Basic Psychosocial Needs

For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?

• Playing soft or soothing music

• Encouraging the client to be less active during the day

• Serving the client a cup of coffee and a snack in the evening

• Increasing the client's activity 2 hours before bedtime

A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which responses by the nurse are appropriate? Select all that apply.

• Don't worry, your mother still has some time left.

• Let's talk about your mother's illness and how it will progress.

• You sound like you have some questions about your mother dying. Let's talk about that.

• Don't worry, hospice will take care of your mother.

• Tell me how you're feeling about your mother dying.

A client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which action best indicates that the client has achieved an increased level of psychological comfort?

• Making decreased eye contact

• Asking to see family members

• Joking about his present condition

• Sleeping undisturbed for 3 hours

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

• To determine whether the client is psychologically ready for surgery

• To express concerns to the client about the surgery

• To reduce the risk of postoperative complications

• To explain the risks associated with the surgery and obtain informed consent

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best?

• You're doing fine.

• What is your biggest concern right now?

• Give it some time and you'll be OK.

• You don't believe you're doing well?

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention should the nurse implement?

• Discussing the client's concern with her husband

• Referring the client to a psychiatrist

• Inviting a client who has had a similar experience to speak with this client

• Referring the client to a sex therapist

Which change does a nurse demonstrate when she helps a young mother adjust to the birth of her child?

• Unplanned

• Situational

• Maturational

• Physiologic

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse include in the care plan?

• Banning personal belongings from the bedside

• Involving the family and the client in planning care

• Providing detailed explanations of the client's conditions and treatment

• Allowing the family to visit only when the client asks to see them

During an admission assessment, a nurse asks why a client is 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?

• There is no way to know whether you have cancer until the surgeon performs a biopsy.

• It isn't unusual for a man your age to have an enlarged prostate. Try not to worry.

• It's important to keep a positive attitude. There is a good chance you don't have cancer.

• You think you have cancer?

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:

• My name is Mary and I'm your nurse for today.

• I'm sorry. I was busy with another client.

• You seem upset this morning.

• You've had your light on for 20 minutes?

A client with newly diagnosed breast cancer asks a nurse, "Why me? I've always been a good person. What have I done to deserve this?" Which response by the nurse would be most therapeutic?

• Don't worry. You'll probably live longer than I will.

• I'm sure a cure will be found soon.

• You seem upset. Let's talk about something happy.

• Would you like to talk about this?

The Client Self-Determination Act of 1990 requires all hospitals to discuss advance directives with all clients. Which statement by the client demonstrates understanding of advance directives, living wills, and health care power of attorney?

• They guide the client's treatment in certain health care situations.

• They can't provide do-not-resuscitate (DNR) orders for clients with terminal illnesses.

• They allow physicians to make decisions about treatment.

• They permit physicians to give verbal DNR orders.

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

• Encouraging the client to suppress his feelings regarding obesity

• Reinforcing the client's concerns about his physical appearance

• Communicating with the client in an abrupt, forceful manner

• Teaching the client alternative ways to lose weight

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be best?

• Most people your age develop some type of colon problem.

• Your physician can discuss this in more detail.

• You sound concerned about what's happening.

• You'll have to have some tests before the physician can rule out cancer.

A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. What is appropriate for the nurse to say to the client?

• Don't you realize that resistance can develop if you don't take your medications properly?

• You must take your medication as instructed. Do you need supervision?

• Why aren't you taking your medications? Don't you want to get better?

• Taking several medications can be difficult. Tell me about the difficulties you're having.

A nurse is caring for a client with advanced cancer. Based on the nursing progress notes below, what should be the nurse's next intervention?

• Reread the Patient's Bill of Rights to the client.

• Call the client's spouse to discuss the client's statements.

• Tell the client that he can receive adequate pain relief only in the hospital.

• Explain that an advance directive can express the client's wishes.

During the admission process, an elderly client seems confused. The nurse understands that the client's confusion is most likely related to:

• Depression.

• Altered long-term memory.

• Decreased level of consciousness (LOC).

• Stress of an unfamiliar situation.

A client's friend is visibly distressed by the client's condition and lack of improvement. He says he feels powerless and unable to help his friend. How should the nurse respond?

• Agree with the client's friend.

• Tell the client's friend that there's nothing he can do.

• State that she understands how he must feel.

• Ask the client's friend if he'd like to help with comfort measures.

In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is:

• Clarification.

• Reflection.

• Restating.

• Self-disclosure.

A nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells her that he doesn't wish to discuss it. The client refuses to allow his family to visit. The nursing diagnosis that best describes the client's problem is:

• A nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells her that he doesn't wish to discuss it. The client refuses to allow his family to visit. The nursing diagnosis that best describes the client's problem is:

• Powerlessness.

• Disturbed body image.

• Fear.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful? Select all that apply.

• Calling a family meeting to tell the absent children that they must participate in helping the client

• Suggesting the spouse seek psychological counseling to help her cope with exhaustion

• Recommending community resources for adult day care and respite care

• Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease

• Asking whether friends or church members can help with errands or provide short periods of relief

• Recommending that the client be placed in a long-term care facility

A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply.

• Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures.

• Respect the client's cultural beliefs.

• Ask the client if he has cultural or religious requirements that should be considered in his care.

• Explain the nurse's beliefs so that the client will understand the differences.

• Understand that all cultures experience pain in the same way.

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 therapeutic?

• I'll bring you a sedative to calm you down.

• I'll sit here with you for a while. Would it help you to talk about it?

• Don't worry. I'm sure everything will be OK if you just give it time.

• You probably should have had surgery sooner so the tumor could have been caught earlier.

A 74-year-old client has three grown children who have families of their own. The client is retired and looks back on his life with satisfaction. According to Erikson, the nurse assesses that the client is in a stage of:

• Generativity.

• Ego integrity.

• Ego identity.

• Industry.

A client who has been admitted for surgery seems preoccupied and anxious the night before the operation. Which comment by the nurse would promote therapeutic communication?

• Are you worried about your surgery tomorrow?

• Would you like me to call a chaplain to talk with you about any concerns you may have about surgery?

• You seem worried about something. Would it help to talk about it?

• It isn't unusual to worry about surgery. If you'd like, I'll ask the physician for something to help you sleep.

A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the client's anxiety?

• Everything will be fine. Don't worry.

• Read this manual; then ask me any questions you may have.

• Why don't you listen to the radio?

• Let's talk about what's bothering you.

A nurse is trying to establish rapport with a newly admitted client. Which technique promotes effective communication with a client?

• Giving false reassurance

• Asking closed-ended questions

• Giving advice

• Reflecting

After his spouse has visited, a client begins crying and saying that his spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels she can't handle the situation. What should the nurse do at this time?

• Tell the client that his spouse is probably under a lot of stress.

• Instruct the client to stop pounding on the overbed table.

• Call facility security to control the situation.

• Use the call system to request assistance.

A nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife. Becoming tearful, he says he's been spoiled by a happy, satisfying sex life with his wife and says he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?

• Risk for situational low self-esteem

• Unilateral neglect

• Social isolation

• Risk for loneliness

A client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply.

• Take a seat next to the client and sit quietly.

• Take a seat next to the client and sit quietly.

• Leave the room to allow the client to collect his thoughts.

• Say to the client, "You're feeling upset about the news you got about the transplant."

• Say to the client, "The treatments are only 3 days a week. You can live with that."

A 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 is most therapeutic?

• You're wondering whether you've made the right decision about your treatment.

• Many people beat cancer. You need to keep a positive attitude.

• Colon cancer can now be cured in many cases. Let's hope you'll be one of the lucky ones.

• Everyone who has cancer worries, but you have every reason to be hopeful.

A nurse writes a note in a client's chart that says: "The physician is incompetent because he ordered the incorrect drug dosage." This statement may lead to a charge of:

• Assault.

• Slander.

• Battery.

• Libel.

An assessment of a client's orientation is best obtained by:

• Asking the client's name, where he lives, and what time it is.

• Asking the client to repeat a series of three digits spoken slowly.

• Pointing to common objects and asking the client to name them.

• Using the Glasgow Coma Scale and computing the score.

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

• Age

• Previous coping skills

• Self-esteem

• Perception of the problem

A nurse is caring for a 40-year-old client. Which client behavior indicates adult cognitive development?

• The client has perceptions based on reality.

• The client assumes responsibility for actions.

• The client generates new levels of awareness.

• The client demonstrates maximum ability to solve problems and learn new skills.

A client with colorectal carcinoma is devastated after learning that the cancer has spread to the liver and lungs and the client has only a 5% chance of surviving for 5 years. Which comment by the nurse would best help the client cope with this news?

• I've seen clients in your situation who have lived almost 20 years.

• It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?

• This might be a good time to think about an advance directive in case you run into problems while you're here.

• Those are just numbers. You have to live each day fully and not worry about dying.

Two days after undergoing a modified radical mastectomy, a client tells the nurse, "Now I won't be sexually attractive to my husband." Based on this statement, which nursing diagnosis is most appropriate?

• Anxiety

• Disturbed body image

• Ineffective sexuality patterns

• Ineffective coping

While providing care to a married client, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond? Select all that apply.

• Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.

• Report suspicions of abuse to the local authorities.

• Assist the client in developing a safety plan for times of increased violence.

• Call the client's husband to discuss the situation.

• Tell the client that she needs to leave the abusive situation as soon as possible.

• Provide the client with telephone numbers of local shelters and safe houses.

As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond?

• Everyone who is admitted to this facility must sign this. We need to know what we should do in case something unexpected happens.

• I hate talking about this because it may upset you. Federal law requires your wife to sign this and there is nothing we can do about that.

• We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them.

• Hospital policy requires us to have your wife sign this. That doesn't mean that we expect anything to go wrong.

A nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor should the nurse most likely consider?

• Inadequate diet

• Divorce

• Job promotion

• Adopting a child

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of his spouse. Which nursing diagnosis is most appropriate for this client?

• Activity intolerance

• Complicated grieving

• Ineffective role performance

• Impaired physical mobility

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 is most therapeutic?

• Keep your chin up. Things will look better tomorrow.

• You're making great progress. A week ago, you couldn't even get out of bed.

• Why are you feeling so down today? This isn't like you.

• You sound really discouraged today.

A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest?

• Change jobs.

• Take stress-management classes.

• Take stress-management classes.

• Leave work at work.

A nurse approaches a client with a recent colostomy for a routine assessment and finds him tearful. Her most appropriate response would be to:

• State that she'll come back another time.

• Ask the client if he's having pain or discomfort.

• Tell the client that she needs to perform an assessment.

• Sit down with the client and ask if he'd like to talk about anything.

A client is having trouble adjusting to a colostomy that was put in place 4 days ago because of rectal cancer. Which condition is most common?

• Anxiety

• Low self-esteem

• Increased discomfort

• Altered body image

A nurse is caring for a terminally ill client. Place the five stages of death and dying described by Elisabeth Kübler-Ross in the order in which they occur. Use all options.1. Bargaining2. Denila and Isolation3. Acceptance4. Anger5. Depression

A registered nurse (RN) is supervising the work of a licensed practical nurse (LPN) who's caring for a client diagnosed with a terminal illness. Which statement by the LPN should be corrected by the RN?

• Some clients write living wills indicating their end-of-life preferences.

• The law says you must write a new living will each time you're admitted to the hospital.

• You could designate someone to make end-of-life decisions when you can't make them yourself.

• Some people tell their physicians they don't want to have cardiopulmonary resuscitation.

A nurse is caring for a young adult with hepatitis A. The client is crying and saying that she hates the way she looks with yellow skin. Which response is most appropriate?

• I'll leave you alone for awhile until you feel better.

• Don't cry. It doesn't look as bad as you think.

• Try covering your face with a little make-up. The discoloration will be hardly noticeable.

• I know you're upset; your skin will return to its normal color as you get well.