Unit 4: Basic Psychosocial Needs

A client has just lost her husband with an apparent suicide. In the emergency department, the client tells the nurse that she has never lost an immediate family member and "feels so numb right now." Which response by the nurse is best?

"His death will be a terrible loss." The statement that his death will be a terrible loss validates the bereaved person's sense of loss and communicates the message that she is understood and supported. The other statements are unhelpful and banal responses at the time of a loss.

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. How would the nurse respond?

"Is there anyone else I can call to support you at this time?" The clients are displaying evidence of spiritual pain and distress. The nurse acknowledges that this can be a normal part of the grieving process and does not pressure the clients to access spiritual supports if they have been refused. However, the nurse does not just accept this refusal and not explore other methods of support. Instead, the nurse should offer to call someone the clients may want to have with them as a support at this time. At this time of acute grief and spiritual pain, the nurse should not attempt to explore the client's spiritual beliefs. This can be explored later in the grieving process when the clients demonstrate readiness for this exploration.

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." 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

Which description best matches the role of a parish nurse?

A nurse who works to reintegrate the healing tradition into the life of a faith community. Parish nurses and health ministry teams work to reintegrate the healing tradition into the life of faith communities. The key roles of the parish nurse are health educator, personal health counselor, referral agent, trainer of volunteers, developer of support groups, integrator of faith and health, and health advocate. Parish nurses are not visiting nurses or home health nurses.

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. 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 would be most helpful when coaching a client to stop smoking?

Establish the client's daily smoking pattern. 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?

Explore the nurse's own feelings about the issues of anencephaly and organ donation. 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 should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy. 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. Telling the client that the neonatal death will be prolonged and painful to her is not helpful. Death may occur very soon after birth. Contacting the client's family members is not appropriate. 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?

Give the client the opportunity to select from two outfits and cue follow-through instructions. 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 states, "If my heart stops beating, I do not want to be resuscitated." Which action would the nurse take?

Ask if the client discussed this with the healthcare provider. When a client is admitted to a hospital, the nurse is responsible for providing information about the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. The primary right to decide belongs to the client or family, but a healthcare provider's order must be obtained and should describe the actions that the nurses would take if the client requires CPR. The nurse would ask if the client has discussed these wishes with the healthcare provider in order to assist with obtaining the written order. A notarized advance directive is not needed to establish the client's wishes.

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 is most appropriate?

Can you tell me more about how you are feeling right now about your treatment?" In asking the client how they are feeling about treatment, the nurse is engaging in active listening by focusing on the actual information offered by the client. This promotes interactions focused on the client's feelings and concerns. Addressing the client's feelings validates the client as a person and helps establish trust. Focusing only on side effects of chemotherapy is an assumption by the nurse and narrows the client's ability to respond. Simply making statements about how the feelings are common will not facilitate exploration of the client's feelings. Asking the client to say how the nurse can help does not encourage more discussion about how the client feels.

A client with an infected abdominal wound must be placed on contact precautions for 10 days. What should the nurse do to help meet the client's emotional needs?

Describe why the client is on contact precautions and what will occur there, and reassure the client To meet the client's need for information and help reduce the client's anxiety, the nurse should describe the reasons for contact precautions and how they are carried out and should also provide reassurance and empathy. To reduce the client's feelings of isolation, visitors should be allowed to spend time with the client or telephone. The client needn't limit movements while on contact precautions. Unnecessary personal items usually aren't permitted when a client is on contact isolation.

Which statement about religion and spirituality is most accurate?

Religion is an organized system of spiritual beliefs. Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion nor is it a recent development

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 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.

The emergency room nurse is providing care to a client who admits to being a victim of domestic violence. Which statement by the client indicates to the nurse that the client will accept safe shelter living? Select all that apply.

"A social worker can help me set up a place to stay." "I would like to get a restraining order from my partner." The two client statements, "A social worker can help me set up a place to stay" and "I would like to get a restraining order from my partner," indicate that the client is ready to change living conditions. If the client tells the partner the client is not coming home or accepts a house from the family then the client is not gaining independence. The statement that the client still needs a plan for the children does not indicate that the client is ready for a change in living conditions and independence.

Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my spouse." How should the nurse respond?

"Can you tell me more about what your goals for a sexual relationship with your spouse are?" The nurse should explore the client's feelings about the sexual relationship with her spouse as this was the topic of her statement. Platitudes that offer unfounded reassurance will not help the nurse explore the client's fears. The nurse should explore the client's feelings first, before offering any discussion with the spouse. Discussing reconstructive procedures is premature as the nurse has not assessed the client's goals yet.

After an episode of severe pain, a client says to the nurse, "The pain really frightened me. I thought I was going to die." Which statement is the most appropriate response from the nurse?

"I understand that pain can be a frightening experience The nurse's most appropriate response is to acknowledge and validate the client's concerns. Questioning the client's fears is not a therapeutic response and can make the client feel defensive. False reassurance that the client should not be afraid disregards the client's fears and does not promote further communication between the client and nurse. Dismissing the client's feelings and telling the client to relax do not encourage sharing of feelings.

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?

"I won't continue to talk with you if you curse." 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 with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response?

"That's a difficult question to answer, and this must be very frightening for you." This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly." In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

The health care provider (HCP) recommends that a client have a partial bowel resection and an ileostomy. Later, the client says to the nurse, "That doctor of mine surely likes to play big. I will bet the more he can cut, the better he likes it." Which reply by the nurse is most therapeutic?

"What do you mean by that statement?" When the client seems to be questioning the HCP's goals, it is best for the nurse to present an open statement and ask what the client means. This technique helps the client express feelings. Telling the client about the surgery is less therapeutic when the client is upset. While it is the client's right to get a second opinion, this suggestion does not address the client's feelings. Making assumptions can also interfere with communication, especially if the assumption is incorrect.

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?" 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 gives birth to a neonate at 30 weeks' gestation. The neonate is stable on minimal ventilator settings. The client's previous infant, who was born at 24 weeks gestation, did not survive. The family is Roman Catholic and requests that neonate be baptized as soon as possible. What response by the nurse is most appropriate?

"What would you like me to do to help arrange the baptism?" Patient-centered care involves honoring client preferences. It is common practice to baptize infants who are at risk of death in the Roman Catholic faith. While a 30-week gestation infant on minimal ventilator settings would be expected to survive, the family has had real experiences with neonatal death, and spiritual practices can provide comfort. The nurse should ask the family about their preferences and try to honor them. The family may indeed be requesting the baptism because they are fearful their infant might die. The nurse can reassure the family that the infant is doing well but must also respect the client's spiritual preferences. After the family shares their preferences, the nurse can offer the local chaplain as a resource.

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 mostappropriate response by the nurse?

"You have a right to withdraw consent. Can you share more about your decision?" 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.

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client?

"You may want to have an abortion if you find out you are pregnant." This statement hinders the therapeutic relationship because it advises the client to make a personal choice that may be against the client's values and beliefs. This statement would block further communication about the options that are available to the client. The other statements appropriately respond to feelings a victim may have following sexual assault or violent attack and provide reassurance that the victim acted as rationally and appropriately as anyone could in a life-threatening situation and let the client know that the nurse understands the emotions one commonly feels following a violent attack.

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?

"Your son can make an electronic history to facilitate his care if he gets sick away from home." 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 nurse is caring for multiple grieving clients. Which client is most likely to experience disenfranchised grief?

A 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident The 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident is most likely to experience disenfranchised grief, as this is not a loss that is typically recognized by others, because they are divorced. The 60-year-old client whose child has been diagnosed with terminal cancer is probably currently experiencing anticipatory grief, as the client is anticipating the death of a child. The 70-year-old client whose best friend died from a heart attack and the 80-year-old client whose spouse died from Alzheimer disease do not have any indications that they will experience disenfranchised grief, as the loss of a close friend or spouse is well-recognized by others.

A 30-year-old client shares with the nurse that he or she has had a really hard time since the divorce 1 year ago, struggling with depression and anxiety. The client had a makeover and will be going on vacation with a best friend next month. The client has started thinking about dating again. The nurse understands that this client is in which stage of the grief process?

Acceptance The client is in the acceptance stage of grief regarding the divorce. The client has come to terms with the new reality, accepted the new reality, and is focusing on the positives and living life to the fullest. The bargaining stage of grief is characterized by making deals or promises of doing things differently if only there could be a different outcome. Depression would appear as intense sadness, feelings of hopelessness and often crying, and the client has most likely already worked through this stage, as the client reported struggling with depression over the last year since the divorce. Ongoing is not one of the stages of grief, and this client appears to be dealing with the grief well at this point.

When planning discharge instructions with a client who has had an abdominal hysterectomy, what should the nurse do first?

Assess the client's available social supports. Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate.

A client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, "I'm so frustrated with my doctors. The wound care doctor tells me this won't heal and I need to have my toes amputated, and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, what should the nurse do?

Contact the client's case manager to set up a care conference. The nurse is ultimately responsible to coordinate the client's care while hospitalized; therefore, it is the nurse's responsibility to arrange a care conference to help get the client's questions, concerns, and frustrations addressed. Assuring the client that the HCPs know what they are doing does not address the client's concern or frustration with receiving conflicting information. While it is true that the client is ultimately responsible for health, asking the client to accept the consequences is a form of blaming the client. The HCPs' progress notes will not provide information that will address the client's concern or resolve the conflicting courses of action that the two HCPs are proposing.

A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her injuries is complete, and she is ready for discharge. What should the nurse do to ensure the woman's safety and security prior to discharge? Select all that apply.

Determine if the client knows the location of the ex-boyfriend. Ask if she plans to see the ex-boyfriend again. Provide information on resources and a safety plan. Ensure that she has a safe place to stay after discharge. The crucial interventions involve safety and support. Asking for consent is a health privacy issue, not a safety issue, and is not essential to the discharge process.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He's doing too much. I told him to let me help, but he won't let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, what should the nurse do?

Direct the body and eyes at the wife and client. Assuming cultural appropriateness of eye contact with the client and his wife, this body language would make the nurse's nonverbal message congruent with the nurse's verbal message and demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and wife conveys a lack of assurance about the nurse's focus and comments.

An older adult client shares with the nurse having never gotten over the grief of losing a parent 22 years ago. The client states that the parent completed suicide and the client found the parent and called for emergency assistance. The nurse assesses that the client is experiencing which type of grief?

Dysfunctional Dysfunctional grief is intense grief that does not result in reconciliation of feelings, such as this client is experiencing. Anticipatory grieving is grief before the actual loss occurs. Uncomplicated grief is a grief reaction that normally follows a significant loss and proceeds normally. Disenfranchised grief is grief that is not openly acknowledged, socially sanctioned, or publicly shared.

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. 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.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which intervention is the nursing priority?

Explain procedures and unit routines to the client, as well as checking orientation. Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar environment to a new one. Checking orientation gives feedback as to how the client is coping with the changes. Since there is fear and anxiety, it would be a challenge for the client to contact the family. "Why" questions tend to be judgmental and do not address the main concerns. Checking on the client is not sufficient; explanations will help ease the anxiety.

A new mother who is breastfeeding her baby has developed a deep vein thrombosis and needs to be started on a heparin drip for treatment. The client states, "I need to nurse my baby." How would the nurse respond to this client?

Explain the importance of the heparin in resolving the thrombosis and examine ways the baby could room in with the mother with assistance. Explanation of the importance of the heparin drip in resolving her problem while also addressing and responding to the client's concerns regarding the newborn reflects a response to the client's psychosocial needs as well as physical needs.

A client has been diagnosed with invasive testicular cancer and asks if it is necessary to undergo further treatment after surgery. What would be an appropriate response by the nurse?

Explore what the client thinks will help make a decision. The client appears uncertain as to the course of action after the surgery and is questioning how to proceed and what options are available. The client needs to make the decision regarding the course of treatment, and then may decide to discuss it further with the physician and oncologist. It is important for the nurse to clarify concerns and options. Then the client may choose to talk with a chaplain, social worker, physician, or oncologist.

The nurse manager has employed three nurses from a culture that is different from that of most of the nurses who currently work on this unit. Which strategy would help the newly employed nurses socialize into the team and promote the cultural competence of all of the nurses?

Hold a culture sharing session at monthly meetings. Cultural competence is necessary for all nurses to provide culturally appropriate care and meet the needs of a diverse client population. Allowing staff time to share individual culturally specific information provides the opportunity to learn from each other and form relationships. This strategy also facilitates nurse identification with personal cultural attributes. It is important to provide support to the nurses from different cultures. Assigning one nurse to each shift may undermine the initial goal and result in attrition. Restricting language to only English could decrease client satisfaction for those who also speak a similar language. Asking staff to invite new staff to after-work activities is not appropriate because not all staff may have time to participate in these activities and could result in decreased staff morale.

What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness?

How is your condition affecting your family members and their usual roles? Clarification of the concerns the client has regarding the impact of the illness on the family is very important. This answer asks how members are affected. This is an important step before examining ways that the nurse might support the family during their period of adjustment. The other choices do not directly address the current situation and how the nurse can best assist the family.

A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, "You're going to tell me who did this to you. What's his name?" Which is the nurse's best response?

Please come with me, sir. I need some important information." With this level of anger in a crisis, the father needs simple but firm directions to leave the room, calm down, and then to talk. Doing so relieves the daughter of any pressure from her father. Telling the father to stop yelling or be quiet provides no concrete directions to the father and may embarrass him in front of his daughter. Telling the father that if he does not stop yelling, the nurse will call Security is a threat, possibly leading to an escalation of the situation.

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.

Provide emotional support. Serve as an attentive listener. Expect the family to express grief. Arrange for the family to view the body. 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.

The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse?

Seek input from all groups and strive for consensus on what would benefit most or all of these people. The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.

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

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt People with Spiritual dysfunction or Spiritual distress may verbalize such distress or express a need for help.

A client expresses experiencing stress when working but enjoys the challenges this work presents. What would the nurse suggest?

Take stress-management classes. The nurse would suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach how to manage stress more effectively. The client may not be able to make the job fun. The information provided by the client does not indicate that spending too little time with the family and taking the job home contribute to the client's stress.

A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. What would be done to obtain informed consent for the procedure?

The nurse should contact the person identified as the healthcare power of attorney. Clients may have several types of legal documents regarding healthcare decisions. A healthcare power of attorney is a document that authorizes a person to make healthcare decisions if the client is unable. A DNR order designates when to withhold life support but does not include food or fluids. A client may have a living will to state what sort of treatment is wanted at the end of life, but it may not be legally binding in all states, provinces, or territories. A last will and testament allocates the client's possessions but does not address healthcare needs.

A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?

The nurse should listen attentively and provide realistic verbal reassurance. Clients routinely experience preoperative anxiety. Nurses should use basic communication skills to reduce their apprehension. Other answers are incorrect because they don't address the client's immediate need.

After the spouse has visited, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels incapable of handling the situation. What should the nurse do at this time?

Use the call system to request assistance. A nurse who feels unable to handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client the spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

When providing nursing care to a client of African descent, which cultural factors should the nurse consider?

Values and beliefs are often present oriented. Cultural factors that should be considered when providing care to a client of African descent include the recognition that the family is usually matriarchal, values and beliefs are present oriented, there is strong family unity and cooperation, and families are frequently highly religious and highly respect the clergy.

A client is having trouble adjusting to a colostomy surgically created 4 days ago. The nurse prioritizes which nursing diagnosis?

altered body image Altered body image is common in clients dealing with a new colostomy and its care. The client won't likely show signs of anxiety, but may not be comfortable caring for the colostomy. Low self-esteem may be a concern, but it isn't as common as an altered body image. The client should have less discomfort postoperatively than before the surgery.

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.

asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs The client is directly asking the nurse for assistance in strengthening faith. For this reason, it is reasonalble 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 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 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 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 caring for a client whose left foot was surgically removed due to gangrene. The client tells the nurse that focusing more on their spiritual life helped overcome the loss of a foot. Which statement appropriately describes the spiritual dimension?

being in harmony with the universe The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness, or death. Worshiping family and friends or seeking joy from materialistic objects can make a person happy on an individual level, but the spiritual dimensions is a quality that goes beyond religious affiliation and strives for inspiration, reverence, awe, meaning, and purpose even for those who do not believe in any god.

The nurse enters the nondiabetic client's room shortly after a group of health care providers has made rounds. The client asks, "Why did the doctor tell the others that I am not compliant with my diabetes regimen?" The nurse is aware that which ethical principle has been violated

confidentiality All nurses should be aware of the confidential nature of information obtained in daily practice. Discussion of clients with other members of the health care team is often necessary; these discussions should occur in a private area where it is unlikely that the discussion can be overheard. Respect for persons involves treating others in such a way that enables them to make choices. Trust is an essential element in the nurse-client relationship. Fidelity is promise keeping—the duty to be faithful to one's commitments.

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 blindness 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.

When a nurse asks themselves questions such as "Why am I here?" the nurse is attempting to

develop a philosophical base for clearer thinking. in terms of spiritual care, your own background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining your own spirituality, values, and beliefs is essential.

When planning a culturally sensitive health education program, the nurse should:

integrate folk beliefs and traditions into the content. Strategies to reach clients in all cultures should include incorporating the folk beliefs and traditions of the target population into the program. Identification of a centrally located building with available access by the target population, use of materials in the native or primary language of the target population, and involvement by all community leaders will also help the program succeed.

A client suspects the end of life is near. However, others talk about only pleasant matters and maintain a persistently cheerful façade. The nurse plans care for this client by recognizing that these behaviors will most likely cause the client to experience which feeling?

isolation Clients tend to experience isolation and loneliness when those around them are trying to hide or mask the truth. They are then left to face the realities of death alone. Clients do not experience relief or hopefulness when others are falsely cheerful. Independence is promoted by offering realistic choices about care at the end of life.

Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness?

living each day as it comes as fully as possible When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because

nursing practice involves numerous interactions between laws and individual values. A code of ethics is necessary to guide nurses' conduct especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

The client is Asian and does not speak English. 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 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 client with a fetal demise at 40 weeks asks the nurse, "How could God let this happen?" An appropriate goal for the client with a nursing diagnosis of Spiritual distress related to infant loss as verbalized by the client would be that the client will

participate in supportive spiritual practices. The goal for the client should focus on supporting the client's strengths and utilizing what techniques have worked in the past.

The nurse is counseling the family of an older adult who died today. Which factor facilitates attainment of a positive bereavement outcome?

possessing adequate financial resources 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.

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

previous coping skills Coping is the process through which a person uses cognitive and noncognitive resources to resolve problems. Cognitive responses result from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive in nature and include the thought and learning necessary to identify the source of stress in a current crisis situation. Therefore, such coping skills would have the most influence on the outcome of a crisis situation. Previous coping skills could determine whether age has a positive or negative impact during a crisis. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis, as well as arriving at a better solution to the problem. The involved person's correct or incorrect perception of the problem could result in a positive or negative outcome.

A nurse is administering a prescribed dose of an injection to a middle-aged client with Bell's palsy. What are the sources of fulfillment in the middle-years of an adult client's life?

productive activity The middle years are fulfilled through productive activity—in Erikson's term, generativity. This time is of growth and renewed questioning, in some ways very similar to adolescence. For young adults, their beliefs and attitudes change due to some situations such as advanced study or education or new religious affiliations possibly intertwined with achieving intimate relationships, choosing careers, and starting families. The challenge during this stage is to establish one's own sense of faith and commitment based on personal experience and reflection on meaning in life.

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?

social worker 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 college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

spiritual alienation 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.

A family has moved from Spain to a primarily Spanish-speaking neighborhood near a large English-speaking metropolitan area in North America. The nurse caring for this family recognizes that which family member will likely require the greatest amount of time to learn the English language?

the 45-year-old mother in the family who does not work outside the home The 45-year-old mother will have the greatest challenge in learning the English language because she does not work outside the home and lives in a community of their ethnic culture. Children usually assimilate more rapidly and learn the language of the dominant culture more rapidly because they leave home each day to go to school, making new friends in the dominant culture. Wage earners also tend to learn a new language more quickly through the work setting. Language acquisition is tied to necessity and assimilation rather than to the degree of difficulty.

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?

the nurse's comfort and knowledge level related to the process of spiritual counselling 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.

When the client tells the nurse that they believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing

theism Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used when?

to allow her mother to continue in her role as a mother 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?

when a client near discharge is threatening to harm an ex-partner 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.