PrepU Passpoint Basic Psychosocial Needs
A 10-year-old child with sickle cell anemia continues to wet the bed at night. The child feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which response by the nurse would be most appropriate?
"A bladder training program may help to decrease nighttime wetting." Explanation: About half of all children with sickle cell anemia have problems with enuresis because the kidneys are damaged and can no longer concentrate urine. Bladder training programs may improve the situation. Restricting fluids in someone with sickle cell anemia can lead to a vaso-occlusive crisis. Suggesting that friends sleep over at the child's house does not show an understanding of the child's feelings.
The parents of a child who is dying of leukemia ask a nurse about the family participating in the care of the child. What would be the best response by the nurse?
"We encourage all members of the family to be as involved with the care as desired and comfortable." Explanation: Families of terminally ill children should be encouraged to be involved in all aspects of the child's care no matter what type of facility the child is receiving care in. This should be on their own terms and within their own comfort level. All responses are technically correct but the most correct validates the level of comfort and desire with the provision of care.
An 18-year-old client who died in a car accident has an organ donation card consenting to donate both kidneys. Which nursing action is done immediately after the client is pronounced dead?
Contact the organ procurement organization (OPO). Explanation: An organ donation card is considered a legal consent; therefore, there is no need to ask the family for consent. The OPO should be contacted to determine if the client is a candidate for donation and if the client has legal consent. Procurement and transplantation is done by the OPTN, not the doctor at the hospital. The OPTN is contacted, but after an initial evaluation has been done by the OPO and a determination made that the client is a donor and is eligible to donate.
A father arrives in a busy emergency department and is upset with his wife for bringing their two-year-old child with epiglottitis in for treatment. Which intervention by the nurse is best?
Recognize the father's behavior as his attempt to cope with the situation. Explanation: Lack of control over his child's situation has resulted in irrational behavior by this father. The nurse should try to calm both parents and let them know they did the right thing due to the seriousness of their child's situation. Leaving the room, calling for security, or sending the parents out won't help the child, nor will it reduce frustration or inappropriate behavior.
A client at an inpatient psychiatric unit suddenly becomes loud and visibly anxious. What is the best action for the nurse to take?
Say to the client, "Let's go talk in your room." Explanation: When the nurse suggests they talk in the client's room, the nurse acknowledges that the client is important and preserves the client's dignity with minimal restriction. Calling for help to escort the client to his/her room is inappropriate because the client has not yet been given a chance to go alone. The nurse should use the least restrictive form of treatment at all times. Facing the client and demanding quiet is not appropriate because it challenges the client. Telling the client to calm down because the client is safe is a placating response that will likely increase the client's anxiety.
A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply.
Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care. 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.
A client is being seen in the emergency department and starts speaking in language not spoken by nursing staff. What is the nurse's first intervention?
Seek out a facility-approved translator. Explanation: When a client is seeking care from a facility, it is imperative that translation services are available for those who do not speak the area's dominant language. This ensures that the client understands procedures, medication, and care within the facility. Using sign language or hand gestures will not help the client understand the services. Finding another nurse is an option; however, that can disrupt care of others. Calling local multicultural sites such as clinics is not effective or reliable.
A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which nursing intervention would be most appropriate?
Suggest methods and measures that conserve energy. Explanation: Sexual dysfunction in clients with COPD is the direct result of dyspnea and reduced energy levels. Measures to reduce physical exertion, enhance oxygenation, and accommodate decreased energy levels may aid sexual activity. If the problem persists, a consult with a sex therapist might be necessary. A gynecologic consult isn't necessary. Discussing this with her husband may not resolve the problem.
The nurse is caring for a client with dementia that has a tendency to wander into other client areas, posing a safety risk for the client and others. Which method would be most beneficial for this client to promote safety that is the least restrictive?
Use an electronic monitoring system. Explanation: The goal of care for clients with dementia is to maintain the highest level of functioning. When restraints must be used, the least restrictive type of restraint possible should be used. A lap tray over a wheelchair severely limits the client's mobility and can cause injury if the client tries to get out of the wheelchair. A recliner with a sheet tied around the client is restrictive and a form of restraint. Four side rails elevated are a form of restraint and the client may climb over the rails to get out. An electronic monitoring system is an effective way of managing a client who wanders.
A hospitalized client notes difficulty resting. Which intervention would help promote rest?
assisting the client with deep-breathing exercises Explanation: Deep-breathing exercises are beneficial to promoting rest because they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. Although sedatives may be used occasionally for assistance with rest, regular use is not advised because dependence may develop.
A child who is hospitalized with a fractured left arm, a concussion, and multiple bruises in various stages of healing appears withdrawn. Emergency department staff report suspected child abuse to the authorities. Which behavior does the nurse anticipate observing in the child?
acting quietly and passively about the pain Explanation: Children who are victims of abuse usually show little emotion. Crying and acting sensitive to the pain, being happy to see new people, and maintaining good eye contact with the parents are conspicuous behaviors that an abused child would typically avoid for fear of provoking further abuse.
A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on life with satisfaction. According to Erickson, which stage is this client currently experiencing?
ego integrity. Explanation: An adult at age 74 is in the stage of ego integrity versus despair. Intimacy, ego identity, and industry all apply to earlier stages of development.
A client lives with a parent and the client's three children. Which type of family does this describe?
extended Explanation: An extended family consists of the biological or adoptive parents and one or more grandparents or other family members living together. A nuclear family consists of a husband, wife, and children. A dysfunctional family is one that demonstrates unhealthy relationship problems among family members. A blended family is one in which children from previous marriages live together.
A client states, "I am stressed by my job but enjoy the challenge. What is the best response by the nurse?
"Take stress management classes." Explanation: Stress management classes will educate the client on how to better manage the stress in his life, after identifying the factors that contribute to the stress. Alternatives may be found to leaving his job, which he enjoys. Not spending enough time with his family and not taking his job home with him haven't been identified as contributing factors to his stress.
The nurse is helping a client with a terminal illness understand advance directives. Which statement by the client demonstrates an understanding of these documents?
"They guide the client's treatment in certain health care situations." Explanation: Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can't give those instructions personally when required. Depending on the client's wishes, an advance directive may or may not include DNR orders. Advance directives allow the client, not the health care provider, to make decisions about treatment. They don't permit verbal orders; all HCP orders must be written and signed.
A client with terminal cancer tells a nurse, "I've given up. I have no hope left. I'm ready to die." Which response is most therapeutic?
"You've given up hope?" Explanation: The use of reflection invites the client to talk more about his concerns. Deferring the conversation to a social worker or health care provider closes the conversation. Telling the client that cures for cancer are found every day gives false hope.
The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation?
Contact the chaplain to arrange a visit with the client. Explanation: The nurse's primary duty is to honor the client's request for a meeting with a spiritual adviser.
An adult client scheduled for surgery chooses to waive the right to informed consent. What should the nurse do?
Document that the client waived the right in the medical record. Explanation: A client who waives the right to informed consent does not waive accountability for the hospital to provide competent care. The client only declined to hear the details of the procedure and did not refuse treatment. Accepting to go for surgery is implied consent; therefore, the nurse should not decline to send the client for surgery. Because the client is of legal age, another family member should not be asked for consent. This may violate the client's right to confidentiality. The client has a right to self determination; therefore, the correct action is to document that the client waived their right to informed consent.
The nurse is caring for a client who is unconscious. Using the American Nurses Association Code of Ethics for Nurses, what statements reflect the nurses' primary purpose of nursing practice for this client? Select all that apply.
The primary commitment of a nurse is always to the client. The nurse always acts as the spokesperson for the client. Explanation: The nurse's primary commitment is always to the client, whether as an individual, family, group, or community. The nurse serves as the advocate or spokesperson for the client, who frequently does not understand the complexity of his or her illness or disease and is unaware of treatment modalities and outcomes of care. The other activities are all important practice guidelines, but they are not the primary purpose of nursing practice.
A nurse observes a client touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission. These are examples of which condition?
poor boundaries. Explanation: The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep?
Play soft or soothing music. Explanation: By providing soft or soothing music, the nurse promotes relaxation, which fosters rest and sleep. To promote sleep, the nurse also should encourage the client to increase activity during the day, avoid providing stimulating beverages (such as caffeinated coffee) in the evening, and offer an evening snack with warm milk. Also, the nurse should encourage the client to decrease activity two hours before bedtime to promote sleep.
A client on an inpatient psychiatric unit is pacing the hallway and appears agitated. When nurse approaches, the client says loudly, "Leave me alone." Which response by the nurse would be best?
Say, "You sound upset. I'd like to help." Explanation: The nurse should say that this client sounds upset and that the nurse would like to help; this demonstrates concern and encourages the client to discuss feelings. Given the likelihood of an increase in anxiety level, the client should not be left alone. Summoning help would probably escalate the client's anxiety. Saying nothing and pacing with the client does not acknowledge the client's emotional state.
The nurse explains hospital policies to a newly admitted adult client. Which statement by the client indicates the need for further teaching?
"I have the right to leave the building unassisted to smoke." Explanation: A client does not have the right to disobey hospital rules and regulations, which would include a rule requiring the client to take someone to smoke. Smoking is permitted only in designated areas (if at all), and the client must follow this safety guideline. Clients do have the right to refuse any care or treatment and to request a review of their medical records.
A nurse is caring for a client with a terminal illness. The nurse determines that a client has entered the first stage of the grieving process when the client makes which statement?
"I think they mixed up my test results." Explanation: Shock and dismay are early signs of denial—the first stage of grief. The other options are associated with later stages of grief.
Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for chemotherapy. When the nurse enters the client's room, the client is sobbing and states, "I thought the chemotherapy would help, but now I feel worse." Which response by the nurse would be most therapeutic? Select all that apply.
"I'll sit here with you for a while. Would it help you to talk about it?" "You're feeling worse since chemotherapy started?" Explanation: Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the client to express feelings. The nurse should be supportive and develop goals together with the client to give the client some control over an anxiety-inducing situation. Another therapeutic approach would be to reflect on the client's comments, focusing on the specific words. Because the other options ignore the client's feelings and block communication, they wouldn't reduce anxiety.
A nurse is caring for a client whose cultural background is different from the nurse's own. Which actions are appropriate? Select all that apply.
Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs. Ask the client if there are cultural requirements that should be considered during the client's care. Explanation: Nonverbal cues may have different meanings in different cultures. In some cultures, eye contact is a sign of disrespect; in others, it shows respect and attentiveness. The nurse should always respect the client's cultural and religious beliefs and should ask the client if there are any special needs associated with these beliefs, such as food restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture; it is not the client's responsibility to understand the nurse's culture. A nurse should never impose the nurse's own beliefs on clients. Culture influences a client's experience with pain. For example, in some cultures, pain is openly expressed, whereas in other cultures it is quietly endured.
A woman is brought to the emergency department by her husband, who reports that she accidentally fell down basement stairs and broke her arm. The client is quiet, withdrawn, and not making eye contact. During the examination, inspection reveals numerous bruises at different stages of healing over the client's legs, arms, and abdomen. Which nursing response(s) would be most appropriate to gather additional information? Select all that apply.
"Do you wish to tell me anything more about how you fell down the stairs?" "I've noticed several bruises on your body. Can you tell me how they happened?" "I am a mandated reporter of any abuse. Do you understand that I have to report my suspicions?" Explanation: Nurses are obligated both ethically and legally to report abuse. In many states, the failure to report actual or suspected abuse is a crime in itself. It is important for the nurse to use therapeutic communications such as "Can you tell me more" or Do you understand..." when speaking with a victim of abuse. The nurse should not use statements or questions that are accusatory or judgmental of the client or their situation. Nurses are protected by law against suits from alleged abusers if they file a report of suspected abuse in good faith that turns out to be erroneous.
A nurse observes a medical student walk into a client's room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene?
Explain to the client that she has the right to refuse to answer questions asked by the medical student. Explanation: The client has the right to confidentiality about her health information. She may refuse to share her information if she wishes. The nurse can stay with the client until the medical student finishes his questioning if the client agrees to answer questions. Encouraging the client to cooperate with the medical student violates the client's rights. Telling the client that the only way for the medical student to learn is for her to cooperate is inappropriate and also violates the client's rights.
A nurse is providing care for a client who experienced an extensive myocardial infarction (MI). The client exhibits behavior characteristic of the denial stage of the grieving process. What is the priority action by the nurse?
Let the client know that the nurse is available to talk. Explanation: Letting the client know that the nurse is available to talk acknowledges the client's feelings. It can help the client cope until he or she is ready to move from the denial stage to the next stage of the grieving process. Pointing out other clients who have had MIs and are doing well offers false reassurance to this client and is a breach of confidentiality. The client cannot be forced to accept the diagnosis. Denial is a protective mechanism that enables the client to cope with crisis until the client can use more effective coping behaviors.
After contributing to a health education class on heart attack prevention, a nurse encounters a student from the previous year, who happily reports applying much from the class to everyday life. During the 5-minute meeting, the nurse notes that the former student is approximately 50 lb (22.7 kg) overweight, smokes, and is eating a bag of potato chips. Based on this information, what can the nurse conclude?
The application of behavioral changes needs to be reevaluated. Explanation: The nurse's brief data collection reveals obesity, smoking, and consumption of high-fat foods, which are all risk factors for a heart attack. Because these risk factors are alterable, the nurse should realize that this student's behaviors have not changed significantly and should be reevaluated. None of the collected data suggests that this student has a hearing impairment or did not attend the entire class. The student's behavior does not demonstrate accurate knowledge of heart attack prevention.
The Patient Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. What should the nurse tell the client about such advance directives as living wills and health care power of attorney? Select all that apply.
They guide the client's treatment in certain health care situations. The advance directive is only valid in the state where it was written and subject to that state's laws. Explanation: Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can't give those instructions personally when required. Depending on the client's wishes, they may or may not include DNR orders. Advance directives allow the client, not the physician, to make decisions about treatment. They don't permit the physician to give DNR orders unless the client specifies this request in the documents. Advance directive laws vary from state to state.
A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?
"I'll tell you what the monitors show." Explanation: The client deserves a truthful answer, and the nurse should be objective without giving opinions. Relating what the monitors show is objective and truthful. Vague answers may be misleading and aren't therapeutic.
A client receiving chemotherapy reports decreased energy leading to boredom from a lack of activity. Which statement by the client indicates an understanding of appropriate ways to deal with this lack of diversional activity?
"I'll play card games with my friends." Explanation: During chemotherapy, playing cards is an appropriate diversional activity because it does not require a great deal of energy. To conserve energy, the client should avoid such activities as taking long trips, bowling, and eating in restaurants every day. However, the client may take occasional short trips and can dine out on special occasions.
A nurse is talking to grieving parents whose child died from sudden infant death syndrome (SIDS). What should the nurse emphasize to the parents?
"The death couldn't have been prevented and isn't your fault." Explanation: The nurse can best help the parents whose child has died from SIDS by countering the false belief that the death is their fault or that they could have prevented it. Informing the parents that an autopsy needs to be performed is a secondary concern. Suggesting that the parents are still young and can have more children minimizes their feelings of grief. Instructing the parents to place other infants on their backs to sleep implies that the parents did something to cause the death.
A client's spouse, severely upset over the client's condition and lack of improvement, reports feeling powerless. Which response by the nurse is best?
"Would you like to help with some comfort measures for your spouse?" Explanation: The spouse expresses a need to help the client, and the nurse can encourage the spouse to do whatever he or she feels comfortable with, such as putting lubricant on the client's lips, a moist cloth on the forehead, or lotion on the skin. The nurse may not understand the situation, and agreeing with a person does not diminish powerlessness. There are many ways the spouse can assist. Validating the frustration is appropriate but not the best response. Offering to call a spiritual advisor may be helpful but is not the best response.
A client on an inpatient psychiatric unit is pacing up and down the hallway. The client has a history of aggression. Which comment made by the nurse would be the most appropriate?
"You are pacing. Let's walk together and talk about it." Explanation: The nurse should acknowledge the client's behavior and explore feelings. Therefore, offering to walk and talk with the client offers a positive and appropriate nursing action. Quiet time in the client's room does not address the pacing. Asking if pacing helps with the anxiety or having a tech walk with the client may both be therapeutic, but neither offers the nurse's support.
A client is admitted for a wedge resection of the left-lower lung lobe after a chest radiograph revealed a lesion. The client is anxious and asks to smoke. Which statement by the nurse would be most therapeutic?
"You seem anxious about the surgery. Do you see smoking as helping?" Explanation: The nurse's comment that the client seems anxious about the surgery acknowledges the client's feelings and encourages the client to evaluate previous behavior. Telling the client that smoking is the reason the client is facing surgery belittles the client and is argumentative. Saying that the health care provider left orders for the client not to smoke does not address the client's anxiety. Telling the client that it is permissible to smoke before the surgery but not after would be highly detrimental to the client.
An alert and oriented client refuses chemotherapy. The client's family believes that the client should receive it. Which is the nurse's best response to the client?
"You understand that this decision is ultimately yours to make." Explanation: A competent client has the right to refuse care. The role of the nurse is to advocate for the client and respect the client's decision. In that role, it is essential for the nurse to make sure that the client is informed regarding the outcome of any choices made. The nurse should not offer advice or attempt to influence the client with personal beliefs or family influence.
A client in college who has recently been diagnosed with human papillomavirus (HPV) infection comes to the health clinic and is anxious and tearful. Which nursing intervention would be most appropriate?
Ask the client to discuss concerns. Explanation: Encouraging the client to discuss concerns establishes a nonjudgmental, therapeutic relationship and would be the best initial response. Other interventions might be appropriate at some point. After a therapeutic relationship is established, the nurse should discuss the dangers of multiple sex partners in a nonjudgmental manner.
A client must be placed on airborne precautions for several days. To help meet the client's emotional needs, what should the nurse do?
Describe the reasons for isolation and how it's carried out, and provide reassurance. Explanation: To meet the client's need for information and help reduce anxiety, the nurse should describe the reasons for isolation and how it's carried out and also should provide reassurance and empathy. Visitors should be allowed to reduce the client's feelings of isolation. The client doesn't have to limit movements while in the isolation room. Unless personal items are needed, they usually aren't permitted in the isolation room.
A client in a senior center informs the nurse, "My spouse recently passed away, and a few weeks later two of my friends and a family member died." Which action should the nurse implement to assist this client?
Encourage the client to seek grief counseling. Explanation: In most instances, a grieving spouse can benefit from grief counseling. Some clients find group counseling more beneficial; others prefer individual counseling. Recommending that the client seek activities to keep busy and spend time with friends are options as the person moves through the grief process, but does not address the current situation. Teaching about the grief process is not applicable at this time and ignores the client's grieving.
A client learns that she is pregnant, and asks the nurse for the names of abortion clinics. The nurse does not believe abortion is moral alternative. What is the most appropriate response by the nurse?
Give the client the available preprinted list of clinics. Explanation: Nurses should provide nonjudgmental care. A nurse cannot withhold care based on personal religious beliefs. Alternately, the nurse could ask a colleague to provide this client with the information.
During rounds, a client who was admitted with gross hematuria asks the nurse about the admitting diagnosis. To facilitate effective communication, what is the nurse's best response?
Provide privacy for the conversation. Explanation: The nurse should provide privacy for the client who asks a question about a diagnosis. Their conversation is a form of active listening, which focuses solely on the client's needs. Asking if the client has hospitalization concerns does not address the question. Changing the subject or giving advice tends to block therapeutic communication.
A client is admitted to a psychiatric unit and refuses consent for electroconvulsive therapy. What is the priority action by the nurse?
Sit with the client and ask what concerns the client would like to discuss about the procedure. Explanation: The nurse should sit with the client and ask about questions and concerns. Sitting indicates a willingness to fully answer questions and provide positive regard to the client. Offering additional educational reading material does not allow the client to verbalize concerns, and it does not allow the nurse to provide teaching. Reviewing the client's medical record does not address the client's concerns about the procedure. The nurse needs to meet personally with the client to answer questions and provide teaching before documenting a refusal of treatment.
The nurse is caring for a client diagnosed with diabetes mellitus. When collecting data from this client, what finding best indicates the client is not coping with the disease?
The client cries whenever diabetes is mentioned. Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain of 2 pounds (0.9 kg in a month is not significant and does not indicate that the client is not coping with a new disease process. Monitoring glucose levels and omitting a dose of insulin if a meal is missed demonstrates that the client is aware of the complications of the disease. Add a Note
A chronically ill school-age child is admitted to the hospital. What action by the nurse addresses the child's vulnerability to a common stressor?
arranges for the hospital teacher to visit Explanation: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?
introducing new issues to the client Explanation: The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.
The nurse distinguishes which assessment as evidence of an adult's developmental stage?
previous problem-solving strategies Explanation: The nurse can use previous problem-solving strategies to evaluate an adult's developmental stage as it relates to intellectual functioning. The other choices are related to physiological attributes.
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?
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, "I think the surgeon is rude, and clients always end up with infections." The nurse is at risk of being accused of which of the following?
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 pregnant client in the first trimester comes to the clinic. During the visit, the client says, "My husband is so excited, but I'm worried because I'm not feeling the same way. Does this mean that I will be a bad mother?" Which response by the nurse would be most appropriate?
"What you're feeling right now is entirely normal for where you are at this stage." Explanation: Misgivings and fears, including ambivalence or the lack of excitement are common in the beginning of pregnancy. The client needs to know that her feelings are entirely normal. These feelings do not necessarily mean that the client requires counseling at this time. The client may benefit by discussing her feelings with her husband or someone else she is close to, but it is more important for the nurse to communicate to the client that her feelings are normal.
A client is admitted to the hospital with an exacerbation of chronic systemic lupus erythematosus (SLE). The client starts yelling at the nurse when the call bell is not answered immediately. What is the most appropriate response for the nurse?
"You seem to be angry. Tell me about what you are feeling." Explanation: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Although stress can exacerbate the symptoms of SLE, telling the client to calm down does not acknowledge the client's feelings. Offering to get the nursing supervisor does not acknowledge the client's feelings either. Leaving the client implies that the nurse has no interest in what the client has said.
When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be
"You seem upset this morning." Explanation: To be therapeutic, the nurse should always comment on the client's statements. The client's words are strong, and obviously angry. By making an introducing or apologizing, the nurse ignores the client's problem. Repeating the client's statement would only add to the client's anger.
As the nurse helps a client to the bathroom, the client says, "When you get to the point where you can't even go to the bathroom by yourself, you might as well be dead." Which response by the nurse would be most therapeutic?
"You sound really discouraged today." Explanation: Sharing an observation with the client conveys awareness of the client's feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.
During an admission data collection, the nurse asks a client why he's being admitted to the facility. The client responds, "The physician found a lump in my prostate gland. I guess I have cancer." Which response by the nurse would be most therapeutic?
"You think you have cancer?" Explanation: This response acknowledges the client's concern and shows a willingness to listen. Although a biopsy is needed to confirm cancer, telling the client this wouldn't permit him to discuss his concerns. Urging the client not to worry or advising him to maintain a positive attitude is a clichéd response. Offering advice about how he should handle the problem also wouldn't be therapeutic.
The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, "I don't know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway." Which response by the nurse would be most therapeutic?
"You're wondering whether you've made the right decision about the treatment." Explanation: By rephrasing the client's statement and focusing on the client's concerns, the nurse encourages further discussion of feelings. Telling the client to keep a positive attitude incorrectly implies that the nurse knows how to deal with the situation best. Saying that cancer of the colon may be cured ignores the client's feelings. Mentioning that everyone with cancer worries overlooks the uniqueness of the client's feelings and implies that these feelings aren't acceptable.
The nurse noted on the progress note of a 17-year-old client scheduled for surgery that the surgeon has explained the procedure, including benefits and adverse effects. However, the consent was signed by the surgeon and not the client. What should the nurse do?
Ask the parents to sign the consent. Explanation: Age 17 is not a legal age of adulthood in the United States. The parents should sign the consent. The client is underage and should not be required to sign a consent except if the child is emancipated or in case of emergencies. The manager cannot sign the consent. If there is no legal guardian or parent, a court-appointed guardian signs the form.
A 5-year-old is admitted to the emergency department with a broken clavicle. The nurse notices bruises in various stages of healing on the torso and extremities. The parent enters the room and angrily demands to take the child home. Which action is most appropriate?
Step out of the room, notify the charge nurse, and then call security. Explanation: In order to ensure the nurse's safety as well as the safety of the child, the best course of action would be to leave the room and immediately notify the charge nurse, and then call security. The nurse wouldn't want to further anger the parent and create the potential for violence by taking the child out of the room. Asking for personal information and telling the parent the child cannot be taken is an inappropriate action.
The nurse observes a client's health and home environment. Which finding requires the nurse to obtain a referral from the health care provider for an assistive device?
The client does not demonstrate any confidence in an ability to walk. Explanation: The use of assistive devices can support coping on the part of the client as well as the caregiver. They allow the client greater independence. Clients need to be taught how to use assistive devices properly and where to store them so that they do not pose safety hazards. Assistive devices do not relieve the caregiver of all responsibility for the client.
The nurse is talking with a client that is grieving over the death of a spouse. Which action exhibited by the client would cause the nurse to suggest counseling?
The client refuses to acknowledge the spouse's family and blames them for the death. Explanation: Abnormal grief may manifest itself as exaggerated or excessive expressions of normal grief reactions, such as anger, sadness, or depression. It's therapeutic to review a person's life with loved ones. Funeral planning can be therapeutic because it allows the individual to do one last thing for a loved one. It's therapeutic to share treasured items with staff and other family members.
A nurse is caring for a client with multiple myeloma. Which finding indicates that the client is not coping well with the prognosis?
avoids conversations concerning his or her health Explanation: A client with multiple myeloma who avoids conversation may be denying his or her condition, which can interfere with treatment. Crying is a normal response to the prognosis. Asking questions about the prognosis is a normal coping response, as is showing concern for the family.
A nurse receiving morning report is told that the family members of a terminally ill client require a lot of attention. Which intervention should the nurse implement to meet the psychosocial needs of the family?
flexible visitation, allowing participation in client care, and rest breaks for the family and client Explanation: A person's psychosocial needs during the dying process of a relative may include flexible visitation, participation in client care, and rest breaks. Informing the family of imminent death may be considered noncaring; limiting the number of family at the bedside should be based on client care and safety needs, and condition. Visitation should accommodate the wishes of the family member as long as client care is not compromised.
Although a client's physiological response to a health crisis is important to the health outcome, which nursing intervention must also be addressed?
helping the client effectively cope with the crisis Explanation: Although all of the answers are important in the care of the client, if the individual can't cope with the emotional, spiritual, and psychological aspects of the crisis, the other components of care may be less effective as well.
A nurse is providing care for a client with multiple myeloma. Which resource may best help the client adapt to the disease?
support group Explanation: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences may help the client with multiple myeloma understand disease-related problems and give the client a forum in which to vent feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, cannot share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life.
A nurse is gathering data from a client who has been raped. Which strategy would be most effective when talking with this client?
using open-ended questions and listening intently Explanation: The client who has been raped can express her feelings about the incident and better organize her thoughts if the nurse uses open-ended questions and listens intently. Listening without asking questions is not therapeutic if the client does not feel like talking. Closed-ended questions can usually be answered with a single word and do not facilitate the expression of feelings. The purpose of the interview is to listen to the client, not to talk to the client; however, the nurse should answer any questions the client has about rape.
A prenatal client says she can't believe she has such mixed feelings about being pregnant. She tried for 10 years to become pregnant and now feels guilty for her conflicting reactions. Which response by the nurse is best?
"You're experiencing the normal ambivalence pregnant mothers feel." Explanation: Conflicting, ambivalent feelings regarding pregnancy are normal for pregnant women. These feelings don't call for counseling or other professional interventions. Ambivalence is felt by most pregnant women, not exclusively mothers who had difficulty becoming pregnant.
A licensed practical nurse is attending an in-service program about postpartum affective disorders. The LPN demonstrates understanding of the information by identifying that which percentage of postpartum clients experience "postpartum blues"?
80% Explanation: "Postpartum blues"—a transient mood alteration that arises during the first 3 weeks postpartum and is typically self-limiting—affects up to 80% of postpartum clients. A more severe mood alteration, postpartum depression, is seen in approximately 20% of clients and involves changes that occur within a few days after birth and may last for a few days to more than a year.
A client is beginning rehabilitation following a stroke. The family is very demanding and never leaves the client's bedside. Which dynamic should the nurse recognize as having a critical impact on the client's well-being?
The client's condition has an effect on every member of the family. Explanation: According to family theory, any change in a family member, such as illness, produces role changes in all family members and affects the entire family, even if the client eventually recovers completely.
An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client?
Ensure case management is actively involved in the client's care to facilitate care coordination. Explanation: The nurse should ensure case management is actively involved in the client's care, as case management is essential to coordinating care for this client such as social work, physical therapy, home health care, and more. Clients are discharged from hospitals sooner and managing more complex health concerns at home in the current health care environment, and social work is instrumental in ensuring clients have access to all services they need. Administering home medications is important, but not the most important intervention for cost-effective care. This client may be able to return to previous independent living arrangements, especially with social work and additional home care services, so requesting nursing home placement is inappropriate for this client. The nurse should always listen to a client's concerns with compassion, but this client may be able to live independently still, and so a nursing home is not the most cost-effective intervention.
A client is having difficulty paying for complex home health care needs. Which action by the nurse promotes cost-effective care?
Ensure client is utilizing all available options for assistance in paying for home health care. Explanation: As health care costs increase, the focus is shifting to outpatient care, preventative care, and health promotion. Clients are managing more complex medical conditions at home, leading to new challenges in health care. Paying for home care can be a challenge, and the nurse plays a key role in helping the client find and utilize all appropriate services for assistance in paying for home care. Recommending the client go to the emergency department for care or requesting admission to the hospital does not promote cost-effective care, and is not necessary for conditions that can be managed at home. Advising the client that there is nothing the nurse can do to help is not true, and does not promote cost-effective care, as the client will likely utilize higher-cost services for care, such as the emergency department, or will not get the care needed and may experience a worsening condition.
A preschooler is admitted to the hospital the day before scheduled surgery. The child has never been hospitalized before. What can the nurse do to help reduce the child's anxiety about surgery?
Give the child dolls and medical equipment to play out the experience. Explanation: By playing with medical equipment and acting out the experience with dolls, the preschooler can begin to reduce anxiety about his surgery. The nurse should schedule teaching shortly before surgery because preschoolers have little concept of time and a delay between teaching and surgery may increase anxiety by giving the child time to worry. Detailed explanations are inappropriate for this child's developmental stage and may promote anxiety. The nurse should avoid phrases such as "put to sleep" because they may have a negative meaning to the child.
A client says to the nurse, "I know that I'm going to die." Which response by the nurse would be best?
"Tell me why you think you are going to die." Explanation: A therapeutic approach would be to reflect on the client's comments, focusing on the specific words. Responding with a statement asking if the client is afraid is not therapeutic and does not respond to the client's statement. Saying "Don't worry" is placating and negates the client's feelings. Making a statement about being worried may be therapeutic during the conversation but not as the conversation opening statement.
A nurse is caring for a client with diabetes who gave birth to a 5-lb (2.3-kg) baby at 33 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). The mother is upset and grieving over the early birth and the need for her neonate to be in the NICU. Which nursing action would be most helpful to the client?
Seek involvement of external support systems to provide emotional support and material resources. Explanation: Based on their knowledge of the client's unique needs and coping mechanisms, close family and friends can offer support and resources to deal most effectively with the client's concerns. Generalizing the client's feelings does not take into consideration the client's unique experience. Encouraging the client to distract herself from her grief does not help her to deal with the situation. The client's minister is just one source of support for the client; to best help the client, the nurse should seek support for the client from all available support systems.
A client underwent a urinary diversion procedure and now has a continent ileal reservoir (Kock pouch). Which action indicates to the nurse that the client is coping with an altered body image?
The client is wearing street clothes and has combed hair. Explanation: Hair combing and putting on street clothes indicate that the client accepts the body change. Anger, as evidenced by confrontational behavior, shows that the client is not coping with altered body image. Saying that the surgeon will change the client back indicates denial of reality. Avoiding stoma care may indicate that the client is having difficulty accepting an altered body image.
The nurse should question the signed consent form for surgery for which of the following clients?
a 54-year-old client with a fractured femur committed to a mental health unit Explanation: The fact that the client is committed to a mental health unit indicates that the client may not be able to make reasonable judgments and decisions about treatment and other significant areas of life. Therefore, the nurse should explore whether this client has given informed consent. Chemotherapy does not affect competency. There is no indication that the older adult client living in a nursing home is not competent; people reside in nursing homes for many reasons unrelated to mental status. A client with a brain tumor may also be competent to given informed consent; the tumor may be impacting an area of the brain unrelated to this type of cognition.
When preparing for a spiritual counselor to visit a hospitalized client, the nurse should
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.
An adolescent admitted with a fractured femur had an open reduction and internal fixation two days ago and is currently in traction and asks the nurse what would happen if a terrorist decided to bomb the hospital. What's the nurse's best response?
"What do you think might happen if terrorists attacked?" Explanation: Something prompted the child to ask such a question, and the nurse needs to take advantage of this opportunity to further explore his concerns and fears. Telling the child to concentrate on getting well discounts the boy's feelings and may actually increase his anxiety. Telling the boy that his parents would be called doesn't provide reassurance or help build a therapeutic relationship that can promote health and wellness. Telling the child his thinking is silly is dismissive and chides the boy for asking the question.
A mother asks a nurse about measures for disciplining her toddler. Which recommendation by the nurse is best?
"When using a time-out, make sure your child knows the rules ahead of time." Explanation: The mother should make sure that her child knows the rules before enforcing a time-out. The nurse should recommend the use of a time-out, but specify that time-out should be limited to 1 minute per each year of age. The child should be placed in a neutral, uninteresting environment for time-out. Children of this age-group require simple explanations of why the behavior requiring a time-out is unacceptable.
A mother and father of Iranian heritage bring their 14-month-old son to the health care facility, and he is subsequently admitted for leukemia. When the female pediatric oncologist introduces herself, the parents become uncooperative and refuse treatment. The nurse interprets which condition as being most likely responsible for the change in the parents' behavior?
the gender of the health care provider who will be treating their child Explanation: The tradition of male authority is still strong among individuals of Iranian heritage. Therefore, accepting that a woman will be making life-and-death decisions for their son might be very difficult for these parents. Discussing other options with the parents, such as turning the case over to a male oncologist who is Muslim, would be appropriate. The gender issue is a stronger cultural factor than the religious difference. There is no basis to relate the parents' behavior to fear of being charged with abuse or neglect. Attributing the behavior to aggressiveness associated with individuals from the Middle East reflects a cultural stereotype, not a cultural value.
A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse?
"You have a right to withdraw consent. Can you share more about your decision?" Explanation: The nurse understands that a client must give consent for a procedure and may withdraw that consent if the client chooses. This answer demonstrates that the client's change of decision is worth exploring. Indicating that the client can have the tube removed afterwards does not respect the current request. Leading the client by assigning the decision to fear is not as helpful as having an open-ended approach. Simply accepting the decision without exploration of the client's feelings is negligent communication by the nurse.
A surgical client newly diagnosed with breast cancer cries and tells a nurse she knows the laboratory made a mistake about her diagnosis. Which response by the nurse is best?
"Would you like to talk about your concerns?" Explanation: Denial is a common response to a diagnosis of cancer. The nurse would ask the client if she would like to talk. "Why" questions are not appropriate. The nurse cannot understand how the client feels.
A registered nurse (RN) is supervising a licensed practical nurse (LPN). The LPN is caring for a client diagnosed with a terminal illness. Which statement by the LPN should the RN correct?
"The law says you have to write a new living will each time you go to the hospital." Explanation: One living will is sufficient for all hospitalizations unless the client wishes to make changes. The "No Code" or "Do Not Resuscitate" status is discussed with the health care provider, who then enters this in the client's chart. A living will explains a person's end-of-life preferences. A durable power of attorney for health care can be written to designate who will make health care decisions for the client in the event the client can't make decisions for himself.
A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse?
"Tell me more about your feelings." Explanation: Asking the caregiver about feelings of guilt acknowledges those feelings and demonstrates the nurse's willingness to listen. Telling the caregiver not to feel guilty dismisses the feelings and discourages further discussion. Falsely reassuring the child's caregiver sends the message that the nurse is not really interested in the caregiver's feelings. Asking the caregiver why he or she did not watch the child more closely is not therapeutic and would make the caregiver feel defensive.
A nurse is caring for a client with advanced cancer. After reading the nursing note below, determine the nurse's next intervention.Progress notes: 1/7, 1545Ct. states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital; I want to be in my own bed." R. Daly, RN
Explain the use of an advance directive to express the client's wishes. Explanation: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the health care provider to administer no life-sustaining treatment, and a durable power of attorney for health care, which names another person to act on the client's behalf for medical decisions if the client can't act for himself/herself. The Patient's Bill of Rights doesn't specifically address the client's wishes regarding future care. Calling the spouse is a breach of the client's right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge of the resources available in the community through hospice and home care agencies in collaboration with the client's health care provider.
The nurse is assessing the psychosocial status of a postpartum client. Which statement indicates that the mother is likely to have a successful parent-neonate attachment?
"I want to lie skin to skin with my baby for as long as possible after delivery." Explanation: Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the first hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery.
