NUR 240 EAQ - Psychosocial Integrity

Which is an appropriate response to a client who is 8 weeks pregnant and is concerned because she doesn't "feel like making love to her husband since becoming pregnant" and she doesn't "think he understands"?

"A decrease in libido is common during the first trimester of pregnancy."

The nurse educates a group of parents about the psychosocial changes of adolescents. Which statement made by parents indicates inadequate learning?

"Adolescents love their parents in every situation."

The nurse is providing care to a child of Iraqi descent diagnosed with lead toxicity. Which question is most appropriate for the nurse to include in the assessment process to determine the source of the lead?

"Do you use lozeena when cooking for your child?"

Which questions would allow the nurse to assess a preschool-age child diagnosed with asthma for delayed peer relationships? Select all that apply. One, some, or all responses may be correct.

1.) "Does your child use 'babylike' terms when talking?" 2.) "Does your child play with the other children in the playroom?"

A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?

A defense against underlying depression and fear.

Which factor would be important when selecting a room for a client with bipolar I disorder who is hyperactive and talking nonstop in a loud, demanding voice?

A quiet and restful atmosphere.

Which description of myelomeningocele is accurate?

A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.

Which response would the nurse make to a client with schizophrenia who uses the word "worriation" when talking?

Ask for clarification of the word's meaning.

Which is the most important nursing action when caring for a client who has a newborn with a neurological impairment?

Assisting the client with the grieving process.

Based on the given table, which post-traumatic client is in need of counseling after a traumatic event?

Client B

Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant women is cared for in her current residence?

Cultural desire

Which defense mechanism is most commonly used by clients who are alcoholics?

Denial

Which would the nurse do to assist the attachment process between the primipara mother and her newborn?

Encourage continuous rooming-in.

Which intervention is best for a client who has a borderline personality disorder?

Establishing clear boundaries.

An 11-year-old child is found to have acute lymphocytic leukemia (ALL), and the health care provider discusses the diagnosis and treatment with the child and family. Which age-appropriate behavior would the nurse expect from the child regarding the life-threatening diagnosis?

Expressing anger by being insolent.

Which outcome do self-help groups such as Alcoholics Anonymous (AA) help their members to achieve?

Foster changes in behavior.

Which approach would the nurse take when a client with borderline personality disorder states that the nurse is uncaring after the nurse sets limits?

Help the client identify feelings.

Which would the nurse encourage for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment?

Making up missed work.

Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)?

Monitor for cardiac dysrhythmias.

For a client with an obsessive-compulsive disorder, which rationale explains the function of obsessions and compulsions?

Unconscious control of unacceptable feelings.

Which response would the nurse make to a depressed client who asks, "Do you think they'll ever let me out of here"?

"How do you feel about leaving here?"

Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?

"It seems like the world is a pretty scary place for you."

Which initial response would the nurse make during a routine yearly physical to an older adult who says, "I haven't had sex lately because I can't get an erection anymore"?

"Let's discuss this concern a little more."

A client is experiencing a prolonged labor and is frustrated and very concerned about the situation. The nurse acknowledges the client's feelings and then makes which response?

"May I rub your back? Let me know if the pressure makes you feel better or worse."

Which response would the nurse use when a parent, suspected of child abuse, gives information that contradicts the information given by the child.

"Tell me again how your child fell down the stairs."

A client who has just given birth examines her newborn. She notes a nevus vascularis on her forehead and becomes upset. How would the nurse respond?

"These areas usually spread and then regress."

A client with a parotid tumor expresses anxiety about a planned surgery to remove the tumor. The client states that perhaps surgery should be performed soon, even if the preoperative radiotherapy is not completed. How should the nurse respond?

"You are concerned about the delay of surgery?"

Which response would the nurse make to a client who says, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy after performing a complex ritual?"

"You're concerned about what other people are thinking about you?""

Which response would the nurse make to a client with bipolar I mood disorder, manic episode, who says to the nurse, "I don't know what I'm doing here. I never felt better in my life; I've got the world on a string around my finger"?

"You're feeling pretty elated right now."

Which would the nurse include in the plan of care for an adolescent who is diagnosed with a chronic illness?

Achieving independence from family.

The nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." Which does this nurse's comment reflect?

Demonstration of a personal bias.

Which method would the nurse expect to be used successfully with a client who has a phobia about closed spaces?

Desensitization

Which therapy would have the highest success rate for people with phobias?

Desensitization involving relaxation techniques.

Which behavior occurs first in the bulimia nervosa cyclical pattern?

Dieting is used as an attempt to maintain control over life.

Which finding would the nurse observe in a client with vascular neurocognitive disorder?

Difficulty recalling recent events related to cerebral hypoxia.

Which activity would the nurse suggest for a client with bipolar disorder who has accelerating manic behavior?

Engaging the client in conversation while walking slowly in the hall.

Which action related to gender is often expected in regards to socialization for school-age girls within the community setting?

Expressing feelings openly.

Which type of sexual disorder describes a client who has a sexual obsession with shoes? Select all that apply. One, some, or all responses may be correct.

Fetishistic

Which action would the nurse take for a frail, depressed, older client who frequently paces the halls and becomes physically tired from the activity?

Have the client perform simple, repetitive tasks.

For clients who are about to enter a detoxification program for alcohol abuse, which nursing action will help them increase responsibility for self-control?

Help them adopt more healthful coping patterns.

According to Erikson's theory, at which stage does a child start to have fantasies and an active imagination?

Initiative versus guilt

A 68-year-old client with a new ileostomy remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." Which conflict according to Erikson does this comment exhibit?

Integrity versus despair

Which of these is a one-on-one communication between the nurse and another person?

Interpersonal communication

Which action would the nurse take to help a client participate in an activity whose depression is beginning to lift but remains aloof from the other clients on the mental health unit?

Invite another client to take part in a joint activity with the nurse and the client.

Which discharge criterion would be appropriate for a client with obsessive-compulsive disorder who is using ritualistic behaviors?

Is able to intervene when increasing levels of anxiety occur.

The nurse has learned that infants born to very young mothers are at risk for neglect or abuse, primarily because of which characteristic typical of adolescent mothers?

Is involved in seeking her own identity.

Which key factor would the nurse consider when assessing how a client will cope with body image changes?

Perception of the change.

A client verbalizes anger toward the staff after being denied an unaccompanied day pass to leave the psychiatric facility. Which feeling is most likely to be the source of the client's anger?

Powerlessness

Which action would the nurse take when a client with schizophrenia talks about being controlled by others?

React to the feeling tone of the client's delusion.

A client is exclusively preoccupied with thoughts of her mother's death. According to Engel's stages of grieving, which stage is the client experiencing?

Resolving the loss.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?

Revising the client's will and planning a visit to a friend.

Which type of group is Alcoholics Anonymous (AA)?

Self-help group

Which theoretical explanation underlies the development of anorexia nervosa in a female adolescent?

The adolescent struggles with dependence and independence and there is inaccurate perception of body image.

Which factor is most significant for the nurse working with the family of an infant born with a genetic disorder?

The family's readiness to talk about problems their infant may have in the future.

Which essential action would the nurse take for a client whose behavior is characterized by suspicious delusions?

Try to establish trust through consistency of care.

Which intervention would be essential for the nurse to take for a hyperactive client?

Using a firm but caring and consistent approach.

Which changes can be noticed in adolescents during the process of development of emotional autonomy? Select all that apply. One, some, or all responses may be correct.

1.) Adolescents do not run to their parents if they are upset. 2.) Adolescents do not see their parents as an absolute authority. 3.) Adolescents interact with their parents as peers.

Which findings would alert the nurse that a client with schizophrenia is experiencing positive symptoms? Select all that apply. One, some, or all responses may be correct.

1.) Agitated behavior 2.) Delusions of grandeur 3.) Auditory hallucinations

Which sources of stress would the nurse plan to include in the assessment for a 9-year-old client who is scheduled for a routine health maintenance visit? Select all that apply. One, some, or all responses may be correct.

1.) Fair play 2.) Propriety 3.) Interruptions 4.) Rebelliousness

Which toddler behaviors would the nurse identify as ritualism during the health history portion of the assessment? Select all that apply. One, some, or all responses may be correct.

1.) Using the same cup with each meal. 2.) Refusing to eat if the different foods are touching. 3.) Rejecting a meal because it is served in a different bowl.