PrepU Basic Psychosocial Needs
The nurse is caring for a client with a terminal illness who is awaiting transfer to hospice. The client states, "It is all out of my hands now." How should the nurse respond? "I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" "Are you feeling like you do not have control? Would you like to discuss the planned transfer to hospice?" "I hear you saying you do not feel in control. What coping technique do you usually use when feeling this way?" "Change and transition can be challenging. We are here to support you. What can I do now to help?"
Correct response: "I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" Explanation: The client has a complex situation involving both a transfer to a new area of care and facing a terminal illness. While the nurse may have the focus of preparing the client for transfer to a new care area, this may not be the client's primary concern. Assuming the client's comment is related to the transfer could impede exploration of the client's actual reason for the comment. The priority is to clarify the comment's meaning before offering to explore coping strategies or how the nurse can help.
The client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which response by the nurse is most appropriate? "You're being very childish." "Come back tomorrow, and your medication will be ready." "I'm sorry if you can't wait." "I won't continue to talk with you if you curse."
Correct response: "I won't continue to talk with you if you curse." Explanation: Stating "I won't continue to talk with you if you curse" sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement "You're being very childish" reprimands the client, possibly causing the anger to escalate. The statement "I'm sorry if you can't wait" fails to provide feedback to the client about her behavior. The statement "Come back tomorrow, and your medication will be ready" ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.
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." "Could I call the health care provider for you?" "This is a normal response to the loss of a loved one." "Would you like me to call your spouse?"
Correct response: "I would like to sit with you and talk about your child." Explanation: This choice is the focused therapeutic response that would generate client-focused discussion. Calling someone else is not client focused and nursing intervention based. Stating that this is a normal response is nontherapeutic, and calling the health care provider is incorrect because the it is within the nurse's scope of practice to resolve this issue.
A teen client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression? "Sleep shouldn't be too much of a problem, because the baby will soon start to sleep through the night." "Since I'm breastfeeding, I can eat all the food I want and not feel fat. The baby will use all the calories." "If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." "I'm going to give the baby the best care possible without asking anyone for help to show all those people who think I can't do it."
Correct response: "If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." Explanation: Feelings of guilt combined with a lack of self-care (not eating or sleeping enough) can predispose a new mother to postpartum depression, especially one who has had previous episodes of depression. Sleep is essential to both the mother and baby, but sleeping through the night does not usually occur in the first few weeks after birth. While breastfeeding mothers do need good nutrition, unlimited eating after childbirth may inhibit the return to a normal weight and could create depression in a new mother, especially a vulnerable one. Attempting to care for an infant with no help from others is likely to cause stress that could lead to depression, especially in an adolescent.
A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse? "People with strong beliefs have better outcomes." "Think about your leader when you have moments of doubt." "It's good to have something to believe in." "It sounds like that offers you a sense of security."
Correct response: "It sounds like that offers you a sense of security." Explanation: Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.
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? "Think about your leader when you have moments of doubt." "It's good to have something to believe in." "People with strong beliefs have better outcomes." "It sounds like that offers you a sense of security."
Correct response: "It sounds like that offers you a sense of security." Explanation: Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.
A client says to a nurse, "I know I am going to die." How should the nurse respond? "Tell me more about what you mean when you say you know you are going to die." "I hear that you are afraid of dying. I can reassure you that your condition is stable now." "It sounds like you are worried about dying. This is common for people in hospital." "I hear you telling me you are afraid. What can I do to help you feel more secure?"
Correct response: "Tell me more about what you mean when you say you know you are going to die." Explanation: Asking the client to share more information about why the client thinks he or she is going to die is a therapeutic approach that reflects on the client's comments and focuses on the client's specific words. Telling the client that these feelings are common or that the client is doing quite well do not facilitate further exploration of the client's feelings. Such statements offer false reassurance and ignore the client's needs. The client did not mention being afraid and asking what the nurse can do focuses the client on the nurse instead of opening a dialogue into the feelings behind the client's statement.
A seriously ill client asks the nurse "Am I dying?" What is the best response the nurse can give to enhance therapeutic communication with this client? "This must be very difficult for you. What is on your mind?" "Let's not worry about that right now. Let me give you this bed bath." "Yes. But there is nothing to worry about since you will be going to a better place." "I do not know. I hope not."
Correct response: "This must be very difficult for you. What is on your mind?" Explanation: The most therapeutic response the nurse can offer would be to validate the client's concerns and fears, and follow that with an open-ended question to allow the client to communicate his or her thoughts, such as "This must be very difficult for you. What is on your mind?" The nurse should avoid making unhelpful responses that minimize the client's concerns or dismiss the client's fears and concerns, such as "Let's not worry about that right now." Or "I do not know, I hope not." Even though the client's desire to talk about these issues may come at the inconvenient time for the nurse, such as when the nurse needs to give medications or a bath, the nurse should make every effort to listen and communicate empathetically when the client desires to talk about these issues. Statements that dismiss the client's concerns and make assumptions regarding religious beliefs should also be avoided, such as "There is nothing to worry about since you will be going to a better place."
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? "How is it best for you to approach your boss?" "What have you done so far to try to solve this problem?" "What are your alternative plans at this time?" "When is the best time of day to approach your boss?"
Correct response: "What have you done so far to try to solve this problem?" Explanation: To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.
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?" "How is it best for you to approach your boss?" "What are your alternative plans at this time?" "When is the best time of day to approach your boss?"
Correct response: "What have you done so far to try to solve this problem?" Explanation: To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.
A client admitted for investigation of a tumor asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic? "Your healthcare provider can tell you more about that." "Tumors are very common and not always cancerous." "We won't know for sure until you undergo some tests." "You sound concerned about what the tests results might be."
Correct response: "You sound concerned about what the tests results might be." Explanation: This response allows the client to express the client's feelings and promotes further discussion. Referring the client to the healthcare provider ends the discussion and prevents exploration of the client's feelings. Generalizing about tumors shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he won't get the right care if he gets sick at college." What is the nurse's best response? "I can have his records sent to the school's health center." "Your son is going to need to learn to manage his own disease." "Make sure your son always carries his nephrologist's phone number." "Your son can make an electronic history to facilitate his care if he gets sick away from home."
Correct response: "Your son can make an electronic history to facilitate his care if he gets sick away from home." Explanation: Access to a well-constructed electronic history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary, and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern.
A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do? Tell the client that it would be best if she did not see the baby. Contact the health care provider for advice related to the client's visitation. Allow the client to see the baby through the nursery window. Allow the client to see and hold the baby for as long as she desires.
Correct response: Allow the client to see and hold the baby for as long as she desires. Explanation: The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the health care provider and social worker.Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client.Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby.Contacting the health care provider for advice related to the client's visitation is not necessary.
A 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? Refer the client to the dietician. Assess the parent's ability to read. Obtain a social service consult. Notify the health care provider (HCP).
Correct response: Assess the parent's ability to read. Explanation: Three severe reactions in 3 months indicate a serious problem with adhering to the prevention plan. The nurse should first determine if the parent can actually read the label. The underlying problem may be that the parent is visually impaired or unable to read. The parent's reading level determines what additional support is needed. Referrals to social service or dietary may be indicated, but the nurse does not yet have enough information about the problem. The nurse would communicate with the HCP after assessing the situation to recommend referrals.
The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. What is the nurse's role in this situation? Assist the client in obtaining information to make an informed decision. Encourage the client to pray for clarity on the matter and offer support. Provide examples of ways clients handle spiritual and care planning conflicts. Inform the client's healthcare provider of the client's concerns.
Correct response: Assist the client in obtaining information to make an informed decision. Explanation: The nurse's role in resolving conflicts between spiritual beliefs and treatments is to assist the client in obtaining the information needed to make an informed decision and to support the client's decision making. Telling the client to pray does not assist the client in the decision-making process. The healthcare provider does not manage client decisions when it comes to spiritual beliefs. Offering examples of other clients does not help this client.
Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills? The code of ethics challenges nurses to practice in an ethical and caring way. There are many subcultures in our country, and it is important to know about these cultures and their practices. Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care. It is important to facilitate the process of acculturation for people of different cultures.
Correct response: Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care. Explanation: Becoming sensitive to clients of different cultural backgrounds is necessary in order to provide ethical care. In addition, nurses must develop cultural competency to care for these clients effectively. People of different cultures make the decision of acculturation or preservation of their own culture. A nurse cannot be familiar with beliefs of all subcultures; however, it is important to have a framework for better understanding and appreciating persons from different cultures. Codes of ethics challenge nurses to provide ethical care, but this does not explain the relationship between ethical care and culturally sensitive care.
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? Explore the client's obsessive thoughts that are resulting in high anxiety. Ask the client about plans for managing the financial obligations. Determine the client's ability to cope with the job loss and family obligations. Interview family members to determine the dynamics of the family relationships.
Correct response: Determine the client's ability to cope with the job loss and family obligations. Explanation: The client is experiencing stressors that are making it difficult to cope, resulting in anxiety. It is important to assess the client's coping abilities related to the job loss and meeting family obligations. This situation could become a crisis if it overwhelms the client's usual methods of coping. The client is a single parent, which also adds the burden of childcare. The client is not concerned about the family dynamics or obsessive thoughts. Responding to the client's cues is vital in addressing the client's concerns.
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? Explore the client's obsessive thoughts that are resulting in high anxiety. Interview family members to determine the dynamics of the family relationships. Determine the client's ability to cope with the job loss and family obligations. Ask the client about plans for managing the financial obligations.
Correct response: Determine the client's ability to cope with the job loss and family obligations. Explanation: The client is experiencing stressors that are making it difficult to cope, resulting in anxiety. It is important to assess the client's coping abilities related to the job loss and meeting family obligations. This situation could become a crisis if it overwhelms the client's usual methods of coping. The client is a single parent, which also adds the burden of childcare. The client is not concerned about the family dynamics or obsessive thoughts. Responding to the client's cues is vital in addressing the client's concerns.
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. Tell the infant that it will be over within a minute. Provide the infant with soft toys or a feeding bottle. Ask a child specialist to be present during treatment.
Correct response: Encourage parents to be present during the treatment. Explanation: When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child.
Which would be most helpful when coaching a client to stop smoking? Review the negative effects of smoking on the body. Establish the client's daily smoking pattern. Explain how smoking worsens high blood pressure. Discuss the effects of passive smoking on environmental pollution.
Correct response: Establish the client's daily smoking pattern. Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.
A 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? Contact the client's minister to discuss the client's options related to the pregnancy. Explore the nurse's own feelings about the issues of anencephaly and organ donation. Advise the client that the prolonged neonatal death will be very painful for her. Ask the client if her family agrees with her decision.
Correct response: Explore the nurse's own feelings about the issues of anencephaly and organ donation. Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some infants with anencephaly live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse may have a strong reaction to the client's decision, so to support taking a nonjudgmental stance, the nurse should explore his or her own feelings about the issue of anencephaly and organ donation. The nurse try to persuade the client to terminate the pregnancy or imply that this would be a better course. Contacting the client's minister to explore the client's options is not appropriate; the client may have already discussed the matter with her minister or may not be religious. Telling the client that the neonatal death will be prolonged and painful to her is not helpful and may also be inaccurate, as death may occur very soon after birth. Contacting the client's family members is not appropriate, as the client may wish not to discuss the matter with her family.
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. Ask the client if her family agrees with her decision. Contact the client's minister to discuss the client's options related to the pregnancy. Advise the client that the prolonged neonatal death will be very painful for her.
Correct response: Explore the nurse's own feelings about the issues of anencephaly and organ donation. Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some infants with anencephaly live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse may have a strong reaction to the client's decision, so to support taking a nonjudgmental stance, the nurse should explore his or her own feelings about the issue of anencephaly and organ donation. The nurse try to persuade the client to terminate the pregnancy or imply that this would be a better course. Contacting the client's minister to explore the client's options is not appropriate; the client may have already discussed the matter with her minister or may not be religious. Telling the client that the neonatal death will be prolonged and painful to her is not helpful and may also be inaccurate, as death may occur very soon after birth. Contacting the client's family members is not appropriate, as the client may wish not to discuss the matter with her family.
An elderly client with primary degenerative dementia is slow in following simple directions and is indecisive selecting clothes to be worn for the day. What is the best approach for the nurse to take? Time limit the indecision and let the client know that activities of daily living need to be completed faster. Allow the client to select from the outfits and minimize other distractions in the environment. Give the client the opportunity to select from two outfits and cue follow-through instructions. Pick an outfit and assist with dressing because the client is too distracted to complete this activity without help.
Correct response: Give the client the opportunity to select from two outfits and cue follow-through instructions. Explanation: Dementia results in an impairment of abstract thinking and in decision making. As much as possible, it is important to give simple choices and to cue the client to follow through because of the memory lapses. Giving too many choices makes it difficult to make a decision. Giving no choice takes away any decision making opportunities.
A client expresses a desire to discuss spiritual and religious beliefs with someone. What is the best nursing intervention at this point? Tell the client to speak with family members or friends. Ask if the client would like to speak with the nurse daily. Begin meeting as often as the client likes to discuss spirituality. Interview the client further to gather more details.
Correct response: Interview the client further to gather more details. Explanation: A thorough assessment is the initial step in providing nursing care of any type. Asking if the client wants to speak to the nurse daily or discussing spirituality with the client are not forms of assessment. Telling the client to speak to family members or friends about spirituality shifts the focus and removes the nurse's responsibility to the client.
A nurse 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? The in-laws offer the only opportunity to obtain social support for the client. Strong social support is of relatively little importance as a coping factor. Low-quality support relationships often negatively affect coping in a crisis. The relationship with the in-laws can enhance the client's sense of control.
Correct response: Low-quality support relationships often negatively affect coping in a crisis. Explanation: Strong social support enhances mental and physical health, providing a significant buffer against distress. Relationships of low-quality support are known to impact a person's coping effectiveness negatively.
A single parent has only one child. The parent shares dreading the fall when the child leaves for college. Which type(s) of loss is this client likely to experience? Select all that apply. Situational loss Psychological loss Maturational loss Actual loss Perceived loss Anticipatory loss
Correct response: Perceived loss Psychological loss Maturational loss Anticipatory loss Explanation: This client would be experiencing perceived, psychological, maturational and anticipatory losses. This situation describes one of a perceived and psychological loss rather than an actual loss, as the child is not dying or leaving forever. The parent just perceives a change in relationship. This is a classic maturational loss scenario, as it is a result of the normal development process. As the parent knows about this loss prior to it happening, the parent is anticipating the loss and therefore experiencing anticipatory loss also. Actual loss is a loss that can be recognized by others as well as the person suffering the loss, such as the loss of a limb, loss of a child, money or job. Perceived loss is felt by the person, but intangible to others, such as loss of youth, financial status or a valued environment. Physical and psychological losses are directly related to actual and perceived losses. Physical loss involves the loss of something tangible such as a limb or job, and psychological loss involves the altered self-image and inability to return to a previous job due to the loss of a limb or other loss. These losses are simultaneous. Situational loss is experienced as a result of an unpredictable event, such as a traumatic injury, disease, death or natural disaster. Anticipatory loss occurs when a person displays loss and grief behaviors before the loss has taken place, such as client with cancer mourning the loss of her hair before it occurs. Maturational loss is experiences as a result of natural development processes, such as the loss a parent experiences when sending a child to kindergarten or college, or the loss a first child experiences when a sibling is born.
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. Arrange for the family to view the body. Direct the family to the funeral home. Provide emotional support. Expect the family to express grief. Serve as an attentive listener.
Correct response: Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body. Explanation: Postmortem care of a client includes care of the family. When a client dies, the family needs emotional support. The nurse serves as an attentive listener and should expect the family to express grief. Part of this care is preparing the client so the family can view the body. The nurse should not direct the family to the funeral home. The family should not have to wait to view the body; plans can be made for the viewing to occur in the care facility.
A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? Instruct the client in methods for low-cost, highly nutritious meal preparation. Determine whether the client qualifies for local assistance programs. Ask the client if she has a job and the amount of income earned. Refer the client to a social worker for enrollment in a food assistance program.
Correct response: Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program.Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's needs for additional funds for food.Determining whether the client qualifies for government assistance is part of the role of the social worker, not the nurse.Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.
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. Appeal to the client's best friend to stay and act as the interpreter. Request that a health related interpreter to come to the home. Use the oldest child as the interpreter during the home visits. Ask the client's spouse to be the interpreter during each visit. Utilize a trained telephone interpreter while providing care.
Correct response: Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care. Explanation: When speaking with a client that does not speak the dominant language, the nurse should use a trained interpreter. If an on-site interpreter is unavailable, the nurse should other methods including bilingual staff, webcam, or telephonic interpreting. Family and friends should be avoided as interpreters as they may be protective of the client or not agree with the treatments offered and therefore not the most reliable translators.
An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is Potential for Enhanced spiritual well-being related to distress at missing Methodist church services. Spiritual distress related to inability to attend church services evidenced by verbal states of guilt. Spiritual need as evidenced by verbalization and distress at missing Methodist church services. Dysfunctional grieving related to inability to attend church services as a result of the client's medical condition.
Correct response: Spiritual distress related to inability to attend church services evidenced by verbal states of guilt. Explanation: People with Spiritual dysfunction or Spiritual distress may verbalize such distress or express a need for help.
A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which is the most appropriate step for the nurse to take to help the client? Support the client in developing attainable socialization goals. Refer the client to special interest clubs for newcomers. Have the client plan a social activity for the upcoming weekend. Model culturally appropriate interactional skills.
Correct response: Support the client in developing attainable socialization goals. Explanation: Supporting the client in goal-setting around social interaction is the first step in promoting change for wellness. Merely referring a client to a social activity is only a short-term solution, and may not be an intervention desired by the client. Modeling is important; however, interactional skills are individualized and must be authentic to be successful for the client. Suggesting solutions such as planning a specific activity with anyone is not appropriate to social wellness.
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 suggests that the client has a premonition about dying soon and needs to talk about it. The client should be placed on suicide precautions and seen by a psychiatrist. The request is age appropriate and should be honored. The client is depressed and should be watched for further signs of depression.
Correct response: The request is age appropriate and should be honored. Explanation: Given the client's age, making final plans is age appropriate. The absence of any signs of ill health, depression, or suicidal ideation makes the other options inappropriate.
The nurse is preparing written information for an older adult who is to manage intermittent self-catheterization. Which strategy will be most effective? Prepare information at an tenth-grade reading level. Use short words. Use charts to help convey information. Print the material in a condensed font.
Correct response: Use short words. Explanation: The nurse should use short words, sentences, and paragraphs and avoid medical jargon. Correct terminology should be used when appropriate (e.g., type 1 diabetes, not "sugar diabetes"). The format should be as simple as possible; charts are not necessary and may be confusing to some clients. Information should be prepared at a fifth-grade reading level. The information should be presented in large-sized type.
A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply. reading aloud Bible passages that relate to the client's needs identifying current or past spiritual supports offering to pray with the client to help resolve the conflict asking the client about original spiritual beliefs exploring factors that are creating conflict with client's beliefs
Correct response: asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs Explanation: The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonable for the nurse to explore the client's faith origins as well as what the usual sources of spiritual support were or are. Commonly, a hospitalized client is separated from those of common faith practices so this should be explored. The nurse can also carefully explore what is contributing the challenges to faith the client is expressing. The scenario does not state that the client is Christian so reading from the Bible is an assumption by the reader, first. Second, the nurse would not take the step of reading to the client from a religious text unless this was a direct request by the client. Nurses should also not offer to pray with the client but should only engage in this if directly asked and if this is something the nurse is comfortable with.
A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? reassuring the client that such pain is normal after vaginal birth administering additional pain medications preparing a warm sitz bath for the client assessing the perineum
Correct response: assessing the perineum Explanation: Pain after childbirth is generally well managed with pain control medications; since they did not help this woman, further assessment is necessary. The first nursing action would be to assess the source of the pain; the woman may have sustained a laceration or a hematoma as a result of childbirth. Assessing the perineum may help the nurse to determine the source of the pain and may require follow-up by the health care provider (HCP) . Subsequent nursing interventions may include pain medication, sitz bath, or education regarding the healing process.
A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? assisting the client with bathing and dressing by giving clear, simple directions drawing up a schedule and making certain that it is adhered to bathing and dressing the client each morning until the client is willing to perform self-care independently devising a bathing and dressing schedule for each morning SUBMIT ANSWER
Correct response: assisting the client with bathing and dressing by giving clear, simple directions Explanation: This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required.
A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss? history of breast cancer in the family concerns regarding the cancer and how the surgery will affect the client impact of surgery on the family's coping abilities how body image changes will affect the client's sexual activity
Correct response: concerns regarding the cancer and how the surgery will affect the client Explanation: The primary concerns to address at this time are the effect on the client of the diagnosis of cancer and the impending mastectomy. The other choices are also appropriate to address but are not the priority at this time.
A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss? history of breast cancer in the family impact of surgery on the family's coping abilities concerns regarding the cancer and how the surgery will affect the client how body image changes will affect the client's sexual activity
Correct response: concerns regarding the cancer and how the surgery will affect the client Explanation: The primary concerns to address at this time are the effect on the client of the diagnosis of cancer and the impending mastectomy. The other choices are also appropriate to address but are not the priority at this time.
Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what? cultural imposition cultural assimilation cultural blindness stereotyping
Correct response: cultural blindness Explanation: Cultural blindness is characterized by ignoring cultural differences or considerations and proceeding as if they do not exist. This phenomenon may underlie the failure to incorporate cultural considerations into dietary choices. Stereotyping assumes homogeneity of members of other cultures while cultural assimilation involves the replacement of values with those of a dominant culture. Cultural imposition presumes that everyone should conform to a majority belief system.
The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply. freedom from coercion discussion of pertinent information verification from next of kin caregiver preference and opinion the client's agreement to the plan of care
Correct response: discussion of pertinent information the client's agreement to the plan of care freedom from coercion Explanation: Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin.
The client is Asian and non-English speaking. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom? pain constipation hunger depression
Correct response: pain Explanation: The client may be describing symptoms of pain. Culture specific symptoms for "feeling bad" include numbness, thinking too much, feeling hot under the skin. Asian clients may describe pain in terms of Yin and Yang (hot and cold). Nurse's knowledge of pain associated with health problems is necessary to assist this client manage pain. Clients from some cultures may associate mental health symptoms with evil spirits and will not report them as being unusual. Clients from Asian cultures may not describe symptoms locally but in a diffuse fashion.
A 65-year-old client's only son lives 500 miles (800 km) away. For which reason is the client at higher risk for psychosocial distress? The client: is able to use denial as a coping mechanism. does not have to deal with other stressors right now. perceives having minimal social support. has been successful in dealing with stress throughout life.
Correct response: perceives having minimal social support. Explanation: The person who has minimal social support, has not been successful in dealing with stressors, and has multiple other stressors is at greater risk for psychosocial distress. Being successful in dealing with stress throughout life would decrease the client's risk for psychosocial distress. Not having to deal with other stressors would be helpful in managing the current stressful situation. The denial coping mechanism, if used for short periods, can decrease the risk for psychosocial distress.
In working with a rape victim, which intervention is most important? telling the client that the rapist will eventually be caught, put on trial, and jailed recommending that the client resume sexual relations with her partner as soon as possible continuing to encourage the client to report the rape to the legal authorities periodically reminding the client that she did not deserve and did not cause the rape
Correct response: periodically reminding the client that she did not deserve and did not cause the rape Explanation: Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted.
The nurse is counseling the family of an older adult who died today. Which factor facilitates attainment of a positive bereavement outcome? being a teenager being a spouse possessing adequate financial resources having a history of anxiety
Correct response: possessing adequate financial resources Explanation: Having adequate financial resources facilitates bereavement. Younger people are at higher risk for negative bereavement outcomes. Having a history of depressive illness or anxiety is a risk factor for negative bereavement outcomes. Being a spouse does not make grieving easier.
The nurse is counseling the family of an older adult who died today. Which factor facilitates attainment of a positive bereavement outcome? being a teenager possessing adequate financial resources having a history of anxiety being a spouse
Correct response: possessing adequate financial resources Explanation: Having adequate financial resources facilitates bereavement. Younger people are at higher risk for negative bereavement outcomes. Having a history of depressive illness or anxiety is a risk factor for negative bereavement outcomes. Being a spouse does not make grieving easier.
The nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors? responsible drinking patterns motor vehicle accidents effects of cigarette smoking preventative vaccinations
Correct response: preventative vaccinations Explanation: Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults.
A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? reassuring the client by telling her that surgery is a common procedure telling the client not to be afraid. providing the client with information about what to expect postoperatively stressing the importance of following the health care provider's (HCP's) instructions after surgery
Correct response: providing the client with information about what to expect postoperatively Explanation: Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.
A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? telling the client not to be afraid. providing the client with information about what to expect postoperatively reassuring the client by telling her that surgery is a common procedure stressing the importance of following the health care provider's (HCP's) instructions after surgery
Correct response: providing the client with information about what to expect postoperatively Explanation: Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.
A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? telling the client not to be afraid. reassuring the client by telling her that surgery is a common procedure providing the client with information about what to expect postoperatively stressing the importance of following the health care provider's (HCP's) instructions after surgery
Correct response: providing the client with information about what to expect postoperatively Explanation: Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.
A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. What best protects the client's right to self-determination? revisiting the decision when the uncle is not present at the bedside holding a family meeting and encouraging the client to speak on her own behalf respecting the client's desire to have the uncle make choices on her behalf teaching the client about her right to autonomy
Correct response: respecting the client's desire to have the uncle make choices on her behalf Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.
A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of what? libel slander negligence assault
Correct response: slander Explanation: Slander involves words communicated verbally to a third party that harm or injure the personal or professional reputation of another person. The other options do not define the situation described in the question.
A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? pharmacist social worker dietitian infection control nurse
Correct response: social worker Explanation: The social worker is the most essential team member to be involved in discharge planning to meet the client's needs and offer suggestions for the best community resources.There is no indication that the client should follow a special diet, so a dietitian is not needed at this time.The pharmacist may be consulted to teach the client about taking medications, but the focus of the care conference is planning for discharge to the community.The infection control nurse should follow up with teaching about preventing the spread of the disease after discharge.
A nurse has attended an in-service workshop to address the phenomenon of ageism in the healthcare system. Which practice is indicative of ageism? assessing the skin turgor of older adults differently than for younger adults providing slightly smaller servings of food for clients who are elderly implementing falls prevention measures in a setting where older adults receive care speaking to older adults in a way one would with clients who have mild cognitive deficits
Correct response: speaking to older adults in a way one would with clients who have mild cognitive deficits Explanation: Accommodation of normal, age-related changes such as decreased skin turgor and slightly decreased nutritional needs is not an indication of ageism. Similarly, safety measures are unlikely to be motivated by ageist beliefs. Assuming that all older adults have cognitively deficits, however, is an indication of ageism.
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 guilt spiritual alienation spiritual anger spiritual loss
Correct response: spiritual alienation Explanation: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.
Which factor is a priority when evaluating discharge plans for an older adult after a lower left lobectomy for lung cancer? the distance the client lives from the hospital the client's knowledge of the causes of lung cancer the client's ability to do home blood pressure monitoring support available for assisting the client at home
Correct response: support available for assisting the client at home Explanation: Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support for assistance and self-care at home. If the client has support at home, the distance from the hospital may be irrelevant. The client or support team will monitor vital signs as needed, but blood pressure monitoring is not specifically indicated. It is more important at this point for the client to understand how to manage his care at home, rather than knowing the causes of lung cancer.
When preparing for a spiritual counselor to visit a hospitalized client, the nurse should ask the spiritual counselor to summarize the visit in the client's medical record. take measures to ensure privacy during the counselor's visit. ensure that the hospital administration approves the counselor. ask to be present during the visit to explain any medical information or answer questions about the client's care.
Correct response: take measures to ensure privacy during the counselor's visit. Explanation: Visits between a client and a spiritual counselor require privacy. The details of the meeting are not typically documented in the client's chart, though the fact that the visit took place is often noted. The nurse may be present during the meeting but this should take place at the client's request. Spiritual counselors do not require administrative approval; clients and their families are normally able to seek spiritual help from whomever they prefer.
Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? engaging in physical activity talking with the nurse playing a card game with other clients keeping track of feelings in a journal
Correct response: talking with the nurse Explanation: Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.
A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling? whether the client is receiving palliative care measures or is approaching end of life the degree of alignment between the client's spiritual beliefs and those held by the nurse the family's wishes related to their involvement in the client's spiritual practices the nurse's comfort and knowledge level related to the process of spiritual counselling
Correct response: the nurse's comfort and knowledge level related to the process of spiritual counselling Explanation: A nurse who feels competent to counsel the client may assist the client in achieving spiritual goals through spiritual counselling. The level of ability of the nurse to perform in this role is not directly related to the level of congruence between the nurse's beliefs and that of the client; people of all faiths are permitted to counsel those of others. The nurse would consider the client's condition when offering counselling, but this is not the most important factor--the nurse's abilities are. Family involvement may be necessary, but this would be determined by the nurse asking the client's preference rather than being based on the family's preference.
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? when making decisions about her care alone and not in combination with other defense mechanisms to permit her mother to seek unconventional treatments to allow her mother to continue in her role as a mother
Correct response: to allow her mother to continue in her role as a mother Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation.
In which situation can a client's confidentiality be breached legally? in a student nurse's clinical paper about a client when a client near discharge is threatening to harm an ex-partner to answer a request from a client's spouse about the client's medication when a client's employer requests the client's diagnosis to initiate medical claims
Correct response: when a client near discharge is threatening to harm an ex-partner Explanation: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.