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The nurse is caring for an elderly client admitted for acute confusion in light of a urinary tract infection in the year 2021. When asked today’s year and president, the client tells the nurse that it is 1975 and the president is President Clinton. Which response by the nurse is most appropriate?
A nurse is helping prepare a 58-year-old client for his annual well visit. While speaking with the client, the client discloses that his wife is in the late stages of cancer and he is unsure about how he is going to be able to care for her and their child while she is dying. Which of the following nursing diagnoses would be most appropriate for the nurse to assign the client?
A 23-year-old client is seen in the emergency room for concerns of a simple cyst. Upon further imaging and testing, the client’s cyst was determined to be a malignant tumor. The client tells the nurse, “Those doctors just need to remove this cyst and let me on my way! I didn’t come here to get cancer!” The nurse understands the client is going through which grief reaction?
A nurse is preparing a client admitted for severe anxiety and depressive episodes. The client asks the nurse how to manage her episodes of anxiety and depression outside of the hospital setting. Which response by the nurse is most appropriate?
A nurse is helping a client order lunch. The client requests only foods that fall within the kosher diet due to religious preferences. Which of the following meal choices would be best for the client?
The nurse mediates a group therapy session for clients with severe anxiety. Which of the following behavioral strategies might the nurse offer to the clients to help decrease anxiety?
Select all that apply.
B. guided imagery
C. emotion internalization
A client with bipolar disorder admitted for a depressive episode tells a nurse that he hates his life and he is worthless. The client states that the world would be better off without him and he wants to die. Which response by the nurse is most appropriate?
A nurse is working with a client to help them transition their negative thoughts into positive thoughts. The nurse is demonstrating which behavioral strategy?
A client with schizophrenia is working with a nurse to establish healthy and acceptable behaviors while in a sub-acute psychiatric facility. Which of the following expectations would be an inappropriate goal for the client?
A client with a history of disturbed thought processes begins yelling out into the hallway that his roommate is trying to kill him with a knife. The nurse investigating the situation observes that the client’s roommate is quietly reading a book in their room and denies any of the client’s allegations. There is no knife in the room. Which response by the nurse to the client is most therapeutic?
A client with late-stage dementia is admitted to a long-term healthcare facility. He recently lost his wife to cancer and was unable to care for himself at home due to his cognitive decline. Which of the following nursing diagnoses would be most appropriate for this client?
A nurse is caring for a client in a long-term healthcare facility. Upon review of the client’s chart, the nurse recognizes that the client has refused a bath nightly for 1 week. The client has strong body odor and dirt visible under their nails. Which response by the nurse is most appropriate?
A client with liver cirrhosis and long-term history of alcohol abuse is admitted to the hospital. The nurse should monitor the client closely for which symptoms related to alcohol withdrawal?
Select all that apply.
A. hand tremor
A client with terminal illness near the end of life tells the nurse that in the event that something happens to the client where he is no longer able to make decisions for himself, he has paperwork to allow his wife to make decisions for him. The nurse documents this in the chart as which of the following?
An 89-year-old client in end-stage kidney failure is discussing continuing medical options for his care. He is currently on dialysis three days a week. The client tells the nurse that the burden of dialysis and always being sick is wearing on the client and his family. Which of the following responses by the nurse is most therapeutic?