Basic Psychosocial Needs

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Basic Psychosocial Needs - Quiz

Human behavior changes with the situation they are faced with and one-person actions have a very huge impact on how those around them react in the same situation. How well do you understand the psychosocial needs of those around you and how to advice others dealing with the issues? Take the quiz below to find out.


Questions and Answers
  • 1. 

    Elisabeth Kübler-Ross identifies five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage?

    • A.

      Denial and isolation

    • B.

      Depression

    • C.

      Anger

    • D.

      Bargaining

    Correct Answer
    B. Depression
    Explanation
    RATIONALE: According to Kübler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that may be directed to family members, God, health care workers, and others. In bargaining, the client asks God for more time, and in return promises to do something good.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 987.

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  • 2. 

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

    • A.

      Playing soft or soothing music

    • B.

      Encouraging the client to be less active during the day

    • C.

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

    • D.

      Increasing the client's activity 2 hours before bedtime

    Correct Answer
    A. Playing soft or soothing music
    Explanation
    RATIONALE: Playing soft or soothing music promotes relaxation, which fosters rest and sleep. To promote sleep, the nurse should also encourage the client to increase his activity during the day, avoid providing stimulating beverages (such as caffeinated coffee) in the evening, and offer an evening snack with warm milk. The nurse should also encourage the client to decrease his activity 2 hours before bedtime to promote sleep.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1170.

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  • 3. 

    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.

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    • E.

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

    Correct Answer(s)
    B. Let's talk about your mother's illness and how it will progress.
    C. You sound like you have some questions about your mother dying. Let's talk about that.
    E. Tell me how you're feeling about your mother dying.
    Explanation
    RATIONALE: Conveying information and providing clear communication can alleviate fears and strengthen the individual's sense of control. Encouraging verbalization of feelings helps build a therapeutic relationship based on trust and reduces anxiety. Telling the daughter not to worry ignores her feelings and discourages further communication.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 491.

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  • 4. 

    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?

    • A.

      Making decreased eye contact

    • B.

      Asking to see family members

    • C.

      Joking about his present condition

    • D.

      Sleeping undisturbed for 3 hours

    Correct Answer
    D. Sleeping undisturbed for 3 hours
    Explanation
    RATIONALE: Sleeping undisturbed for a period of time indicates that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 969.

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  • 5. 

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

    • A.

      To determine whether the client is psychologically ready for surgery

    • B.

      To express concerns to the client about the surgery

    • C.

      To reduce the risk of postoperative complications

    • D.

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

    Correct Answer
    C. To reduce the risk of postoperative complications
    Explanation
    RATIONALE: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness for surgery. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks to the client when obtaining informed consent.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 886.

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  • 6. 

    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?

    • A.

      You're doing fine.

    • B.

      What is your biggest concern right now?

    • C.

      Give it some time and you'll be OK.

    • D.

      You don't believe you're doing well?

    Correct Answer
    B. What is your biggest concern right now?
    Explanation
    RATIONALE: Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 491.

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  • 7. 

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

    • A.

      Discussing the client's concern with her husband

    • B.

      Referring the client to a psychiatrist

    • C.

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

    • D.

      Referring the client to a sex therapist

    Correct Answer
    C. Inviting a client who has had a similar experience to speak with this client
    Explanation
    RATIONALE: Having someone who has had a similar surgery and concerns speak with this client would be beneficial. Discussing the client's concerns with her husband doesn't address the client's needs. She is coping normally and doesn't need professional help. In fact, the client may feel that the nurse violated confidentiality.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1147.

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  • 8. 

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

    • A.

      Unplanned

    • B.

      Situational

    • C.

      Maturational

    • D.

      Physiologic

    Correct Answer
    B. Situational
    Explanation
    RATIONALE: Adjustment to the birth of a child is an example of a situational change, which arises from interaction between individuals and their environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to maturation associated with puberty. Physiologic change refers to events associated with aging and menopause.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 527.

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  • 9. 

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

    • A.

      Banning personal belongings from the bedside

    • B.

      Involving the family and the client in planning care

    • C.

      Providing detailed explanations of the client's conditions and treatment

    • D.

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

    Correct Answer
    B. Involving the family and the client in planning care
    Explanation
    RATIONALE: For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse should provide simple, not detailed, explanations to the client and his family because stress may have diminished their comprehension. The nurse should encourage the family to visit as often as the client's condition permits.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1298.

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  • 10. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

      You think you have cancer?

    Correct Answer
    D. You think you have cancer?
    Explanation
    RATIONALE: This response acknowledges the client's concern and shows the nurse's willingness to listen. Although a biopsy is the only way to confirm cancer, telling the client this wouldn't permit him to discuss his concerns. Urging the client not to worry or advising him to maintain a positive attitude is an overused response. Offering advice about how he should handle the problem wouldn't be therapeutic either.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 11. 

    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:

    • A.

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

    • B.

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

    • C.

      You seem upset this morning.

    • D.

      You've had your light on for 20 minutes?

    Correct Answer
    C. You seem upset this morning.
    Explanation
    RATIONALE: To be therapeutic, the nurse should always comment on the client's statements. The client's words are strong, and it's obvious that he's angry. By introducing herself or apologizing, the nurse ignores the client's problem. Repeating the client's statement would only add to his anger.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 12. 

    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?

    • A.

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

    • B.

      I'm sure a cure will be found soon.

    • C.

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

    • D.

      Would you like to talk about this?

    Correct Answer
    D. Would you like to talk about this?
    Explanation
    RATIONALE: Listening, responding quickly, and providing support promote therapeutic communication. Offering to talk about the client's feelings validates those feelings and allows the client to express them. Telling the client not to worry and saying a cure will be found soon ignores the client's feelings. Stating that the client seems unhappy then attempting to change the subject identifies the client's feelings but doesn't follow through by exploring them.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 13. 

    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?

    • A.

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

    • B.

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

    • C.

      They allow physicians to make decisions about treatment.

    • D.

      They permit physicians to give verbal DNR orders.

    Correct Answer
    A. They guide the client's treatment in certain health care situations.
    Explanation
    RATIONALE: Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can't give those instructions personally when required. Depending on the client's wishes, an advance directive may or may not include DNR orders. Advance directives allow the client, not the physician, to make decisions about treatment. They don't permit verbal orders; all physician's orders must be written and signed.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 881.

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  • 14. 

    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?

    • A.

      Encouraging the client to suppress his feelings regarding obesity

    • B.

      Reinforcing the client's concerns about his physical appearance

    • C.

      Communicating with the client in an abrupt, forceful manner

    • D.

      Teaching the client alternative ways to lose weight

    Correct Answer
    D. Teaching the client alternative ways to lose weight
    Explanation
    RATIONALE: Teaching the client alternative ways to lose weight is the appropriate intervention. Instead of encouraging the client to suppress his feelings, the nurse should encourage him to express them, especially feelings related to obesity. Reinforcing the client's concerns about his physical appearance worsens his anxiety and leads to more self-destructive behavior. An abrupt, forceful manner discourages therapeutic communication with the client.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 15. 

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

    • A.

      Most people your age develop some type of colon problem.

    • B.

      Your physician can discuss this in more detail.

    • C.

      You sound concerned about what's happening.

    • D.

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

    Correct Answer
    C. You sound concerned about what's happening.
    Explanation
    RATIONALE: This response conveys empathy and invites further discussion of the client's concerns. The other options block communication by failing to address the client's concerns and feelings.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 16. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    D. Taking several medications can be difficult. Tell me about the difficulties you're having.
    Explanation
    RATIONALE: Acknowledging that a multidrug regimen can be difficult conveys empathy. Asking the client to discuss difficulties promotes active participation. The nurse may then provide more education and help remove such potential obstacles to compliance as lack of finances. The other responses are closed questions that require only a yes-or-no answer. They also have an adversarial tone and are judgmental, blocking further therapeutic communication. "Why" questions should be avoided because clients may interpret such questions as accusations and become defensive.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 17. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    D. Explain that an advance directive can express the client's wishes.
    Explanation
    RATIONALE: The nurse should explain how an advance directive can be used to express the client's wishes. An advance directive is a legal document that's used as a guideline for life-sustaining medical care of the client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the physician not to administer life-sustaining treatment, and a health care power of attorney, which names another person to act on the client's behalf for medical decisions in the event that the client can't act for himself. The Patient's Bill of Rights doesn't specifically address the client's wishes regarding future care. Calling the spouse is a breach of the client's right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge on the nurse's part of the resources available through collaboration with hospice and home care agencies.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 990.

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  • 18. 

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

    • A.

      Depression.

    • B.

      Altered long-term memory.

    • C.

      Decreased level of consciousness (LOC).

    • D.

      Stress of an unfamiliar situation.

    Correct Answer
    D. Stress of an unfamiliar situation.
    Explanation
    RATIONALE: The stress of being in an unfamiliar situation, such as admission to a hospital, can cause confusion in elderly clients. Depression doesn't produce confusion, but it can cause mood changes, weight loss, anorexia, constipation, and early-morning awakening. In elderly clients, long-term memory usually remains intact, although short-term memory may be altered. Decreased LOC doesn't normally result from aging; therefore, it's a less likely cause of confusion in this client.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1256.

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  • 19. 

    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?

    • A.

      Agree with the client's friend.

    • B.

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

    • C.

      State that she understands how he must feel.

    • D.

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

    Correct Answer
    D. Ask the client's friend if he'd like to help with comfort measures.
    Explanation
    RATIONALE: The client's friend expressed a need to help. The nurse should encourage him to do whatever he feels comfortable doing, such as applying lubricant to the client's lips, placing a moist cloth on the forehead, or applying lotion to the client's skin. Agreeing with the client's friend or stating that she understands how the friend feels doesn't diminish the friend's sense of powerlessness. There are many ways the client's friend can help if he chooses to do so.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 965.

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  • 20. 

    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:

    • A.

      Clarification.

    • B.

      Reflection.

    • C.

      Restating.

    • D.

      Self-disclosure.

    Correct Answer
    D. Self-disclosure.
    Explanation
    RATIONALE: Self-disclosure involves the nurse revealing personal information. Using self-disclosure as a therapeutic communication technique facilitates an open and authentic relationship between the nurse and her client. Clarification involves the nurse asking the client for more information. Reflection involves reviewing the client's ideas. Restating is the nurse's repetition of the client's main message.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 21. 

    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.

      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:

    • B.

      Powerlessness.

    • C.

      Disturbed body image.

    • D.

      Fear.

    Correct Answer
    C. Disturbed body image.
    Explanation
    RATIONALE: Disturbed body image is a negative perception of self that makes healthful functioning difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part, refusing to look at a body part, and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may be a candidate for nursing diagnoses of Hopelessness, Powerlessness, and Fear but the signs and symptoms described in the case most closely match the defining characteristics for Disturbed body image.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1279.

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  • 22. 

    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.

    • A.

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

    • B.

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

    • C.

      Recommending community resources for adult day care and respite care

    • D.

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

    • E.

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

    • F.

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

    Correct Answer(s)
    C. Recommending community resources for adult day care and respite care
    D. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease
    E. Asking whether friends or church members can help with errands or provide short periods of relief
    Explanation
    RATIONALE: Many community services exist for Alzheimer's clients and their families. Use of these resources may make it possible for the client to stay at home and alleviate the spouse's exhaustion. The nurse can also support the caregiver by urging her to talk about the difficulties she's facing in caring for her spouse. Friends and church members may be able to help provide care to the client, allowing the caregiver time for rest, exercise, or an enjoyable activity. A family meeting to tell the children to participate more would probably be ineffective and may evoke anger or guilt. Counseling might be helpful, but it wouldn't alleviate the caregiver's physical exhaustion and wouldn't address the client's immediate needs. A long-term care facility isn't an option until the family is ready to make that decision.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 246.

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  • 23. 

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

    • A.

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

    • B.

      Respect the client's cultural beliefs.

    • C.

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

    • D.

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

    • E.

      Understand that all cultures experience pain in the same way.

    Correct Answer(s)
    A. Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures.
    B. Respect the client's cultural beliefs.
    C. Ask the client if he has cultural or religious requirements that should be considered in his care.
    Explanation
    RATIONALE: Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect; in another, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs and ask if he has cultural requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture; it isn't the client's responsibility to understand the nurse's culture. The nurse should never impose her own beliefs on her clients. Culture influences a client's experience with pain. For example, in one culture pain may be openly expressed; whereas in another culture it may be quietly endured.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 43.

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  • 24. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    B. I'll sit here with you for a while. Would it help you to talk about it?
    Explanation
    RATIONALE: In this response, the nurse is engaging in active listening, a therapeutic communication technique that promotes interactions focused on the client's feelings and concerns. Addressing the client's feelings validates her as a person and helps establish trust. Sedating the client would delay dealing with her feelings. Telling the client not to worry and suggesting that the client should have had surgery sooner are nontherapeutic responses that would prevent the nurse from helping the client recognize and deal with her feelings.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 25. 

    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:

    • A.

      Generativity.

    • B.

      Ego integrity.

    • C.

      Ego identity.

    • D.

      Industry.

    Correct Answer
    A. Generativity.
    Explanation
    RATIONALE: At age 74, an adult is in the stage of generativity versus stagnation. Ego integrity, ego identity, and industry all apply to earlier stages of development.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 400.

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  • 26. 

    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?

    • A.

      Are you worried about your surgery tomorrow?

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    C. You seem worried about something. Would it help to talk about it?
    Explanation
    RATIONALE: Sharing the observation that the client seems anxious and then offering to discuss the client's concerns promotes therapeutic communication. Asking if the client is worried is a closed-ended question (one requiring only a yes-or-no answer), which doesn't promote therapeutic communication as effectively. Asking whether the nurse should call a chaplain or offering to intervene based on assumptions about the cause of the client's behavior would be inappropriate.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 27. 

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

    • A.

      Everything will be fine. Don't worry.

    • B.

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

    • C.

      Why don't you listen to the radio?

    • D.

      Let's talk about what's bothering you.

    Correct Answer
    D. Let's talk about what's bothering you.
    Explanation
    RATIONALE: Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the client to express his feelings. The nurse should be supportive and help the client develop goals that will give him some control over an anxiety-inducing situation. Because the other options ignore the client's feelings and block communication, they wouldn't reduce the client's anxiety.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 28. 

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

    • A.

      Giving false reassurance

    • B.

      Asking closed-ended questions

    • C.

      Giving advice

    • D.

      Reflecting

    Correct Answer
    D. Reflecting
    Explanation
    RATIONALE: Reflecting, the process of repeating or restating a client's statement so the client will continue to explore his feelings, promotes effective communication. Giving false reassurance minimizes the client's fears and violates the client's trust in the nurse. False reassurance may also increase the client's anxiety. Giving advice decreases the client's responsibilities and may make the nurse appear controlling. Asking closed-ended questions limits the client's involvement in the conversation and elicits less information than open-ended questions.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 29. 

    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?

    • A.

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

    • B.

      Instruct the client to stop pounding on the overbed table.

    • C.

      Call facility security to control the situation.

    • D.

      Use the call system to request assistance.

    Correct Answer
    D. Use the call system to request assistance.
    Explanation
    RATIONALE: A nurse who feels she can't handle a problem should use the call system to seek assistance. Telling the client his 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.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 678.

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  • 30. 

    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?

    • A.

      Risk for situational low self-esteem

    • B.

      Unilateral neglect

    • C.

      Social isolation

    • D.

      Risk for loneliness

    Correct Answer
    A. Risk for situational low self-esteem
    Explanation
    RATIONALE: The signs and symptoms described in this case are all characteristic of a client with low self-esteem. The diagnosis of Unilateral neglect occurs in neurologic illness or trauma when the client shows a lack of awareness of a body part. This client is at risk for social isolation and loneliness, but there is no indication that these diagnoses are present.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1279.

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  • 31. 

    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.

    • A.

      Take a seat next to the client and sit quietly.

    • B.

      Take a seat next to the client and sit quietly.

    • C.

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

    • D.

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

    • E.

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

    Correct Answer(s)
    A. Take a seat next to the client and sit quietly.
    D. Say to the client, "You're feeling upset about the news you got about the transplant."
    Explanation
    RATIONALE: Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain conversation. By reflecting the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse shouldn't leave the client alone because he might harm himself. Reminding the client of the treatment frequency doesn't address his feelings.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 489.

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  • 32. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    A. You're wondering whether you've made the right decision about your treatment.
    Explanation
    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 33. 

    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:

    • A.

      Assault.

    • B.

      Slander.

    • C.

      Battery.

    • D.

      Libel.

    Correct Answer
    D. Libel.
    Explanation
    RATIONALE: Libel refers to written communication that harms a person's reputation. Assault is an unjustifiable attempt or threat to touch or injure another person. Slander is oral communication that injures a person's reputation. Battery refers to touching another person unlawfully or carrying out threatened physical harm.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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  • 34. 

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

    • A.

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

    • B.

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

    • C.

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

    • D.

      Using the Glasgow Coma Scale and computing the score.

    Correct Answer
    A. Asking the client's name, where he lives, and what time it is.
    Explanation
    RATIONALE: To help assess orientation, the nurse asks the client direct questions about time, place, and person, such as what day or time of day it is, where the client lives, and his name. Asking the client to repeat a series of digits assesses memory, not orientation. Pointing to common objects and asking the client to name them assesses language deficits. The Glasgow Coma Scale assesses level of consciousness, not orientation.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Analysis

    REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 611.

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  • 35. 

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

    • A.

      Age

    • B.

      Previous coping skills

    • C.

      Self-esteem

    • D.

      Perception of the problem

    Correct Answer
    B. Previous coping skills
    Explanation
    RATIONALE: 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.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 931.

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  • 36. 

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

    • A.

      The client has perceptions based on reality.

    • B.

      The client assumes responsibility for actions.

    • C.

      The client generates new levels of awareness.

    • D.

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

    Correct Answer
    C. The client generates new levels of awareness.
    Explanation
    RATIONALE: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Young adults ages 20 to 30 demonstrate maximum ability to solve problems and learn new skills.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 297.

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  • 37. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    B. It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?
    Explanation
    RATIONALE: This response is most therapeutic because it encourages the client to express feelings and concerns. Options 1 and 4 offer false hope and reflect the nurse's empirical observations, not statistics. Option 3 is inappropriate because an informed person who isn't a member of the health care team should discuss (at the client's request) which level of care the client wishes to receive in case of an emergency.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 491.

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  • 38. 

    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?

    • A.

      Anxiety

    • B.

      Disturbed body image

    • C.

      Ineffective sexuality patterns

    • D.

      Ineffective coping

    Correct Answer
    B. Disturbed body image
    Explanation
    RATIONALE: A verbal response to an actual change in physical appearance or structure indicates Disturbed body image, a disruption in the way one perceives one's body. The client may be experiencing anxiety, but her statement doesn't reflect this specifically. She doesn't report an existing difficulty with sexual behavior, which would indicate an ineffective sexuality pattern, nor has she expressed an inability to cope.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1279.

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  • 39. 

    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.

    • A.

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

    • B.

      Report suspicions of abuse to the local authorities.

    • C.

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

    • D.

      Call the client's husband to discuss the situation.

    • E.

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

    • F.

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

    Correct Answer(s)
    A. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.
    C. Assist the client in developing a safety plan for times of increased violence.
    F. Provide the client with telephone numbers of local shelters and safe houses.
    Explanation
    REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1621.

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  • 40. 

    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?

    • A.

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

    • B.

      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.

    • C.

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

    • D.

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

    Correct Answer
    C. We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them.
    Explanation
    RATIONALE: Telling the client's husband that clients have the right to specify advance directives and appoint someone to speak for them provides factual information. The other options don't answer the husband's question or provide the information he requested.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 373.

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  • 41. 

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

    • A.

      Inadequate diet

    • B.

      Divorce

    • C.

      Job promotion

    • D.

      Adopting a child

    Correct Answer
    A. Inadequate diet
    Explanation
    RATIONALE: Poor, inadequate diet is the only option considered a lifestyle factor. Divorce, job promotion, and adopting a child are considered life events.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 980.

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  • 42. 

    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?

    • A.

      Activity intolerance

    • B.

      Complicated grieving

    • C.

      Ineffective role performance

    • D.

      Impaired physical mobility

    Correct Answer
    B. Complicated grieving
    Explanation
    RATIONALE: Behavioral manifestations of Complicated grieving include changes in eating habits, sleep patterns, and activity levels. Diagnoses of Activity intolerance, Ineffective role performance, and Impaired physical mobility don't include these defining characteristics.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1323.

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  • 43. 

    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?

    • A.

      Keep your chin up. Things will look better tomorrow.

    • B.

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

    • C.

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

    • D.

      You sound really discouraged today.

    Correct Answer
    D. You sound really discouraged today.
    Explanation
    RATIONALE: Sharing an observation with the client conveys awareness of his feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 376.

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  • 44. 

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

    • A.

      Change jobs.

    • B.

      Take stress-management classes.

    • C.

      Take stress-management classes.

    • D.

      Leave work at work.

    Correct Answer
    B. Take stress-management classes.
    Explanation
    RATIONALE: The nurse should suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach him how to manage stress more effectively. The client may not have to leave a job he enjoys. The information provided by the client doesn't indicate that spending too little time with his family and taking his job home with him contribute to the client's stress.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1353.

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  • 45. 

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

    • A.

      State that she'll come back another time.

    • B.

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

    • C.

      Tell the client that she needs to perform an assessment.

    • D.

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

    Correct Answer
    D. Sit down with the client and ask if he'd like to talk about anything.
    Explanation
    RATIONALE: Asking open-ended questions and appearing interested in what the client has to say will encourage him to verbalize his feelings. Leaving, even with the promise to come back later, may make the client feel unaccepted. Asking closed-ended questions won't encourage the client to verbalize his feelings. Ignoring the client's present state isn't therapeutic.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 491.

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  • 46. 

    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?

    • A.

      Anxiety

    • B.

      Low self-esteem

    • C.

      Increased discomfort

    • D.

      Altered body image

    Correct Answer
    D. Altered body image
    Explanation
    RATIONALE: 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 he 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 he did before the surgery.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1150.

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  • 47. 

    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

    Correct Answer
    24153
    Explanation
    RATIONALE: According to Kübler-Ross, the order of the five stages of death and dying is denial and isolation, anger, bargaining, depression, and acceptance.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 988.

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  • 48. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    B. The law says you must write a new living will each time you're admitted to the hospital.
    Explanation
    RATIONALE: One living will is sufficient for all hospitalizations unless the client wishes to make changes. A client's no-code or do-not-resuscitate (DNR) status is discussed with the physician, who then enters it into the client's chart. A living will explains an individual's end-of-life preferences. A health care power of attorney designates who will make health care decision for the client if the client can't make decisions for himself.

    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

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  • 49. 

    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?

    • A.

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

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    D. I know you're upset; your skin will return to its normal color as you get well.
    Explanation
    RATIONALE: The nurse must communicate honestly and give the client factual information about her appearance. Leaving the client alone or telling her not to cry ignores the client's feelings and needs. Make-up wouldn't conceal her jaundiced appearance, so using it might upset her more.

    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

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  • 50. 

    A nurse is assessing an adult's developmental stage. Which factor should the nurse consider?

    • A.

      Height and weight

    • B.

      Blood pressure

    • C.

      Previous problem-solving strategies

    • D.

      Pulse rate

    Correct Answer
    C. Previous problem-solving strategies
    Explanation
    RATIONALE: The nurse can use previous problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning. Height and weight, blood pressure, and pulse rate refer to physiological attributes.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

    REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 297.

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