Basic Psychosocial Needs

1. 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.

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.

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.

2. 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

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.

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.

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

Change jobs.

Take stress-management classes.

Leave work at work.

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.

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.

4. 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.

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.

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.

5. 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.

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.

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.

6. 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.

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.

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.

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

Denial and isolation

Depression

Anger

Bargaining

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.

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.

8. A client says to a nurse, "I know I'm going to die." Which response by the nurse would best address the client's statement?

We have special equipment to monitor you and your problem.

Don't worry. We know what we're doing, and you aren't going to die.

Why do you think you're going to die?

Oh no! You're doing quite well considering your condition.

RATIONALE: Asking the client why he thinks he's going to die is a therapeutic approach that reflects on the client's comments, focusing on his specific words. Telling the client that special equipment is available, that the staff knows what to do and not to worry, and that he's doing quite well are nontherapeutic responses. Such statements offer false reassurance and ignore the client's needs.

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.

Explanation

RATIONALE: Asking the client why he thinks he's going to die is a therapeutic approach that reflects on the client's comments, focusing on his specific words. Telling the client that special equipment is available, that the staff knows what to do and not to worry, and that he's doing quite well are nontherapeutic responses. Such statements offer false reassurance and ignore the client's needs.

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.

9. 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

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.

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.

10. 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

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.

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.

11. 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

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.

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.

12. 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.

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.

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.

13. 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?

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.

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.

14. A client, age 40, is admitted for treatment of a breast tumor. She asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic?

Your physician can tell you more about that.

Most women your age have some kind of breast problem.

We won't know for sure until you undergo some tests.

You sound concerned about what the physicians will tell you.

RATIONALE: This response allows the client to express her feelings and promotes further discussion. Referring the client to the physician ends the discussion and prevents exploration of the client's feelings. Generalizing about most women shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

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.

Explanation

RATIONALE: This response allows the client to express her feelings and promotes further discussion. Referring the client to the physician ends the discussion and prevents exploration of the client's feelings. Generalizing about most women shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

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.

15. 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.

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.

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.

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?

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.

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.

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.

17. A client scheduled for cardiac catheterization tells the nurse she's nervous because she's heard of people dying during this procedure. Based on this statement, which nursing diagnosis is most appropriate?

Disturbed body image

Activity intolerance

Complicated grieving

Anxiety

RATIONALE: The client's statements reflect anxiety about the upcoming procedure. Disturbed body image, Activity intolerance, and Complicated grieving aren't appropriate nursing diagnoses based on the client's statement.

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. 967.

Explanation

RATIONALE: The client's statements reflect anxiety about the upcoming procedure. Disturbed body image, Activity intolerance, and Complicated grieving aren't appropriate nursing diagnoses based on the client's statement.

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. 967.

18. 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.

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.

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.

19. 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.

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

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.

20. 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.

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.

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.

21. 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?

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

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.

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.

22. 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?

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

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.

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.

23. On admission, a client is completely immobilized by an acute exacerbation of multiple sclerosis. Two days later, the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of Hopelessness. To address this diagnosis, the nurse should include which intervention in the care plan?

Obtaining an order for sedation

Limiting visitors to 15 minutes per day

Encouraging the client to verbalize feelings

Reinforcing the client's responsibility to the family

RATIONALE: Encouraging clients to verbalize feelings is an example of therapeutic communication, which the nurse uses to help the client express and work through feelings and problems related to his condition. Administering sedation, limiting visits, or reminding the client of his responsibilities wouldn't help him work through 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. 377.

Explanation

RATIONALE: Encouraging clients to verbalize feelings is an example of therapeutic communication, which the nurse uses to help the client express and work through feelings and problems related to his condition. Administering sedation, limiting visits, or reminding the client of his responsibilities wouldn't help him work through 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. 377.

24. 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

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.

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.

25. 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?

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.

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.

26. 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.

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.

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.

Submit

27. 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.

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.

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.

28. 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?

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.

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.

29. 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.

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.

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.

30. A client has just learned that his illness is terminal. Shock and dismay are signs of which stage of the five stages of death and dying?

Denial

Depression

Anger

Bargaining

RATIONALE: Shock and dismay are early signs of denial — the first stage of grief. Depression is the fourth stage of death and dying. Anger is the second stage. Bargaining is the third stage.

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.

Explanation

RATIONALE: Shock and dismay are early signs of denial — the first stage of grief. Depression is the fourth stage of death and dying. Anger is the second stage. Bargaining is the third stage.

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.

31. 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.

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.

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.

32. 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.

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.

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.

33. 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.

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.

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.

34. 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

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.

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.

35. 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.

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.

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.

36. 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

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.

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.

37. 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

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.

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.

38. 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

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.

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.

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

Unplanned

Situational

Maturational

Physiologic

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.

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.

40. 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.

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.

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.

41. A client with an infected abdominal wound must be placed in strict isolation for 10 days. What should the nurse do to help meet the client's emotional needs?

Tell the client that family members and significant others can't visit but may telephone at any time.

Gently explain that the client's movements must be limited while he's in the isolation room.

Describe why the client is in isolation and what will occur there, and reassure the client.

Tell the client to bring whatever personal items he wants into the isolation unit.

RATIONALE: To meet the client's need for information and help reduce his anxiety, the nurse should describe the reasons for isolation and how it's carried out and should also provide reassurance and empathy. To reduce the client's feelings of isolation, visitors should be allowed to spend time with him or telephone. The client needn't limit his movements while in the isolation room. Unnecessary personal items usually aren't permitted in the isolation room.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
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.

Explanation

RATIONALE: To meet the client's need for information and help reduce his anxiety, the nurse should describe the reasons for isolation and how it's carried out and should also provide reassurance and empathy. To reduce the client's feelings of isolation, visitors should be allowed to spend time with him or telephone. The client needn't limit his movements while in the isolation room. Unnecessary personal items usually aren't permitted in the isolation room.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
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.

42. A nurse is assessing a client admitted with end-stage renal failure. The nurse asks the client if he has a legal document that provides instructions for his care and names a health care power of attorney if he can't make his own decisions or express his wishes. What is the name of this document?

Living will

Advance directive

Affidavit

Clinical practice guideline

RATIONALE: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his own wishes. An advance directive includes the living will, which instructs the physician to administer no life-sustaining treatment, and a health care power of attorney, which names another person to make medical decisions on behalf of a client who can't act for himself. An affidavit is a written statement sworn to before a notary public or an officer of the court. A clinical practice guideline is a decision-making tool that practitioners use to determine how most effectively and appropriately to prevent, diagnose, treat, and manage diseases or disorders.

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

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

Explanation

RATIONALE: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his own wishes. An advance directive includes the living will, which instructs the physician to administer no life-sustaining treatment, and a health care power of attorney, which names another person to make medical decisions on behalf of a client who can't act for himself. An affidavit is a written statement sworn to before a notary public or an officer of the court. A clinical practice guideline is a decision-making tool that practitioners use to determine how most effectively and appropriately to prevent, diagnose, treat, and manage diseases or disorders.

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

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

43. 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.

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.

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.

44. 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.

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.

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.

45. 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

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.

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.

46. 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?

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.

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.

47. 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.

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.

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.

48. During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?

Referring a client to support groups

Introducing new issues to the client

Reviewing what's been accomplished during the relationship

Having the client express sadness that the relationship is ending

RATIONALE: The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

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. 369.

Explanation

RATIONALE: The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

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. 369.

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

Height and weight

Blood pressure

Previous problem-solving strategies

Pulse rate

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.

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.

50. 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.

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.

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.

51. 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

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.

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.

52. 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.

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.

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.

Submit

53. Family members report exhaustion and difficulty taking care of a dependent client. The client's interests are best served by:

Asking the client what he wants.

Encouraging family members to discuss the situation among themselves.

Telling the family the client should be transferred to a nursing care facility.

Calling a family conference and asking Social Services for assistance.

RATIONALE: Meeting with Social Services can make the client's family aware of the various types of assistance available to them. Family members may not be aware of alternative care measures available, so encouraging family members to discuss the situation among themselves wouldn't address their concerns. The client should provide input if he's able to do so, but his opinions may not resolve problems related to the family's exhaustion and the difficulty of providing care. The client may not meet stringent criteria for admission to a nursing care facility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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. 161.

Explanation

RATIONALE: Meeting with Social Services can make the client's family aware of the various types of assistance available to them. Family members may not be aware of alternative care measures available, so encouraging family members to discuss the situation among themselves wouldn't address their concerns. The client should provide input if he's able to do so, but his opinions may not resolve problems related to the family's exhaustion and the difficulty of providing care. The client may not meet stringent criteria for admission to a nursing care facility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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. 161.

54. 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

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.

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.

55. 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

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.

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.

56.

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. Bargaining

2. Denila and Isolation

3. Acceptance

4. Anger

5. Depression

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.

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.

Submit

57. 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.

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."

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.

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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58. A nurse is caring for a client who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply.

Illness in one family member can affect all family members.

Family roles don't change because of illness.

A family member may have more than one role at a time in the family.

Children typically aren't affected by adult illness.

The effects of an illness on a family depend on the stage of the family's life cycle.

Changes in sleeping and eating patterns may be signs of stress in a family.

RATIONALE: Illness in one family member can affect all family members, even children. Each member of a family may have several roles to perform. A middle-aged woman, for example, may have the roles of mother, wage-earner, wife, and housekeeper. Families move through certain predictable life cycles (such as a birth, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family may depend on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. When one family member can't fulfill a role because of illness, the roles of the other family members are affected.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
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. 32.

Explanation

RATIONALE: Illness in one family member can affect all family members, even children. Each member of a family may have several roles to perform. A middle-aged woman, for example, may have the roles of mother, wage-earner, wife, and housekeeper. Families move through certain predictable life cycles (such as a birth, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family may depend on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. When one family member can't fulfill a role because of illness, the roles of the other family members are affected.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
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. 32.

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59. 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

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.

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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60. 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.

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1621.

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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