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A nurse is assessing the health status of an older adult client. Although the client denies a problem, the caregiver explains that the client is alert and oriented but consistently has an unkempt appearance, body odor, and soiled clothing. The nurse understands that the client's behavior is likely related to which of the following? - correct answer ✔✔a. Manifesting typical early symptoms of delirium. b. Exhibiting evidence of asymptomatic pathology. c. Experiencing side effects from a medication. d. Restricting activities in response to disease symptoms. Correct Frequently older adults will minimize, deny, or underreport the impact of disease symptoms which require alterations of daily activities in order to compensate for the symptoms. In this case, the issue is not one of impaired cognition, but rather the use of the coping mechanism of denial because of the difficulty in performing self-care functions. During an assessment, an adolescent client whispers to the nurse, "I have to tell you something, but you have to promise you won't tell anyone else." Which of the following is the most appropriate response for the nurse to make? - correct answer ✔✔a. "What is said in this room stays in this room." b. "I cannot make that promise if it affects your or someone else's safety." CorrectNurses should not promise what they cannot do. If a client admits to behaviors that are dangerous to self or others, the nurse is obligated to report these behaviors. c. "I feel that you should share this with your parents first." d. "I am bound by the nurse-client relationship to keep your comments private." A nurse is caring for a terminally ill client of the Muslim faith and observes the client to be unconscious and having Cheyne-Stokes respirations. The family has repositioned the bed so that the client is on the right side facing toward the wall. The nurse does not question this action because of which of the following? - correct answer ✔✔a. This positioning has religious significance for the client and family. CorrectAccording to Muslim teachings, it may be comforting to the dying client and family to turn the client on the right side to face Mecca. When death occurs, the body must be kept covered at all times, and it is preferred that only healthcare professionals of the same gender touch the body. In this situation, observing the position of the client would indicate that the spiritual needs of the client and family were being met. b. The nurse should support the family in their efforts to make the client comfortable.

c. The religious practice of concealing the face of the dying client should be supported. d. This positioning is preferred for a client with respiratory distress. A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the mental health unit. The client is confused and disoriented. When developing a plan of care, which of the following would be the priority intervention for this client? - correct answer ✔✔a. Orient the client to the unit. b. Stabilize the client's psychiatric needs. c. Explain unit rules to the client. d. Accept and make the client feel safe. CorrectClients in a mental health unit need to feel accepted and a client that is confused needs to feel safe. Safety is the client's most basic need, making this the priority intervention. The nurse is assessing the family dynamics of a widow with end stage terminal cancer. Which statement made between the adult children would best indicate the need for further teaching? - correct answer ✔✔a. "Since you are the oldest child, you have the responsibility to decide." b. "If daddy were alive, he would be making these hard decisions, not us." c. "It does not matter what we think, the living will says 'do not resuscitate'." CorrectThe adult children need to have the concept of a 'do not resuscitate' (DNR) clarified. The DNR in a living will expresses the wishes of the client in a written form preceding the situation it addresses. It may also have additional instructional statements with it that give further guidance for particular situations. In any case, the DNR represents the wishes of the client, and does not preclude decisions about care and death by the next of kin. And, despite a DNR wish being expressed in an Advance Directive (sometimes called a Living Will), it requires a healthcare provider order to put a DNR in effect. d. "The doctors have told us that it is time for us to make some tough decisions." A client diagnosed with schizophrenia and experiencing frequent auditory hallucinations is admitted to an inpatient psychiatric unit. Which of the following would be the most effective, initial strategy for the nurse to implement? - correct answer ✔✔a. Agree with the client that the voices are audible. b. Ask the client to describe the components of the hallucination. CorrectInitially, the nurse should try to understand what the voices are saying or telling the client to do. Suicidal or homicidal messages necessitate initiation of safety measures for all members of the healthcare team as well as the client. Once a client describes the hallucination or delusion, do NOT dwell on it. Rather, focus conversation on more reality-based topics. c. Explain to the client that the hallucination is not real. d. Ask the client to rest in a quiet area until the voices are gone.

A client expresses to the nurse that her husband is an alcoholic and has trouble keeping a job for longer than three months. Which of the following is the nurse's best response? - correct answer ✔✔a. "This seems to worry you. May I contact the Hospital Chaplain?" b. "What have you done in the past to help deal with this problem?" CorrectProviding a broad opening allows the client to elaborate and gives the nurse the opportunity to assess problem-solving and coping skills of the client. c. "Have you tried to contact Al-Anon? I can help if you want." d. "I'm so sorry to hear that. Why do you think he drinks?" A nurse is caring for an adolescent client who is recovering from a traumatic below the knee amputation. The day after surgery, the client refuses to look at or touch the affected leg. Which of the following nursing interventions would be most beneficial to this client? - correct answer ✔✔a. Gently examine and redress the stump without frowning or grimacing. CorrectAvoidance is a common reaction to a body image change resulting from a disfiguring injury. Adolescents may be especially sensitive to disruption of body image, due to their developmental stage. The most beneficial intervention for this client is for the nurse to show acceptance by caring for the stump without nonverbal behaviors that would indicate disgust at the appearance of the injury. b. Avoid discussing the amputation until the client initiates conversation. c. Remind the client that full mobility is possible once fitted for a prosthesis. d. Insist that the client participate in bathing and examining his affected leg. A nurse is caring for an adolescent client admitted to the nursing unit three days ago. The client is withdrawn, unwilling to eat, and does not interact with the staff. The nurse correctly understands which of the following would provide the best support for this client? - correct answer ✔✔a. A call from the client's sibling. b. An opportunity to view a popular DVD. c. A visit with a parent. d. A visit with friends from school. CorrectPeers are the most important support and influential component of an adolescent's life. According to Erikson, the development stage for this age group is "Identity vs. role confusion" and requires peer relationships and group memberships. During a group therapy session on a psychiatric unit, the nurse leader observes that one of the clients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation? - correct answer ✔✔a. Encourage another group member to reprimand the client.

b. Tell the client that the interrupting behavior must be discontinued. c. Discuss this observation during the post-meeting evaluation. d. Ask the client to speak privately with a nurse after the meeting. CorrectAsking the client to speak privately with the nurse after the meeting allows the nurse to maintain control of the meeting in a non- confrontational manner. A client comes to a mental health clinic after experiencing a crisis in which a fire destroyed the client's home and took the life of a child. The client states, "I am unable to work or sleep and don't see how I can go on after this." Which of the following is the priority nursing intervention for this client? - correct answer ✔✔a. Relocate the client to a more supportive environment. b. Enroll the client in a grief counseling program. c. Assess the client for potential suicidal behavior. CorrectThe statement "...don't see how I can go on after this," requires immediate further exploration to determine whether action must be taken to protect the client from self-harm. d. Help the client return to a pre-crisis level of functioning. A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate? - correct answer ✔✔a. Remain in the room and answer any questions the parents may have about the stillbirth. b. Remove the infant from the room and allow the parents a period of time to grieve. c. Inquire about any rituals the parents would like to perform at this time. d. Gently inform the parents about the hospital procedures for handling a stillborn infant. The correct answer is: Inquire about any rituals the parents would like to perform at this time. Parents share with a nurse that the beloved pet cat of their preschooler died just before the child was admitted to the hospital. Which of the following statements would be characteristic for a child of this age to make about death? - correct answer ✔✔a. "What happens to cats after they die?" b. "It's my fault Fluffy died because I let him out." c. "All cats get old and die. And Fluffy too." d. "Fluffy didn't really die. He's just sleeping." CorrectThe preschooler has no clear concept of time and usually believes death is temporary and reversible. The dead person (or animal) may have attributes of the living (e.g. 'sleeping', 'eating', 'breathing'), or may be dead to a degree (e.g. 'a little bit dead').

A nurse is admitting a client diagnosed with schizophrenia. In order to establish a therapeutic nurse- client relationship with the client, the nurse's initial actions should include which of the following? - correct answer ✔✔a. Develop a contract b. Establish trust CorrectA priority goal during the first few encounters with a client diagnosed with schizophrenia is to provide an atmosphere in which trust can grow. c. Provide confidentiality d. Maintain consistency The nurse is attempting to comfort parents who just experienced the death of their premature infant. The parents are angry and blaming the nurses and doctors for the death of their child. Which of the following is the most appropriate nursing intervention? - correct answer ✔✔a. Remind the parents that the nurses and doctors did all they could for their infant. b. Refer the parents to grief support group to deal with the loss of their infant. c. Grant time for the parents and family to hold and be with their infant. CorrectGranting time for parents to hold and be with their baby is an appropriate intervention. d. Provide a more detailed explanation for why their infant passed away. A client has recently been diagnosed with inoperable lung cancer and has been referred to hospice. The nurse recognizes that the client has successfully dealt with the anticipated outcome of the disease when the client states which of the following? - correct answer ✔✔a. "I have reviewed my will and advance directives." CorrectThis statement indicates the client is in the acceptance or coping phase of grieving. b. "If I can live, I will never smoke a cigarette again." c. "I just don't want to talk with anyone right now." d. "I plan on planting a vegetable garden next year." An adult is seen in the healthcare provider's office with multiple bruises and lacerations consistent with physical abuse. During the nursing assessment, the client reports that the injuries were intentionally inflicted by the spouse and verbalizes fear that it will happen again. Which of the following statements would indicate that the nurse's initial counseling has been effective? - correct answer ✔✔a. "The next time the hitting starts, I will tell my spouse to stop immediately or I'll be forced to call the police." b. "I will take some money, clothes, and important papers to my parents' home and go there if things start to get bad again." CorrectAll persons experiencing violence should be counseled to develop a safety plan that provides for escape when violence recurs. After the initial counseling session, verbalization of this initial plan is a positive outcome. Necessary items should be pre-positioned at the destination, or packed and put where the perpetrator will not find them.

c. "I'll go home and pack my bag, putting it out in the open so my spouse understands that I'm serious about leaving." d. "I'll tell my spouse that I have spoken with you and that I have decided we need to start counseling soon as a couple." A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. Which of the following may negatively affect the client's adjustment to living with family members? - correct answer ✔✔a. Older clients often recover more quickly when encouraged to interact with family. b. The client is unable to complete all ADLs. c. The family is insisting on maintaining financial control for the client. CorrectWhile it might be appropriate for family members to assist with financial matters, unless client is declared incompetent there is no need for them to maintain complete control. This may be perceived as very threatening to the client. d. The family is actively involved in the discharge plans. A client who is suffering from delusions states, "I can't stay in group today. I am expecting the governor to be here any minute!" The nurse leading the group responds, "I understand, but right now it is time for group and we expect everyone to attend." Which of the following explains why the nurse's statement would be considered therapeutic? - correct answer ✔✔a. It discourages other group members from trying to avoid group b. It articulates what is expected without reinforcing the delusion CorrectThis response is clear and matter-of-fact; it does not draw attention to the client in the group situation, does not argue with the client, does not reinforce the delusion, but accomplishes the intent of getting the client to stay in the meeting c. It demonstrates to all group members that the nurse is in control d. It sets limits on manipulative behavior without creating a confrontation A client has been prescribed lithium carbonate to control the symptoms of bipolar II disorder. The client presents to the clinic reporting symptoms of lethargy, generalized discomfort, and a poor appetite. Which of the following would be the nurse's priority action? - correct answer ✔✔a. Question the client for concomitant alcohol use b. Ask the client if they have experienced episodes of mania c. Prepare the client for lab work to measure lithium levels CorrectThe client is exhibiting symptoms of relapse of bipolar II disorder: a hypomanic episode and lithium levels should be assessed first for

therapeutic level. Lithium requires careful dosage adjustment to reach and maintain therapeutic levels; the level will be very important for evaluating the client's clinical picture. d. Assess the client to rule out possible flu syndrome A nurse is planning care for a client newly admitted to an inpatient mental health unit for treatment of a gambling addiction. The client is having difficulty concentrating and is worried about the future. Which initial intervention will maximize the client's success for recovery? - correct answer ✔✔a. Recommend the client participate in group discussion. b. Suggest the client replace work out on the treadmill. c. Arrange for the client to attend Gamblers Anonymous. d. Administer an anti-anxiety medication to the client. CorrectCo-morbid anxiety disorders need to be treated and stabilized so the client can effectively focus on behavioral treatment for the addiction. A nurse has completed medication teaching for flouxetine with a client recently diagnosed with recurring panic attacks. Which of the following statements made by the client indicates a need for further teaching? - correct answer ✔✔a. "I can eat whatever I want while I am taking flouxetine." CorrectWeight gain is an adverse side effect of fluoxetine. Caloric intake must be controlled and exercise increased. b. "I need to monitor my blood sugar closely while I am taking flouxetine." c. "It may take up to four weeks or longer before flouxetine takes full effect." d. "When my panic attacks go away and I feel better I must continue taking flouxetine." A nurse has completed medication teaching for disulfiram with an adult child of an alcoholic parent. Which of the following statements made by the adult child indicate an understanding of the nurse's teaching? - correct answer ✔✔a. "I am so glad my dad has agreed to take this drug, I want it to cure his drinking problem." b. "My dad's last drink was eight hours ago, so he may take his the first dose immediately." c. "Dad may have to take this medication for a long time until he gains self-control over alcohol use." CorrectDaily, uninterrupted administration of disulfiram must be continued until the client is fully recovered socially and a basis for permanent self-control has been established. d. "Before being discharged from the hospital, dad will have at least one supervised alcohol-drug reaction." A nurse has completed medication teaching regarding methylphenidate with a client. Which of the following client statements indicates an understanding of the nurse's teaching? - correct answer ✔✔a.

"Avoiding afternoon doses of methylphenidate will help me sleep better." CorrectNervousness and insomnia are common side effects of methylphenidate. Therefore, the medication should be taken at least in the morning to avoid insomnia. b. "Weight gain is common if I take methylphenidate long term." c. "If I don't like how I feel on methylphenidate, I may stop it at any time." d. "Methylphenidate is a safe drug with very few side effects." An adult client is seen in the emergency department and is accompanied by a sibling who reports that the client is incapable of performing self-care activities. The client states, "Freeze thumping lasting circus going." The client appears suspicious and reports hearing threatening voices. The nurse recognizes that the client is exhibiting signs of which disorder? - correct answer ✔✔a. Generalized anxiety disorder b. Bipolar disorder I c. Dissociative fugue d. Paranoid schizophrenia CorrectParanoid schizophrenia is characterized by auditory or visual hallucinations, and perhaps threatening voices. The statement made by the client indicates word salad which is a jumble of words that are meaningless to the listener. This alteration in speech is considered a positive symptom of schizophrenia.