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The nurse is caring for a terminally ill woman who is dying from diagnosed breast cancer. The nurse should know which client behavior is characteristic of anticipatory grieving?
- A. Discusses thoughts and feelings related to loss
- B. Has prolonged emotional reactions and outbursts
- C. Verbalizes unrealistic goals and plans for the future
- D. Ignores untreated medical conditions that require treatment
Correct Answer: A
Rationale: The nurse can determine the client's stage of anticipatory grief by observing the client's behavior. The remaining options are examples of dysfunctional grieving.
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The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which should the nurse assess to yield the best information about this area of functioning?
- A. Judgment
- B. Emotions
- C. Consciousness
- D. Eye movements
Correct Answer: B
Rationale: Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI. The level of consciousness is controlled by the reticular activating system. Insight, judgment, and planning are part of the function of the frontal lobe.
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
- A. Do you have a death wish?'
- B. Do you wish your life was over?'
- C. Do you ever think about ending it all?'
- D. Do you have any thoughts of killing yourself?'
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.