for depression remains extremely depressed and expresses increasing suicidal ideation to the client's primary nurse. What should be the nurse's priority intervention?
ensuring that the client is not permitted to use anything that would be potentially dangerous
A nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the compulsion. Based on this finding, the nurse should assess the client for:
increased anxiety. Explanation: An obsessive-compulsive client who attempts to resist the compulsion must be evaluated for increased anxiety. A compulsion is a repetitive, intentional behavior that the client performs in response to a certain obsession; it's aimed at neutralizing or decreasing anxiety. Resisting the compulsion may increase the client's anxiety. Although a client with OCD may experience a sense of failure, depression, and excessive fear, these feelings aren't responses to resisting the compulsion.
The nurse is assessing a client who has just experienced a crisis. The nurse should first assess this client for which behavior?
increased level of anxiety
A client with schizophrenia reports hearing the voices of the client's dead parents. To help the client ignore the voices, the nurse should recommend that the client:
listen to a personal stereo through headphones and sing along with the music.
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?
providing the client with information about what to expect postoperatively
A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing which factor?
relief from anxiety. Explanation: A client who is exhibiting compulsive behavior is attempting to control his anxiety. The compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an attempt to express hostility.
A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families?
role stereotyping
A client reports that before he leaves home to go anywhere, he counts the money in his wallet as many as 12 times. The nurse judges this behavior to indicate which client need?
the need to channel emotions unacceptable to him with an acceptable activity Explanation: The dynamics of compulsive activity involve a defense against anxiety by persistently doing something to bind or reduce anxiety. This behavior occurs each time threatening thoughts occur that lead to increased anxiety.Believing that the client is channeling excessive sexual energy into an appropriate habit shows an incorrect understanding of the dynamics of the disorder.Judgment that the client counts money repeatedly to compensate for not having had enough money as a child or to avoid the embarrassment of running short is based on insufficient data and represents an oversimplification of the client's problem.
A middle-age adult has been identified as being in the stagnation stage of developmental conflict. What evidence would support this assessment? Select all that apply.
withdrawn from family obligations increased nap and sleeping hours
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may be caused by which factor?
uncertainty and an underlying fear of recurrence Explanation: Clients with cancer report that the lifelong fear of recurrence is one of the most disruptive aspects of the disease. The trajectory of the disease is unpredictable and can be intertwined with many short- and long-term illnesses related to cancer and the treatment modalities. A diagnosis of cancer challenges the individual and the family with a series of crises rather than a time-limited episode. There are no data to indicate that the client has an underlying behavioral disorder.
A family member of a client who is human immunodeficiency virus (HIV) positive is concerned about the possibility of also being HIV positive. What is the best response by the nurse?
"What's your understanding about how HIV is transmitted?" Explanation: The nurse begins by establishing what the family member knows about the transmission of HIV. The family member is not asking about the client's medical condition, so there is no privacy concern. The principal method of contracting HIV is through needlestick injuries or blood contamination from an infected client. However, while it is important that the person know that administering care measures with usual precautions does not result in transmission, the nurse should not dismiss the client's concerns by merely saying not to worry.
A 12-year-old boy has depression and post-trauma response. The boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
sexualized play aggression running away truancy
A client who has bleeding from esophageal varices due to cirrhosis is now medically stabile. The nurse assesses the client's alcohol intake. What information is most important for the nurse to ask about?
influence of alcohol use on employment and on relationships Explanation: Honest, open questioning regarding alcohol intake patterns and the effects on the client's life help address the presenting problem. This could be an important turning point in the client's life. The other choices do not completely meet this.
The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?
semi-Fowler Explanation: A hyphema is the presence of blood in the anterior chamber of the eye. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler position to assist gravity in keeping the hyphema away from the optical center of the cornea.
The nurse is preparing to take a meal tray to the client. The nurse understands that the client follows a kosher diet. Which foods noted on the tray would be of a concern to the nurse?
turkey and cheese sandwich Explanation: Meat and milk products cannot be on the same plate when maintaining a kosher diet. The other choices would be appropriate.
When caring for an adolescent diagnosed with depression, the nurse should remember that depression manifests differently in adolescents than it does in adults. In an adolescent, signs and symptoms of depression are likely to include:
truancy, a change of friends, social withdrawal, and oppositional behavior.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which response by the nurse would be most appropriate?
"I understand, but feel free to visit or call anytime to see how your child is doing." Explanation: The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she should not leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.
A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used when?
to allow her mother to continue in her role as a mother Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation.
During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?
caregiver role strain Explanation: The nurse recognizes the mother's feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with a support group.
