Basic Psychosocial Needs
A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply.
- Request that a health related interpreter to come to the home. - Utilize a trained telephone interpreter while providing care.
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. - Report the behaviors to the unit manager for further investigation.
On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate?
"I am truly sorry you lost your baby."
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?
"I want the social worker to make this decision so Dad won't blame me."
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?
"I will begin with inpatient treatment and participate in an aftercare program."
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."
A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?
"I would like to sit with you and talk about your child."
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?
"If you start to get well and feel better, the skin will return to its normal color."
A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?
"It sounds like that offers you a sense of security."
A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, "You're going to tell me who did this to you. What's his name?" Which is the nurse's best response?
"Please come with me, sir. I need some important information."
A client is 36 weeks' gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse?
"Tell me more about how you are feeling."
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?
"What do you mean by that statement?"
A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. Which question would be appropriate for the nurse to ask to assist the client?
"What have you done so far to try to solve this problem?"
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."
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?"
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?
"You sound concerned about what the tests results might be."
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?
"You're wondering whether you've made the right decision about your treatment."
The nurse is caring for a client whose spouse has just passed away. The nurse knows that according to the Kubler-Ross Model of Grief, there are five stages of grief that most grieving people progress through in order, although not everyone experiences all stages or in this order. Place the stages of grief in the order that is most commonly observed, and that the nurse would expect to see in this grieving client.
- Denial - Anger - Bargaining - Depression - Acceptance
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. - Provide emotional support. - Serve as an attentive listener. - Arrange for the family to view the body.
A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply.
- Explore the possibility of a female nurse being willing to swap clients. - Notify the facility patient-advocate to make them aware of the situation. - Report to the charge nurse to make them aware of the situation.
The nurse is caring for a client who recently lost an infant to sudden infant death syndrome (SIDS). The client talks about how going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate?
Acceptance
An older adult client has received a terminal lung cancer diagnosis. The client's adult children are tearful and afraid to leave their parent's bedside. What type of grieving is this family most likely experiencing?
Anticipatory
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?
Approach the client and ask if there are questions about the condition.
The nurse is in the process of assessing a non-English-speaking client, communicating through an interpreter. To facilitate communication, what should the nurse do first?
Ask client how the client wishes to be addressed.
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?
Ask the social worker to find financial assistance for the client.
A child with a nut allergy presents with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." What should the nurse do first?
Assess the parent's ability to read.
A 12-year-old African-American client has experienced significant blood loss and may require a blood transfusion. The child's mother, father, and sisters are currently present at the child's bedside in the emergency department. How should the nurse direct questions and teaching about the client's condition and treatment?
Assess who is the dominant member of the family and then address that person.
The nurse enters the non-diabetic client's room shortly after a group of health care providers has made rounds. The client asks, "Why did the doctor tell the others that I am not compliant with my diabetes regimen?" The nurse is aware that which ethical principle has been violated?
Confidentiality
The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person?
Console the roommate as grieving begins.
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.
The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family?
Contact the hospice agency to provide grief support for the family.
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
A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which is most important for the nurse to include in the plan of care?
Determine the client's ability to cope with the job loss and family obligations.
A client who underwent cardiac surgery 2 days ago is recovering well. 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?
Direct the body and eyes at the wife and client.
A man on parole robs a bank in a small town and wounds two police officers during a shoot-out while trying to escape. The robber is fatally shot. The police officers are being hailed as heroes in the news, and the man's previous and current criminal history is prominently featured. The nurse is caring for the bank robber's sibling, who is in the emergency department with emotional problems and suicidal ideation. Which type of grief may the sibling be experiencing, which could be contributing to the current emotional state?
Disenfranchised
When the nurse enters a client's room to begin the initial assessment, the client and a partner are passionately kissing and embracing. What action should the nurse take?
Do not disturb the couple, leave the room, and allow them privacy.
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 assess that the client is experiencing which type of grief?
Dysfunctional
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?
Encourage parents to be present during the treatment.
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
Which would be most helpful when coaching a client to stop smoking?
Establish the client's daily smoking pattern.
A nurse is caring for a client with advanced cancer. Based on the accompanying nursing progress notes, what should be the nurse's next intervention?
Explain the use of an advance directive to express the client's wishes.
A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client has decided to continue the pregnancy based on religious beliefs and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate?
Explore the nurse's own feelings about the issues of anencephaly and organ donation.
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?
Gather more information about the client's feelings about the childcare arrangements.
The family of a client who dies lives an hour away from the facility. What should the nurse do to support the family at this time?
Keep the client in the bed until the family arrives.
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.
A client who was a victim of a motor vehicle accident dies in the emergency department. What should be done first to support the client's family at this time?
Provide the family with a private place to begin grieving.
Family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the patient's bedside to perform Anointing of the Sick. The nurse who is providing care for the client should recognize that the family is likely
Roman Catholic
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?
Seek input from all groups and strive for consensus on what would benefit most or all of these people.
When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the
Spiritual Healer
A client's spouse enters the room and becomes very agitated with the fact that the nurse is taking so long to assess the client. The spouse starts pacing within the room and shouts, "What is taking so long?" What is the nurse's best response?
Succinctly and respectfully explain the need to do a proper assessment.
A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest?
Take stress-management classes.
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 parental behaviors.
Which statement best explains why the nurse should acknowledge differences between his or her culture and the client's culture?
The nurse may hold values that could influence the care of the client.
A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure?
The nurse should contact the person identified as the healthcare power of attorney.
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 request is age-appropriate and should be honored
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?
Use the call system to request assistance.
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:
allow her to verbalize her feelings and concerns.
A client is having trouble adjusting to a colostomy surgically created 4 days ago. The nurse prioritizes which nursing diagnosis?
altered body image
A client is admitted with glomerulonephritis. Which psychosocial problems could likely affect this client?
anxiety related to poorly functioning kidneys and body image disturbance
Upon assessment, the client reports that they do not belong to an organized religion. The nurse is correct to interpret this statement as the
client is not affiliated with a specific system of belief regarding a higher power.
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 has migrated to a different country and started working there. Which factor is important for effective functioning?
cultural habituation
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 imposition.
While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience?
fear of the unknown
A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS) inquires about hospice services. What should the nurse tell the client about these services?
for clients with an inevitable death within weeks to months.
When planning a culturally sensitive health education program, the nurse should:
integrate folk beliefs and traditions into the content.
A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?
past and current life actions
The nurse is counseling the family of an older adult who died today. Which factor facilitates attainment of a positive bereavement outcome?
possessing adequate financial resources
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
Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?
previous coping skills
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?
providing the client with support and realistic information on the colostomy
A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?
spiritual alienation
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 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
A client reports for a preoperative appointment in preparation for surgery that will change the client's body from female to male. The client, who was born biologically female, has expressed to the nurse and physician the wish to have been born with the body of a man. What identity is the client demonstrating?
transsexual