NUR221 QUIZ 1
Kubler-Ross stages of grief
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
Five Properties of Defense Mechanisms
1. Manage conflict and affect 2. Relatively unconscious 3. Discrete from one another 4. Often hallmarks of psychiatric syndromes, but reversible 5. Adaptive as well as pathological
the nurse is assessing a client recently admitted to the hospice care. When trying to determine the needs of the client, which assessment is priority? 1.Exploring the relationships and communication patters within the family 2.Identifying the client's religious preferences and name of their spiritual counselor 3.Reviewing the prescribed medications with the client to see if they understand them 4.Determining whether the client's insurance will pay for hospice care
1.Exploring the relationships and communication patters within the family *Assessment of the client and family dynamics is an important part of the assessment when determining stages of the grieving process. This interaction assessment is an important part of planning care.
The hospice nurse is visiting a client who is terminally ill. What assessment is the priority when caring fora client on hospice care? 1.Level of consciousness 2.Pain Management 3.I&O 4.RR
2.Pain Management
The client with a dx of MDD states, "I have been on these antidepressant medications for a week now and I don't feel any better." What statement by the nurse would be appropriate? 1.It took you a long time to get this depressed. Don't expect an immediate turnaround" 2.Oh, I see improvement in your mood everyday since you started the prescirptioj. 3. Sometimes the antidepressant medications take up to 3 weeks before you see a change 4.I will check with your healthcare provider, maybe we need to change the medications
3. Sometimes the antidepressant medications take up to 3 weeks before you see a change
The nurse is delegating the care of a client with bipolar disorder to a UAP. What instruction is critical to a successful plan of care? 1.Allow the client to maintain as much control as possible. 2.Do not argue with the client if they don't want to eat lunch. 3.Be sure to consistently implement the limits set for the client 4.Encourage the client to play card games to keep them busy
3.Be sure to consistently implement the limits set for the client
The interprofessional team is planning end-of-life care for a client with terminal cancer. The clinet's young children recently climbed into bed to snuggle their mom which is an infection control concern. What suggesion by the nurse would be appropriate? 1.We may need to limit the time the clint's young children visit 2.The kids need to touch their mother, maybe we could encourage holding hands 3.If the kids wash their hands before snuggling, short periods should be fine 4.We could encourage the client's spouse to snuggle with the kids at home
3.If the kids wash their hands before snuggling, short periods should be fine *Given the setting and situation, adjustments to the infection control policy is acceptable. Meeting the psychosocial needs of the client and family are more important than the risk of infection.
A client has just been diagnosed with a major depressive disorder following recent problems with the client's mood, work performance, and sleep quality. When planning this client's care, the nurse should anticipate what interventions? Select all that apply. Administration of a selective serotonin reuptake inhibitor (SSRI) Administration of a monoamine oxidase inhibitor (MAOI) Phototherapy Cognitive therapy Repetitive transcranial magnetic stimulation (rTMS)
Administration of a selective serotonin reuptake inhibitor (SSRI) Cognitive therapy *For most clients with a new diagnosis of depression, medication is combined with cognitive and behavioral interventions. Usually an SSRI is tried first. MAOIs are reserved for clients unresponsive to other antidepressants, and rTMS is used for depression unresponsive to conventional treatment. Phototherapy is used specifically for seasonal depression.
Benzodiazepines
Alprazolam, Midazolam. temazepam, clonazepam *Highly addictive and hard to come off, dangerous *short-terms use for anxiety, seizures, alcohol withdrawal, sedation *sedation *sleepy *suppresses ABCs --take at bedtime. Don't skip doses. **risk = sedation, rebound anxiety. Must taper off. **no alcohol! Increase sedation ANTEDOTE = FLUMAZENIL
An inappropriately dressed client has not slept for 3 days and has been making excessive long-distance phone calls. When the client can be heard singing loudly in the examining room, which action will the nurse take? Setting strict limits on dress and behavior Assessing needs for food, liquids, and rest
Assessing needs for food, liquids, and rest
Defense Mechanism: Undoing
Attempt to negate or neutralize one's socially disapproved thoughts, feelings or behaviors by others
Defense Mechanism: Projection
Attribution of one's unacceptable thoughts, feelings or impulses to another person or object.
A client has just been informed of a diagnosis of terminal cancer. The client states, "God has to have mercy on me because my children need me. God knows I'll change if I get through this." The nurse documents that the client is expressing signs of which of Kübler-Ross's stages of grief? Bargaining Anger Denial Depression
Bargaining
Alprazolam (Xanax)
Benzodiazepine
Anxiolytics
Benzoiazepines - sedative Barbiturates - sedative Buspirone - non sedating
Defense Mechanism: Denial
Blocking from awareness intolerable or painful thoughts, feelings, or impulses. Refusing to acknowledge the existence or a real situation nor the feelings associated with it.
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 Uncomplicated Dysfunctional Anticipatory
Disenfranchised
Methadone
Dolophine, Methadose
The nurse is assessing a client recently diagnosed with obsessive-compulsive disorder (OCD). What does the nurse tell the client about the onset of the disorder? It starts in the 20s in male clients. It is diagnosed very early in most clients. Early onset may indicate family history of OCD. It starts in childhood in female clients.
Early onset may indicate family history of OCD.
Which would not be an initial intervention for the client with acute anxiety? Use of open-ended communication techniques Maintaining a nonstimulating environment Touching the client in an attempt to comfort the client Encouraging the client to verbalize feelings and concerns
Encouraging the client to verbalize feelings and concerns
Defense Mechanism: Displacement
Transference of thoughts and feelings too painful or dangerous to express toward an object or situation to another more acceptable or less threatening or neutral.
The nurse is participating in an interdisciplinary care conference for a client who has obsessive-compulsive disorder (OCD). In order to best promote the client's recovery, the care team must:
agree on consistent expectations for the client's behavior. *The care team must be agreed on the expectations for the client in order to promote recovery. It is not possible to identify the precise etiology of a multifactorial disease like OCD. The client's preferences and goals are important, but it is unrealistic to expect the client to lead an interdisciplinary care conference. Adherence is promoted through positive reinforcement, not negative consequences.
Which class of medication is regularly prescribed to provide a gradual withdrawal from alcohol?
antianxiety/anxiolytic
The nurse is developing a plan of care for an elderly client who has experienced the traumatic death of a spouse. Which intervention would the nurse prioritize for the client? arrangement for delivery of meals for the client preparation for a visit to a grief counselor management of the client's financial needs discussion regarding the client's level of anxiety
arrangement for delivery of meals for the client
Lithium toxicity symptoms
course hand tremors confusion hypotension seizures tinnitus coma, death **DO NOT GIVE** diuretics, anti-cholinergics, or nsaids **Increase fluids & Na+
The nurse provides care to a client who is newly diagnosed with hoarding disorder. Which treatments are appropriate for the nurse to include in this client's plan of care? Select all that apply. pharmacotherapy cognitive behavioral therapy (CBT) peer-led support group electroconvulsive therapy (ECT) safety education
pharmacotherapy peer-led support group electroconvulsive therapy (ECT) safety education
Defense Mechanism: Somatization
the expression of psychological stress through physical symptoms
Selye's General Adaptation Syndrome
three-stage process which describes the body's reaction to stress: 1) alarm reaction, 2) resistance, 3) exahaustion
Which would be a finding related to perceptual disturbances during the mental status exam in the client with mania? Limited insight Hallucinations
Hallucinations
The nurse is caring for a client who performs ritualistic hand washing and cleaning for about 30 minutes several times a day. What does the nurse tell the client's partner about caring for this client? Ignore the client's behavior, it will phase out with time. Monitor own health and anxiety levels. Assist the client to complete daily activities. Ask the client to divert attention to other activities.
Monitor own health and anxiety levels. *The nurse asks the client's partner to monitor the partner's own health and anxiety levels. The partner may benefit from an occasional break in the routine. The client must undergo therapy to complete daily activities without assistance. Diverting the client's attention to other activities or ignoring the client's behavior does not help either of them. The partner must understand the client's problem and encourage the client to undergo behavior therapy and take medications.
A woman gave birth yesterday to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. Which intervention would be the priority? Provide time for the mother to grieve for the loss of the imagined baby. Review the causes of a cleft palate with the mother. Encourage the mother to care for herself. Have the mother wait for a day or two to visit the child in the nursery.
Provide time for the mother to grieve for the loss of the imagined baby.
What does the nurse teach the client with obsessive-compulsive disorder about relaxation techniques? A friend should assist with relaxation therapy. Relaxation techniques should be practiced whenever possible. They help to eliminate ritualistic behavior completely. Relaxation techniques should be attempted when anxiety subsides.
Relaxation techniques should be practiced whenever possible.
A client is experiencing a panic attack while in the recreation room. Which intervention(s) would be a priority to promote the client's safety? Select all that apply. Remaining with the client to assess needs Turning off any televisions or radios in the immediate area Requesting a prescription for an antianxiety agent Offering the client therapy to calm down Engaging the client in recreational activities.
Remaining with the client to assess needs Turning off any televisions or radios in the immediate area Offering the client therapy to calm down
A client with bipolar disorder has a plasma lithium concentration of 2.7 mE/L. Which finding would a nurse most likely assess in this client? Select all that apply. Seizures Nystagmus Fasciculations Tinnitus Incoordination
Seizures Nystagmus Fasciculations
Defense Mechanism: Intellectualization
Separation of the emotion aroused by an event from the thoughts or opinions about the event. An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual process of logic, reasoning, and analysis.
Which activities are considered part of harm reduction strategies? SATA Set a time limit before you start drinking and then stop drinking at that time Eat a meal before going out to drink Read self-help books Plan alcohol- free days Practice what to say to peers when pressured to drink
Set a time limit before you start drinking and then stop drinking at that time Eat a meal before going out to drink Read self-help books Plan alcohol- free days Practice what to say to peers when pressured to drink
A client is diagnosed with posttraumatic stress disorder (PTSD). The client is a survivor of a bomb blast. Which symptoms of PTSD is the nurse likely to find in the client? Select all that apply. Showing irritability and outbursts of anger Reexperiencing the trauma through dreams Feeling detached from others Visiting places of the event triggers memories of the trauma Losing a sense of control over one's life
Showing irritability and outbursts of anger Reexperiencing the trauma through dreams Feeling detached from others Visiting places of the event triggers memories of the trauma Losing a sense of control over one's life
When providing care for a client diagnosed with posttraumatic stress disorder (PTSD), the psychiatric nurse assesses for comorbid mental health disorders by asking what? Select all that apply. "Do you ever hear voices telling you want to do?" "Do you often socialize with friends?" "Is depression a problem for you?" "Has anyone ever suggested that you have an alcohol problem?" "Do you ever think about committing suicide?"
"Do you often socialize with friends?" "Is depression a problem for you?" "Has anyone ever suggested that you have an alcohol problem?" "Do you ever think about committing suicide? *Asking whether the client ever hears voices would not be appropriate.
Which questions should the nurse ask the guardian when assessing a school-age client for symptoms of posttraumatic stress disorder (PTSD)? Select all that apply. "Does your child have issues with verbal communication?" "Does your child wet the bed?" "Does your child act out the trauma event when playing?" "Is your child clingy to an adult caregiver?" "Is your child disruptive in social settings?"
"Does your child wet the bed?" "Does your child act out the trauma event when playing?" "Is your child clingy to an adult caregiver?" "Does your child have issues with verbal communication? *Posttraumatic stress disorder occurs following exposure to an actual or threatened traumatic event, such as death, serious injury, or sexual violence. Clinical manifestations of PTSD tend to differ based on the client's age and stage of development. The symptoms that the nurse assesses for when providing care to a school-age client with this diagnosis include bedwetting after the child had learned how to use a toilet, forgetting how or being unable to talk, acting out the scary event during playtime, and being unusually clingy with a parent or other adult. Disruptive, disrespectful, and destructive behaviors are more common in the adolescent client who is diagnosed with PTSD.
A nurse is interviewing a client and suspects an eating disorder. Which client statement would the nurse interpret as demonstrating a risk for the development of an eating disorder? Select all that apply. "Everything about my school work needs to be perfect." "I want things to be the way I want them to be." "I'll stand up for what I want, regardless of what you say." "Things being out of order really bothers me." "I consider myself a really laid-back individual."
"Everything about my school work needs to be perfect." "I want things to be the way I want them to be." "Things being out of order really bothers me."
A client asks the nurse, "How can I tell if what I am experiencing is just regular worrying and not an anxiety disorder?" What is the nurse's best response? "If you are unable to function occupationally and socially because of the anxiety" "If you feel nervous before a big event, you likely have an anxiety disorder." "You have an anxiety disorder if you need medication to help you function." "Trouble falling asleep due to worrying indicates an anxiety disorder."
"If you are unable to function occupationally and socially because of the anxiety"
The nurse is sitting with the client at mealtime. The nurse uses cognitive-behavioral approaches to assist the client with bulimia toward recovery. Which statement by the nurse would be consistent with this approach? "You seem to have a really hard time controlling your eating patterns." "Is there any way you can look at that sandwich as fuel for your body?
"Is there any way you can look at that sandwich as fuel for your body? *CBT has been found to be the most effective treatment for bulimia. This outpatient approach often requires a detailed manual to guide treatment. CBT strategies focus on the client's thinking (cognition) and actions (behavior) about food. Cautioning the client to eat in moderation is nontherapeutic because it does not give the client tools to achieve this outcome. The nurse's statement about lack of control of eating patterns is similar in that it does not give the client cognitive and behavioral tools to effect change. The question "Is this your way of showing your family that you can make decisions?" does not exemplify a CBT approach because it requires the client to spontaneously identify the underlying motivation; it does not provide tools to address the client's thinking.
Which statement by the nurse providing care for a client diagnosed with obsessive-compulsive disorder (OCD), indicates a need for additional education regarding the client's ritualistic hand washing? "Let's talk about how this ritualistic behavior makes you feel." "Let me help you find something less time consuming to do to manage your anxiety."
"Let me help you find something less time consuming to do to manage your anxiety." *People with OCD are usually aware that their ritualistic behavior appear senseless or even bizarre to others. Given that, family and friends may believe that the person "should just stop" the ritualistic behavior. "Just find something else to do" or other unsolicited advice only adds to the guilt and shame that people with OCD experience. It is important for the nurse (and other health professionals) to avoid taking that same point of view. Most times, people with OCD appear "perfectly normal" and therefore capable of controlling their own behavior. The nurse must remember that overwhelming fear and anxiety interfere with the person's ability to monitor or control their own actions. In addition, OCD is often chronic in nature, with symptoms that wax and wane over time. Just because the client has some success in managing thoughts and rituals doesn't mean they will never need professional help in the future.
A nurse observes that a client with posttraumatic stress disorder (PTSD) is experiencing dissociative symptoms. What instruction should the nurse give to the client to prevent being stuck in a daze? "Try and express your feelings." "Come and sit with me for awhile." "Try to sleep." "Look around the room."
"Look around the room."
A client with moderate Alzheimer disease is living with an adult child. Which statement by the adult child would indicate the need for intervention by the nurse? "Taking care of my parent is a big responsibility." "It is distressing when my parent forgets my name." "My parent will not let anyone else do anything for them." "I wish my sibling would come to visit more often."
"My parent will not let anyone else do anything for them."
During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate? "I would make arrangements to have all your children present for the death vigil." "Make sure you have made previous arrangements with the funeral home for burial arrangements." "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." "Have you thought about what you will do when you find your spouse after he has died?"
"Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." Anticipating and planning interventions is a cornerstone of end-of-life care. The nurse encourages communication and anticipatory grieving by using open-ended statements such as "Tell me. . . ." Effective communication techniques include the avoidance of closed-ended statements and giving advice.
A new client with a long-standing history of obsessive-compulsive disorder (OCD) is describing to the nurse the complex ritual of locking and unlocking a door after entering a room alone. What is the nurse's most therapeutic response? "Is there a history of OCD or any other mental health disorders in your family?" "It sounds like you're trying to address a problem that in all likelihood doesn't exist." "The process you're describing sounds like it must require quite a bit of time and energy." "What would you say to me if I had similar rituals with locking and unlocking doors?"
"The process you're describing sounds like it must require quite a bit of time and energy."
While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply. "Let's focus on what your doctor has planned." "This must be very difficult for you." "You still have time for a good life." "I know just how you must feel." "Tell me more about what's on your mind."
"This must be very difficult for you." "Tell me more about what's on your mind."
bartbiturates
"barbitol", phenobarbitol -lasts longer than benzo/3-5 days Higher risk for toxicity **low BP... increased sedation high death rates
What request of the patient being assessed for possible alcohol withdrawal should the nurse make to determine the presence of tremors? A. "please touch your thumb to your little finger" B. "pease extend your arms and spread your fingers apart" C. "please interlock the fingers of both hands" D. "please make a tight fit and hold it for 5 seconds"
"pease extend your arms and spread your fingers apart"
While the nurse is caring for a client with schizophrenia, the client states, "I keep hearing those voices telling me to run away" What response by the nurse is appropriate? 1.Those voices are just in your head and the medication will help in a few days 2.Can you tell me who the voice sounds like and what you think you need to do? 3.Sometimes those voices tell you things that don't make any sense. Just ignore them. 4.Try to listen to me and the others around you that you can see
4.Try to listen to me and the others around you that you can see *For the client experiencing hallucinations, it's important to have them focus on reality
Symptoms of alcohol withdrawal typically begin within what time period after the cessation or marked reduction of alcohol intake by the chronic drinker? 90-120 minutes 6-12 hours 3-5 days 1-2 weeks
6-12 hours
Which are considered physiological signs the nurse expects to observe in a grieving individual? Select all that apply. Hypersomnia Indigestion Weight gain Palpitations Lack of energy
Indigestion Palpitations Lack of energy
Defense Mechanism: Introjection
Acceptance of another's values and opinions as one's own even if they contradict one's values. Integrating the beliefs and values of another individual into one's own ego structure.
A client was physically assaulted 1 week ago. While interviewing the client, the client reports having trouble remembering the event and feeling as if the client is walking around in a dreamlike state. The psychiatric-mental health nurse interprets these findings as most likely associated with which condition? Posttraumatic stress disorder Dissociative stress disorder Amnesic stress disorder Acute stress disorder
Acute stress disorder *Acute stress disorder occurs within the first month of exposure to extreme trauma: combat, rape, physical assault, near-death experience, or witnessing a murder. Symptoms begin during or shortly after the event. The symptom of dissociation, a state of detachment in which people experience the world as dreamlike and unreal, is a primary feature. Poor memory of specific events surrounding the trauma also may accompany the dissociative state. When symptoms of acute stress disorder continue for more than 1 month and are accompanied by functional impairment or stress, the diagnosis changes to acute posttraumatic stress disorder.
A client has responded to a recent diagnosis of lung cancer by making extensive plans for overseas travel with family, despite the extremely poor prognosis. The client is adamant about not discussing cancer and is identified by the nurse as experiencing the denial stage of grief. How can the nurse best facilitate the client's healthy grieving? Enlist the assistance of another nurse to help the client face the reality of the situation. Restate the client's situation in more specific and detailed terms. Supplement conversations with the client by using written material about the diagnosis. Address the client's diagnosis and prognosis at a later time or date.
Address the client's diagnosis and prognosis at a later time or date.
Defense Mechanism: Sublimation
Channeling energy from an unacceptable impulse which cannot be realized into an avenue more acceptable to the person or society and thereby gratifying it. Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive. EX: Mom of son killed by drunk driver, president of MADD.
Which of the following would lead the nurse to identify that a client is experiencing a physiologic response to grief? Choking sensation Sadness Crying Slow movements
Choking sensation
Defense mechanism: Reaction Formation
Defense against undesirable impulse by behaving the opposite from thoughts and feelings. Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors.
Despite being admitted to the hospital yesterday for the treatment of complications of anorexia nervosa, a 19-year-old client continues to have only bites of food and small sips of fluids. Which of the following nursing diagnoses is paramount in this client's care? mbalanced nutrition less than body requirements related to refusal to eat Deficient fluid volume related to inability to meet bodily fluid requirement
Deficient fluid volume related to inability to meet bodily fluid requirement *The risk of dehydration posed by the client's refusal to drink likely supersedes the risk of imbalanced nutrition in the short term. Both diagnoses are more immediate concerns than the client's interactions. There is no immediate evidence of anxiety.
A nurse is caring for a client with posttraumatic stress disorder (PTSD). On reassessing the client, the nurse finds that the client shows signs of another psychiatric disorder as well. Signs of which psychiatric disorders would the nurse likely see in this client? Select all that apply. Depression Mania Schizophrenia Anxiety disorder Obsessive-compulsive disorder
Depression Anxiety disorder
When explaining the difference between anxiety and fear, the mental health nurse shares what? Select all that apply. Fear results in objective, physical responses caused by real danger Anxiety is likely to result from an attempt to overcome stress People who experience anxiety tend to use maladaptive coping mechanisms Obsessive-compulsive behavior is often the result of abandonment Anxiety involves experiencing subjective, uncomfortable feelings resulting from unknown causes
Fear results in objective, physical responses caused by real danger Anxiety is likely to result from an attempt to overcome stress Anxiety involves experiencing subjective, uncomfortable feelings resulting from unknown causes
The nurse is conducting an admission assessment with a 45-year-old client who has been demonstrating signs of bipolar disorder. While conducting the assessment, the client starts speaking in illogical rhymes and using word associations. What is the name for this thought pattern? Excessive euphoric speech Flight of ideas
Flight of ideas
Nursing students are reviewing information about grieving and its assessment findings. The students demonstrate an understanding of the information when they identify which of the following as a behavioral indicator? Sadness Forgetfulness Questioning of beliefs Longing for what was lost
Forgetfulness
In clients with posttraumatic stress disorder (PTSD), there is marked alteration in arousal and reactivity associated with the traumatic event. Knowing this, which behaviors of a client would the nurse interpret as characteristic of PTSD? Select all that apply. Decreased appetite Inability to concentrate on studies Shouting and throwing objects out of anger Causing self-injury Extreme forgetfulness
Inability to concentrate on studies Shouting and throwing objects out of anger Causing self-injury
Mechanism: Suppression
Intentional, voluntary exclusion or unacceptable thoughts, feelings, actions or impulses from awareness
Defense Mechanism: Repression
Involuntary exclusion of painful or unacceptable thoughts, feelings or impulses from consciousness
Defense Mechanism: Rationalization
Justification of one's behaviors, thoughts, feelings or impulses with acceptable reasons rather than the real reasons which may not be logical, rational, or consistent. Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors
Buspirone
Non addictive, non sedating atypical anxiolytics No w/d symptoms takes 2-4 weeks to take effect safe for long term use *take regularly.
Defense Mechanism: Compensation
Overemphasis on an activity to counter the effects of a real or imagined failure, frustration or limitation. Covering up a real or perceived weakness by emphasizing a trait one considers more desirable
Defense Mechanism: Idealization
Overestimation of the valuable qualities and attributes of another person
The nurse is caring for a client who has begun to lose hair from chemotherapy treatment. The client appears withdrawn and answers questions in one-word statements, which is a change from previous behavior. What is the nurse's priority response? Share options for coping with ongoing hair loss with the client. Reassure the client that this phase of the treatment is temporary. Perform a depression screening assessment with the client. Assess the client's feelings about current body image.
Perform a depression screening assessment with the client. This client may be experiencing clinical depression, which is common in clients undergoing treatment for cancer. The client is withdrawn and minimizes interaction with the nurse, which can indicate depression. The nurse should assess the client using a validated depression screening tool, including assessing for suicidality. Offering reassurance about the temporary nature of the hair loss or sharing options does not address the change in the client's mood. While exploring the client's feelings about body image may be appropriate, the priority is determining if depression is present and if so how it needs to be addressed.
What does the nurse teach the client with obsessive-compulsive disorder about reducing anxiety? Select all that apply. Practice guided imagery. Perform progressive muscle relaxation. Reduce time spent on rituals. Breathe deeply when anxiety increases. Refrain from discussing the obsessions.
Practice guided imagery. Perform progressive muscle relaxation. Reduce time spent on rituals. Breathe deeply when anxiety increases.
Defense Mechanism: Substitution
Replacement of unattainable or unacceptable activity with attainable or acceptable activity
Defense Mechanism: Symbolization
Representation of an object, thought, or behavior by another through some common element and carrying the emotion associated with the other. Representation of a complex group of behaviors, feelings, or objects by an object or behavior
The nurse is caring for a client admitted with anorexia nervosa. When creating the nursing interventions for the plan of care, which is the primary objective? Changing the client's irrational thinking about the client's body Restoring nutritional status to norma
Restoring nutritional status to normal *Physiologic safety and homeostasis are the priority concerns. Changing of thought patterns and gaining insight into the effects of anorexia on the client's physical health are not immediate goals in the management of anorexia nervosa because these are psychosocial, not physiologic, aspects of care. Achieving a client's target weight requires a lengthy process that is unlikely to be completed during inpatient care.
Defense Mechanism: Regression
Return to former(earlier) patterns of behavior associated with comfort and security. Retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning.
A nurse is assessing a client who has experienced trauma. The nurse determines that the client is experiencing physiologic hyperarousal based on which finding? Select all that apply. Avoids places associated with the event Has vivid dreams Overreacts to others Startles easily Urinates frequently
Startles easily Overreacts to others *After a traumatic experience, the stress system seems to go on permanent alert, as if the danger might return at any time. In this state of physiologic hyperarousal, the traumatized person is hypervigilant for signs of danger, startles easily, reacts irritably to small annoyances, and sleeps poorly. The state of hyperarousal causes the affected individual to be irritable and overreact to others, which cause others to avoid the person. Frequent urination and vivid dreams are not associated with posttraumatic stress disorder. Avoiding places associated with the trauma is common but not associated with hyperarousal.
defense mechanisms
Sublimation Humor Suppression Compensation Introjection Identification Repression Displacement Reaction Formation Somatization Undoing Rationalization Regression Projection Denial
A nurse is caring for a client who is grieving the loss of a loved one. Which factor will the nurse identify as contributing to the possibility of complicated bereavement? The client has a good support system with meaningful relationships evident. The client was relatively independent of the deceased. The client had few unresolved conflicts in the relationship with the deceased. The client has experienced a number of previous losses.
The client has experienced a number of previous losses.
What interventions does the nurse use to foster self-esteem in the client with obsessive-compulsive disorder (OCD)? Select all that apply. Teach appropriate social skills. Encourage participation in follow-up therapy. Show interest and concern for the client. Assist the client with preparing for sleep and activities of daily living. Involve client in activities that can be easily accomplished.
Teach appropriate social skills. Show interest and concern for the client. Involve client in activities that can be easily accomplished *The questions asks for interventions that improve self-esteem in the client with OCD. The client may have withdrawn from socializing due to embarrassment about OCD behaviors or due to a lack of social skills. Therefore, teaching the client appropriate social skills such as listening attentively can help the client have success and gain confidence in this area. Conveying genuine interest and concern helps the client feel accepted, and supporting the client's successful participation in activities helps the client's confidence. The nurse does encourage the client to participate in follow-up therapy, but the purpose of this intervention is to overcome difficulties in dealing with obsessive thoughts, not to improve confidence and self-esteem. The nurse also monitors and assists with sleep and accomplishment of activities of daily living, but these interventions are to manage practical difficulties posed by OCD.
A client with anorexia nervosa self-describes as "a whale." However, the nurse's assessment reveals that the client is 5 feet 8 inches tall and weighs only 90 pounds. Considering the client's unrealistic body image, which intervention should be included in the care plan? Assigning the client to group therapy in which participants provide realistic feedback about the client's weight Telling the client of the nurse's concern for the client's health and desire to help the client make decisions to keep the client healthy
Telling the client of the nurse's concern for the client's health and desire to help the client make decisions to keep the client healthy *A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about nutritious foods to keep the client healthy.
A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)? The adolescent idealizes the relationship that the adolescent had with the sibling The adolescent expresses intense guilt for the inability to save the sibling The adolescent is fixated on having a fire escape plan in the family's new home The adolescent often begins crying when discussing the tragedy
The adolescent expresses intense guilt for the inability to save the sibling *Guilt for not preventing a death is associated with PTSD in adolescents. Crying is an expected response to tragedy, as is focusing on preventing future incidents. Idealizing a relationship after the person's death is not a pathologic behavior.
A nurse is reviewing the medical records of several clients being treated for eating disorders at the community mental health center. Which behavior would the nurse identify as differentiating a client who is believed to have bulimia nervosa from one who has anorexia nervosa? The client is preoccupied with food consumption. The client is of normal body weight.
The client is of normal body weight. *Bulimia nervosa was once thought to be a type of anorexia nervosa, but research findings have identified it as a separate entity. Preoccupation with body image, compulsive regulation of food intake, and feelings of powerlessness are common to clients with anorexia nervosa and bulimia nervosa. However, the practice of binging and purging is predominant in bulimia nervosa, and the client often maintains a normal body weight. While binging and purging may be an aspect of anorexia nervosa, this disease is characterized by overall restriction of calories, and the client has significantly less than normal body weight.
A nurse is assessing a client with posttraumatic stress disorder (PTSD). Which symptoms in the client would indicate a need for hospitalization? Select all that apply. The client avoids engaging in social activities. The client is overwhelmed with flashbacks of the traumatic event. The client has suicidal tendencies. The client is not able to sleep well. The client has negative feelings about the self.
The client is overwhelmed with flashbacks of the traumatic event. The client has suicidal tendencies.
The nurse is assessing the physiological effects of severe obsessive-compulsive disorder (OCD) in a client. What does the nurse expect to find during assessment? The client sleeps for 8 to 10 hours a day. The client reports unwanted weight gain. The client is unable to maintain adequate personal hygiene. The client is energetic and completes activities quickly.
The client is unable to maintain adequate personal hygiene *In severe OCD, the client is unable to complete routine tasks because of compulsive ritual behaviors. A lot of time is spent on performing rituals and the client may not have enough time to sleep. The client is so obsessed with thoughts and compulsive behaviors that physical needs such as sleep, food, drink, and hygiene are neglected. Thus, the client may report unwanted weight loss. Rituals also interfere with the client's ability to complete activities quickly.
The nurse can document correctly that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client doing what? Demonstrating difficulty actually verbalizing anxious feelings Reporting, "I just can't relax; I've got things to do." The client keeps getting distracted but can be brought back to focus on the current conversation. Telling another client that "there is nothing they can do for me; I just know it's really bad."
The client keeps getting distracted but can be brought back to focus on the current conversation.
A client is experiencing moderate anxiety. Which manifestation would the nurse most likely observe? Select all that apply. The client may pace, run, or fight violently if asked to perform a task the client does not want to perform. The client has flights of ideas and confusion. The client can sustain attention on a particular focus. The client makes distorted inferences because of inadequacy of observed data. The client verbally states, "For some reason, I am feeling anxious now."
The client makes distorted inferences because of inadequacy of observed data. The client verbally states, "For some reason, I am feeling anxious now."
A client with obsessive-compulsive disorder (OCD) spends several hours each day cleansing the home and washing the hands. The client tells the nurse, "I don't think you quite realize how many bacteria, viruses, and fungi live around us." What is the nurse's most accurate interpretation of this client's statement? The client may have contacted a severe infection or contamination earlier in life. The client may lack insight into the OCD.
The client may lack insight into the OCD. *The client's statement is an attempt to present a rational justification for the client's actions. This suggests a lack of insight. There is no direct association between this client's statement and physiologic factors. A lack of insight is a challenge for treatment, but it does not necessarily mean that the client will be unresponsive to treatment. Rituals often have no direct relationship with a past event in the client's life.
A client with posttraumatic stress disorder (PTSD) has been referred for employment. Why might the nurse fear that the client will not be capable of sustaining the job long term? The client may not be healthy enough to start a job. The client may not be able to do the work properly. The client may not be able to get along with coworkers The client may have memory loss, which would affect effectiveness at work.
The client may not be able to get along with coworkers *Clients with PTSD often report difficulties with relationships. One such difficulty is with authority figures, and the client may be unable to take direction from a supervisor. The client would be referred for employment only if healthy enough to start the job. If the client has matching knowledge and experience, the client is likely to be able to do the work properly. Unless the client has a dissociative disorder, the client is unlikely to have short-term memory loss that would reduce the effectiveness of working.
A psychiatric-mental health nurse is assessing a client who has been referred for care following a violent assault. Which finding would the nurse most likely document as reflecting the diagnostic criteria for posttraumatic stress disorder (PTSD)? Select all that apply. The client states, "All I can think about these days is the attack." The client states that the client has a limited support network. The client describes oneself as being constantly "on edge." The client states "completely avoiding the neighborhood where the attack occurred." The client admits that recent withdrawal from many of friends.
The client states, "All I can think about these days is the attack." The client describes oneself as being constantly "on edge." The client states "completely avoiding the neighborhood where the attack occurred."
Which are features of the thinking of a person who has obsessive-compulsive disorder (OCD), according to the cognitive model? Select all that apply. The person with OCD is concerned with perfectionism and has an intolerance of uncertainty. The person with OCD is always aware that his or her behavior is related to OCD. The person with OCD believes one's thoughts are overly important and has a need to control those thoughts as they overestimate the threat posed by their thoughts. The person with OCD employs a minimalist approach to all aspects of his or her life. The person with OCD has an inflated personal responsibility.
The person with OCD believes one's thoughts are overly important and has a need to control those thoughts as they overestimate the threat posed by their thoughts. The person with OCD is concerned with perfectionism and has an intolerance of uncertainty. The person with OCD has an inflated personal responsibility.
What intervention does the nurse implement to enable the client with repetitive behavior to complete daily activities?
Verbally direct the client during the activity. *The nurse talks and guides the client throughout the activity to prevent the client from being distracted by anxious thoughts. Telling the client to take as much time as is needed to complete the task gives the client permission to engage in maladaptive rituals to neutralize anxiety rather than work at developing healthier coping through the use of exposure and response therapy. The client may not be able to estimate the amount of time a normal person would need to complete the given task. The nurse does not try to limit stimuli that activate repetitive behavior. The client must learn to overcome these stresses during behavior therapy. The family does not participate in the activity but the nurse teaches the family about the illness and methods of treatment.
The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. Wears hats and wigs Reports absence of sleep disturbance Covers face with a scarf Participates actively in daily activities
Wears hats and wigs Participates actively in daily activities.
A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform? Select all that apply. Withhold additional doses of lithium. Obtain a blood sample for lithium level. Perform a 12-lead electrocardiogram. Push fluids. Contact the physician.
Withhold additional doses of lithium. Obtain a blood sample for lithium level. Push fluids. Contact the physician.
Lithium toxicity symptoms
acute: GI disturbances: nausea, vomiting, diarrhea neuro finding can occur later chronic- neurologic ataxia, confusion, tremors
complicated grieving
a disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment
Dissociation
a split in consciousness, which allows some thoughts and behaviors to occur simultaneously with others
What term refers to the collection of symptoms that are associated with complications of alcohol withdrawal, including hallucinations, mental confusion, and disorientation? Wernicke encephalopathy Korsakoff syndrome alcoholic cardiomyopathy delirium tremens
delirium tremens
The hospice nurse is assessing a new client to prepare to support the client's reaction to and expression of grief. What assessment(s) should the nurse include? Select all that apply. developmental age type of terminal illness socioeconomic factors religious beliefs race and ethnicity family role and supports
developmental age socioeconomic factors religious beliefs type of terminal illness family role and supports
anticipatory grief
grief experienced prior to a loss May lead to detachment prior to the loss
A family in the second phase of divorce are actually separating and moving to new homes and perhaps new schools. The school-age children may experience which type of feeling at this phase in the divorce? grief for the missing parent relief to have the fighting stop low self-esteem because they feel responsible for the breakup happiness that they do not have to listen to their parents argue anymore
grief for the missing parent
disenfranchised grief
grief involving a deceased person that is a socially ambiguous loss that can't be openly mourned or supported
Which physiologic finding does the nurse anticipate when assessing a client who is experiencing the alarm reaction stage of the general adaptation syndrome (GAS) to stress? constricted pupils decreased blood pressure (BP) decreased respiratory rate increased serum glucose level
increased serum glucose level
Morphine
narcotic drug derived from opium, used to treat severe pain Opoid analgesic
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? Avoid phoning the family to permit the family to grieve. Attend the funeral. Send flowers. Remove the client's name from the care list.
Attend the funeral
Defense Mechanism: Conversion/Somatization
Development of physical symptoms in an effort to resolve unconscious psychological conflict (unconscious analog or malingering). Unconscious transformation of anxiety to a physical symptom that has no organic cause
A client is brought to the emergency department dead on arrival (DOA) from a gunshot wound. The client's family arrives and is escorted to a private area. A multidisciplinary team composed of a physician, nurse, and social worker interacts with the family. All members work together to complete the following tasks. Which are the priority nursing responsibilities? Select all that apply. providing therapeutic touch and support as needed escorting the client's family for viewing of the body caring for body organs which are appropriate for transplantation explaining the cause of the client's death arranging disposition of the client's personal belongings
providing therapeutic touch and support as needed escorting the client's family for viewing of the body caring for body organs which are appropriate for transplantation
Which clinical manifestation(s) suggest that a patient is experiencing Stage I (mild) alcohol withdrawal syndrome? SATA coarse hand tremors Disorientation Hypotension slight diaphoresis mild anxiety
slight diaphoresis mild anxiety coarse hand tremors
The nurse provides care for an adolescent client who presents to a community health clinic with symptoms indicative of posttraumatic stress disorder (PTSD) related to recent sexual trauma. Which question should the nurse ask during the health history interview to determine if the client is experiencing dissociative symptoms? "Are you experiencing difficulty sleeping?" "Do you startle easily since the event?" "Do you remember being forced to have sex?" "Have you experienced explosive anger since the event?"
"Do you remember being forced to have sex?"
After arriving to view a deceased client, the family asks why intravenous lines and tubes are still inserted into the body. Which response should the nurse make to the family? "The client had an advance directive for an autopsy and all tubes need to remain in place." "The tubes will be removed after you visit with the client." "I am waiting for a health care provider's order to remove the tubes and intravenous line." "The mortician requested that all tubes be left in place."
"The client had an advance directive for an autopsy and all tubes need to remain in place."
A nurse is assessing a client with posttraumatic stress disorder (PTSD). During the previous visit, the client reported severe sleep disturbances related to anxiety over anticipating nightmares. During the current visit, the nurse assesses that all signs of PTSD are still present, except that sleep has improved. The nurse knows that no medications have been prescribed to the client. Which is the most appropriate question for the nurse to ask? "Have you been taking drugs or alcohol recently?" "Have there been any changes in your diet recently?" "Do you still have dreams and nightmares associated with the event?" "How many hours do you sleep a day?"
"Have you been taking drugs or alcohol recently?" *Clients who have difficulty sleeping because of anxiety over anticipating nightmares usually end up using drugs and alcohol to improve their sleep. Therefore, the nurse should ask the client about the use of alcohol or other drugs. Asking about persistence of dreams and nightmares or about changes in diet is not warranted, as these changes negatively affect sleep quality and duration. The nurse has already obtained data about the degree of improvement in sleep quality and duration. Therefore, the nurse need not ask again about the number of hours slept daily.
A nurse is counseling a client who lost family members in a cyclone but has never had therapy related to the trauma. Which statement by the client suggests that the client is likely to develop posttraumatic stress disorder (PTSD)? "I don't know what to do without my family." "I feel lonely without my parents." "I am fine, I am going to move on." "I don't feel like eating without my son."
"I am fine, I am going to move on." *Following a traumatic event, people who tend to express their feelings and concerns with their family and friends tend to have less chances of developing PTSD. Therefore, clients who say that they are fine and are over the trauma are likely ignoring their feelings. This may increase the risk of developing PTSD. Clients who easily express feelings and talk about stressful, upsetting, or overwhelming events are less likely to develop PTSD. The clients who state that they cannot do anything without their family, feel lonely without them, or don't want to eat without them are expressing their feelings. Such clients usually acknowledge their feelings and tend to work on them to cope effectively.
A hospice nurse performs a follow-up telephone call to the spouse of a client who died about 1 year ago. The spouse tells the nurse, "I'm always feeling so sad. Life just doesn't feel worth living." Further conversation reveals that the spouse is having trouble sleeping and eating since her husband's death and that the spouse is "drinking more since he died." The nurse identifies which nursing diagnosis as the priority? Ineffective coping Complicated grieving Stress overload Grieving
Complicated grieving Complicated grieving is characterized by prolonged feelings of sadness and feelings of general worthlessness or hopelessness that persist long after the death, prolonged symptoms that interfere with activities, or self-destructive behaviors such as alcohol or substance abuse and suicidal ideation or attempts. Thus, the nursing diagnosis of complicated grieving would be the priority and most appropriate. Although the client may be having trouble coping or experiencing stress, complicated grieving is more applicable. Although there is no time table to denote grieving, the nursing diagnosis of grieving would be more appropriate in the period surrounding the husband's death, rather than 1 year later.
A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. The client states, "I miss my wife every day." The client states, "I have no interest in doing anything." The client attempted suicide 1 month ago. The client no longer indulges in usual activities. The client keeps a picture of the client's wife at the bedside.
The client states, "I have no interest in doing anything." The client attempted suicide 1 month ago. The client no longer indulges in usual activities.
What nursing interventions would most likely improve the therapeutic relationship between the nurse and the patient experiencing alcohol withdrawal? Encourage the pt to share any personal information only in group therapy. Refrain from outlining the tx regimen for the pt to prevent increased anxiety and potential insomnia. Set firm, strict limits to prevent manipulative behavior. Maintain healthy boundaries.
Maintain healthy boundaries.
A client has been diagnosed with a terminal illness and has periods of depression and periods of anger. The client's spouse is concerned, feeling as though their loved one is not moving forward in the stages of grief. What teaching is most appropriate for the nurse to include? Select all that apply. Movement back and forth between stages is expected. Anger follows depression in the stages of grief. Depression is not a stage in the grief process. Bargaining should occur between depression and anger. Movement between stages can be progressive.
Movement back and forth between stages is expected. Movement between stages can be progressive.
The nurse is reviewing the process recording of a school-aged client describing how the client felt about his or her mother's recent suicide. Which nursing interventions are appropriate to add to the plan of care? Select all that apply. Allow the client as much privacy as needed to grieve. Refer client to a support group for kids who have lost parents. State "So you are feeling pretty sad." Offer self by sitting with the client and allowing him or her to express his or her feelings. Encourage the pediatrician to prescribe an antidepressant. Sit directly across from and focused on the child.
Refer client to a support group for kids who have lost parents. State "So you are feeling pretty sad." Offer self by sitting with the client and allowing him or her to express his or her feelings. Sit directly across from and focused on the child.
The nurse caring for a client with posttraumatic stress disorder (PTSD) targets an approach consistent with trauma-informed care. The nurse works collaboratively with the client to achieve which outcome? Determine the client's symptoms of the condition. Understand the client's behaviors. Clarify the client's decisions that contributed to the trauma. Respect the client's meaning of the traumatic experience.
Respect the client's meaning of the traumatic experience. *Trauma-informed care requires the nurse to approach the client safely to avoid secondary trauma and to mindfully consider the circumstances of the client's traumatic experiences. One component of this intervention is to seek to understand the meaning of the traumatic experience for the client. The focus of trauma informed care is not on understanding behaviors or symptoms nor if there are actions that the client could have taken to avoid the traumatic experience.
The psychiatric mental health nurse will perform the initial assessment of a client who has just been diagnosed with posttraumatic stress disorder. Which area would the nurse most likely address first? Quantity and quality of the client's sleep Client's current coping strategies Client's use of drugs and alcohol Specific events of the trauma
Specific events of the trauma *Provided the client is willing, the nurse should begin the assessment by addressing the trauma. This should ideally precede other areas such as substance use, sleep, and coping.
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? Explain that the time of death could not be predicted. Stay with the family while they view the body. Discuss how the client is no longer in pain and is now at rest. Allow the family to feel guilty for leaving the client to die alone.
Stay with the family while they view the body.
A young adult client has been referred for assessment because of a recent history of hyperarousal and insomnia. What assessment findings would suggest a high likelihood of posttraumatic stress disorder (PTSD)? Select all that apply. The client states that the client never got high grades during school The client has unsuccessfully attempted rehabilitation for cocaine and alcohol abuse The client reveals that the client was sexually abused during elementary school The client relies on a close relative for shelter The client describes a biological sister as "a raging alcoholic"
The client describes a biological sister as "a raging alcoholic" The client has unsuccessfully attempted rehabilitation for cocaine and alcohol abuse The client reveals that the client was sexually abused during elementary school
The nurse is preparing a care plan for a client experiencing grief. What are the expected outcomes of a successful intervention? Select all that apply. The client will try to solve problems without any assistance. The client will develop healthy strategies for coping with loss. The client will recognize the negative effects of the loss on the client's life. The client will identify the meaning of the loss. The client will actively participate in social activities.
The client will develop healthy strategies for coping with loss. The client will recognize the negative effects of the loss on the client's life. The client will identify the meaning of the loss. The treatment for a client experiencing grief should help the client to understand the meaning and the impact of the loss on the client's life. The client should be able to use healthy coping strategies to cope with the loss. The client has had a loss and the nurse cannot expect the client to participate in social activities right away. Once the client has completed the process of grieving, these skills would be developed. The client should be encouraged to seek support throughout the grieving process.
When giving a community lecture about PTSD for clients and their families, a nurse will include which topic(s) for discussion? Select all that apply. Finding people who can assist with watching the client during stressful periods. Do not discuss smoking cessation techniques if the client is stressed Daily use of a sedative to assist with rest and sleep. Try to identify triggers that lead to re-experiencing the trauma. Trying various treatment options if one does not help.
Try to identify triggers that lead to re-experiencing the trauma. Trying various treatment options if one does not help.
Defense Mechanism: Identification
Unconscious modeling or patterning of oneself after another person whom one wants to be like. An attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires.
Disulfiram (Antabuse)
Used for alcohol aversion therapy. Clients started on Disulfiram must avoid any form of alcohol or they would develop a severe reaction. Teach pt to avoid some over-the-counter cough preparations, mouthwash etc.
A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's child tells the nurse, "I don't know what to say if my mother asks me if she is going to die." Which responses by the nurse are appropriate? Select all that apply "You are unfamiliar with what to say to your mother if asked about her dying?" "Tell me how you're feeling about your mother dying." "Let's talk about your mother's illness and how it may progress so you are prepared." "You sound like you have some questions about your mother dying. How can I help?" "Don't be concerned, hospice will take care of your mother."
You are unfamiliar with what to say to your mother if asked about her dying?" "Tell me how you're feeling about your mother dying." "Let's talk about your mother's illness and how it may progress so you are prepared." "You sound like you have some questions about your mother dying. How can I help?"
Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief? religious influences cultural influences socioeconomic factors cause of death
cultural influences
A client with a diagnosis of lung cancer is seen in the clinic for follow-up care. Which nursing interventions are essential to include in this client's plan of care to address grief? Select all that apply. Urge the client to continue a usual routine. Encourage participation in religious rituals. Help the client establish coping strategies. Promote good nutrition and sleep habits. Assist the client to form a support system.
Help the client establish coping strategies. Promote good nutrition and sleep habits. Assist the client to form a support system. Encourage participation in religious rituals. Nursing interventions used to help clients move through grief include helping the client mobilize a support system. The nurse can also help the client establish coping behaviors used in the past. Other interventions to include when helping clients move through grief are promoting good nutrition and sleep habits. The nurse should encourage the client to participate in religious rituals that are important to him. The nurse should not urge the client to continue his usual routine because it may not include healthy behaviors. For example, the nurse should not encourage use of alcohol, drugs, and caffeine during the grief process.
A nurse finds that a client with posttraumatic stress disorder (PTSD) is behaving abnormally and suspects that the client has had a flashback of the traumatic event. Which behavioral manifestations of the client would lead the nurse to make this interpretation? Select all that apply. The client complains of severe pain. The client attempted to run away. The client appears terrified. The client looks extremely fatigued. The client is crying loudly.
The client attempted to run away. The client appears terrified. The client is crying loudly.
The nurse is caring for a client with posttraumatic stress disorder (PTSD). After entering the client's room, the nurse finds that the client is having a flashback episode. Which leads the nurse to reach this conclusion? Select all that apply. The client curls up in a defensive posture. The client appears numb with a vacant stare. The client wakes up suddenly from sleep. The client appears terrified. The client is crying and screaming.
The client curls up in a defensive posture. The client appears terrified. The client is crying and screaming.
A nurse is caring for a terminally ill client. The nurse assesses the client for identification of the psychosocial stage of acceptance. Place the five stages of death and dying in the order in which Elisabeth Kübler-Ross noted that they most often occur. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1anger 2depression 3bargaining 4denial and isolation 5acceptance
denial and isolation anger bargaining depression acceptance
The spouse of a client nearing death states, "She has been my whole life, I don't think I can go on without her". What is the appropriate response by the nurse? 1.You are a strong person and you will be able to carry on. 2.Tell me more about your concern that you cannot go on without her 3.Losing someone is always difficult, but it will get easier with time 4.Tell me more about hose many years you have shared with her
2.Tell me more about your concern that you cannot go on without her. :)
Which intervention should a nurse perform during the grieving period when caring for a dying client? Allowing a period of privacy Avoiding criticizing or giving advice Spending time with the client Providing palliative care
Avoiding criticizing or giving advice The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not the required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.
