woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who
... [Show More] tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention?
o Reassure the husband that his wife will be treated well while he is in the
waiting area.
o Require the husband to leave the cubicle while the client is being treated.
Correct
o Ask the hospital security to remove the husband from the treatment room.
o Notify the local police of a suspected spousal abuse situation. Incorrect
This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority, and (D) is the best method of providing this separation. (A) is not the priority at this time, and permission to notify the police should be obtained from the client. (B) is premature.
Abusive husbands are unlikely to respond to manipulation (C) and are also unlikely to leave based on reassurances alone.
Awarded 0.0 points out of 5.0 possible points.
2. 2.ID: 311187983
A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?
o Inquire about emotional factors affecting the client's present condition.
Correct
o Assess priorities to be set for the client's overall nursing care plan.
o Assist the client in verbalizing distress about the disease.
o Encourage the client to emotionally accept the chronicity of the disease.
Holistic care considers biological, psychological, and sociocultural factors that influence one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition (B) should be made. The client is expressing distress, so (A) is redundant. Although priorities (C) should be determined, the client's current emotional distress should be addressed at this time. (D) is not indicated at this time.
Awarded 5.0 points out of 5.0 possible points.
3. 3.ID: 311194939
During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing?
o Focusing.
o Reflection. Incorrect
o Clarification.
o Self-Awareness. Correct
Self-awareness (C) defines the nurse's awareness of his or her own feelings while empathizing with the client. (A) involves restating what the client is saying. (B) involves asking the client to explain feelings more specifically. (D) directs the client to focus on emotional or behavioral responses to feelings.
Awarded 0.0 points out of 5.0 possible points.
4. 4.ID: 311251944
A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client?
o A suicidal client who has made a highly-lethal attempt.
o A client who refuses a blood transfusion due to religious beliefs.
o A client who is planning to have an elective abortion.
o A terminally ill and depressed client with cancer. Correct
A nurse who believes in the sanctity of life may find it difficult to relate to individuals who do not place the same high level of value on life. Clients with cancer, who have not made a conscious decision to end their lives, are most likely to be easily understood by this nurse (A). The clients in (B, C, and D) have exhibited behaviors contrary to the nurse's beliefs, and it may be more difficult for this nurse to empathize with their situation. Category: Psychiatric Mental Health
Awarded 5.0 points out of 5.0 possible points.
5. 5.ID: 311199868
A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse?
o Collect a specimen for a blood alcohol level (BAL).
o Review the results of a Breathalyzer obtained in the emergency department upon admission.
o Do nothing because the time for BAL determination is passed.
o Ask the client about the quantity, frequency, and time the last alcohol drink was ingested. Correct
The priority assessment is to determine the client's risk for alcohol withdrawal, which can appear within 48 hours since the ingestion of the last alcoholic drink, so (D) is priority.
(A) is not indicated at this time. The client with a history of alcoholism is at risk for delirium tremens (DT), which can develop within 48 to 96 hours of the last drink, and should be monitored for symptoms of confusion, hallucinations, and severe autonomic nervous system hyperactivity, not (B). Although (C) may provide data that confirms recent alcohol ingestion, it does not provide historical client information that may indicate the client's risk for DT, a life-threatening syndrome.
Awarded 5.0 points out of 5.0 possible points.
6. 6.ID: 311255958
A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?
o I have known many clients with depression who have felt better after several
weeks of treatment. Correct
o You are no bother to me or to the staff. We want you to get well and not feel sad anymore. Incorrect
o You are feeling very pessimistic, but that is part of your illness. It should go
away as you recover.
o You need to stop thinking negative thoughts. They get in the way of your
recovery.
Stating the observation that others have recovered can give a client hope (C). (A) is ineffective because the client must be taught cognitive strategies to stop negative thinking. (B) is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. (D) interprets the client's feelings and does not provide the same degree of hope. Category: Psychiatric Mental Health
Awarded 0.0 points out of 5.0 possible points.
7. 7.ID: 311192091
Which client statement should the nurse identify as most typical of a client with mania?
o I manage our finances great because I buy in big quantities. Correct
o I can't understand where all our money goes.
o I can't do anything anymore.
o I wonder why my wife is so upset that I spend money easily.
A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflated self-esteem, grandiosity, and a tendency for excessiveness, such as excessive spending (C). (A) is a statement of dispair that is more likely made by a client with depression.
Although a client with mania may lack insight (B) regarding the impact that excessive, bizarre behaviors have on the lives around them (D), the diagnostic criteria that hallmarks mania is excessive involvement in pleasurable activities with painful consequences.
Awarded 5.0 points out of 5.0 possible points.
8. 8.ID: 311223476
A 13-year-old female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement?
o Ask her mother to please stay with her throughout the assessment procedures.
o Tell the client that her fear is understandable under these circumstances.
o Reassure client that the male UAP is a staff member who wants to help her.
o Reassign an all-female healthcare team to the client until her fear subsides.
Correct
A traumatized client needs to be in a non-threatening environment, and reassigning this client to all-female personnel is likely to reduce her anxiety (C). (A) is negating her fear. While validating the client's feeling (B) is important, this statement does not specifically address the client's issue with the male UAP. (D) might be helpful, but it ignores the anxiety the client feels about the presence of a male UAP.
Awarded 5.0 points out of 5.0 possible points.
9. 9.ID: 311192055
The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care?
o Introduce the client to others on the unit.
o Move to a room that allows close observation.
o Ask the client about recent stressful events.
o Search the client's personal belongings. Correct
To ensure that the client has not acquired some means to inflict self harm, a routine search of personal belongings (A), which is a common safety measure and policy, should be implemented until the client stabilizes and suicidal ideations abate. (B) is a component of the therapeutic milieu, but the client's readiness to interact with others should be assessed first. Although recent stressors (C) may have precipitated the suicide attempt, it is more important to ensure the client's safety from self-harm. Close observation should be initiated (D), but it is most important that any hazardous items are removed from the client's possession.
Awarded 5.0 points out of 5.0 possible points.
10. 10.ID: 311203316
A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy?
o Existential.
o Medical.
o Psychoanalytical. Correct
o Interpersonal.
The psychoanalytical model (D) uses concepts that interpret and focus on working through previously unresolved conflicts. The medical model (A) focuses on the diagnosis of a mental illness and its subsequent treatments, such as somatic treatments, pharmacotherapy, and electroconvulsive therapy. The existential model (B) focuses on the person's experience in the here and now, with much less attention focused on the person's past. The interpersonal model (C) focuses on the belief that behavior evolves around interpersonal relationships.
Awarded 5.0 points out of 5.0 possible points [Show Less]