Psychosocial Assessment

A 48-year-old client experiences an exacerbation of multiple sclerosis after being asymptomatic for the past 6 months. How can the nurse best help the client deal with personal fears at this time?

Diagnostic tests confirm that the client’s adrenal glands are producing excessive amounts of adrenocortical hormones. What comorbidity is the client with Cushing’s syndrome likely to experience?

A 75-year-old client in a skilled nursing facility has peripheral arterial disease (PAD). The client with PAD says to the nurse, “No matter what I do, my legs get painful and then numb.” What nursing response is best?

The nurse in a long-term care facility is required by the state’s law to test all newly admitted clients for tuberculosis. The policy of the agency is to administer a Mantoux skin test. The client being cared for with transmission-based precautions feels shunned and abandoned and exhibits signs of sensory deprivation. What nursing measure would be most helpful?

A client is admitted to the hospital with signs and symptoms suggesting cholecystitis. As the nurse takes the client’s admission history, dietary preferences are discussed. The client requests Kosher meals. When the food tray is delivered, it is not marked as Kosher. Which foods would the nurse remove from the dietary tray? Select all that apply.

A low-sodium diet is recommended for a client with hypertension. A nurse responds to a client’s concern that the stress level experienced while at work causes the blood pressure to remain in hypertensive ranges. What nursing suggestion is best?

An unlicensed assistive personnel confides to the nurse that a family member needs eyeglasses. What nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has both eyes patched?

The client with the gastrostomy is silent and withdrawn as the nurse cares for the insertion site. What nursing statement is most appropriate for encouraging the client’s expression of feelings?

The client with urinary incontinence says to the nurse, “What’s the sense in living? I’m just a baby nowadays.” What comment is the best response the nurse can offer?

The nurse is caring for a client in her 8th week of pregnancy who has had two previous miscarriages. The client states, “I do not want to be invested in this pregnancy right now as it is too hard when I lose the baby.” What statement by the nurse is best?

A 16-year-old client confides to the school nurse that she has cramps that accompany the onset of menstruation. The client with possible premenstrual syndrome (PMS) tells the nurse, “I become an irritable witch each month.” What nursing response is most therapeutic?

The nurse in a well-baby clinic assesses the growth and development of healthy infants and toddlers and uses that information as a basis for teaching. The nurse is caring for an Asian infant brought to the emergency department after a motor vehicle accident. When a cluster of family members are present, to whom should the nurse direct questions regarding the infant’s health history?

A 26-year-old primigravid client at 40 weeks’ gestation is admitted to the hospital after contacting the health care provider about not having felt the baby move for 24 hours. The nurse is unable to detect a fetal heartbeat using the external fetal monitor. The health care provider examines the client and determines that there has been intrauterine fetal demise (the fetus is dead). An infusion of oxytocin is prescribed for induction of labor. The client is crying and tells the nurse, “This cannot be true. You must have made a mistake.” What nursing intervention is most appropriate?

Applying heat to the client’s hands to relieve discomfort is recommended. What form of heat application is best for the nurse to suggest?

After the screening test, one client is referred for additional follow-up. Further diagnostic tests confirm that the client has type 2 diabetes mellitus. When given the news, the client becomes angry, stating there has been a mistake in the tests. What nursing action is most appropriate at this time?

The nurse observes the unlicensed assistive personnel ambulating a blind client. What nursing action is best for promoting a blind client’s feeling of self-reliance when eating?

When a client experiences an increased number of anginal episodes, a cardiac catheterization and coronary arteriogram are prescribed. What nursing action can best help reduce the client’s anxiety in this situation?

A high school student presents with fatigue and a low-grade fever. The nurse interacts with the parent of the client with infectious mononucleosis who reports having arguments as a consequence of controlling the adolescent’s extracurricular activities. What nursing response is best?

The health care provider prescribes 0.1 mg of epinephrine subcutaneously for the client. The label indicates that the epinephrine is a 1:1,000 dilution, which means that 1 g of epinephrine has been mixed with 1,000 mL of liquid. What nursing measure is most helpful in reducing the client’s anxiety during an asthma attack?

A client presents to the clinic with abdominal pain. The nurse performs a cultural assessment and learns that the client has a strong belief in the hot-cold theory of diseases.  If the nurse understands the client’s beliefs regarding the hot-cold theory and its effect on health and illness, what statement describes those beliefs most accurately?

A 16-year-old client confides to the school nurse that she has cramps that accompany the onset of menstruation. When interacting with the client with potential premenstrual syndrome (PMS), what nursing action is most beneficial for reducing the client’s feelings of being a victim of her cyclical symptoms?

A 46-year-old client is hospitalized to determine the cause of intermittent gnawing epigastric pain. The admitting nurse obtains the client’s health history and suspects a peptic ulcer. During the client’s admission interview, the client reports being a victim of recurring intimate partner violence.  What is the most important nursing action at this time?

When it becomes evident that the client will require long-term hemodialysis, an internal arteriovenous fistula is created. What nursing intervention is most helpful in assisting the client undergoing hemodialysis to cope with the chronic health condition?

The client comments to the nurse, “This is like a recurring nightmare. This same thing happened during my last two pregnancies. I do not want to lose another fetus.” What response by the nurse is most appropriate at this time?

The baby is delivered stillborn. After the client is stabilized, she is transferred to a private room on a wing adjacent to the labor, delivery, recovery, and postpartum (LDRP) unit. The client’s spouse is present. The client asks the nurse about seeing the newborn. What action is most appropriate for the nurse to take?

The nurse provides instructions about the proper administration of oral medications in liquid form to the parents of an infant. The parents of a 3-year-old child report acting-out behaviors since the birth of a sibling. What is the best instruction for parents who are helping the child overcome the rivalry created by the birth?

A client experienced a cerebral vascular accident (CVA) and is in the rehabilitative stage. The client’s spouse notices situations during which the client laughs or cries inappropriately. The spouse asks the nurse, “Why are these mood swings occurring?” What is the best response by the nurse?

The client expresses concerns about the impending stapedectomy and says to the nurse, “There are so many awful complications that can happen with this surgery.” What response by the nurse is most therapeutic to the client in this situation?

A client is undergoing a coronary artery bypass graft (CABG) procedure. The nurse assesses the client’s mental status upon being transferred from the postanesthesia recovery (PAR) room. The best explanation the nurse can attribute to incorrect answers to the nurse’s questions is that the client:

A client with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital with an opportunistic respiratory infection. The client’s statements to the nurse imply a sense of hopelessness. When planning care for this client, what approach is most therapeutic?

The client with a pulmonary embolism suddenly experiences chest pain and dyspnea and tells the nurse, “I think I am dying.”  What nursing response is best at this time?

A nurse working in a health care provider’s office receives a telephone call from a frantic person whose family member is choking on a piece of hard candy. The friend of the client who has overdosed becomes hysterical. What nursing action is best for managing the friend’s distress?

After the client has been maintained on NPO (nothing by mouth) status for several days, the nasogastric (NG) tube is removed and the client is placed on a bland, low-fat diet. What food should the nurse remove from the client’s breakfast tray?

A 59-year-old client with ovarian cancer is receiving antineoplastic chemotherapy after undergoing a total hysterectomy. The nurse adds the priority of anxiety due to recent cancer diagnosis and the inability to complete routine activities to list of client concerns. What client outcome, if met, best reflects improvement in client status?

The client is informed that the pancreatic cancer has metastasized, making aggressive treatment unrealistic. The client’s condition is terminal. The client asks the nurse, “Am I dying?” What is the best response from the nurse?

During rounds, the nurse observes that the client with Ménière’s disease seems anxious whenever nursing staff enter the room. If the client’s anxiety is due to fear that nursing care will intensify symptoms, what nursing intervention is most appropriate to add to the care plan at this time?

A 65-year-old client with severe chest pain is evaluated in the emergency department. A tentative diagnosis of myocardial infarction (MI) is made. When the client is startled by an alarm caused by a loose electrocardiogram (ECG) lead, what is the best approach for the nurse to take to relieve the client’s anxiety?

A 25-year-old client is admitted for diagnostic tests because the white blood cell count is extremely elevated. The client is suspected of having leukemia. When informed about the possible diagnosis, the client says, “I ate breakfast before the blood tests were drawn, which explains the abnormal results.” What mental defense mechanism is the client using?

The client with the perforated ulcer senses the critical nature of the condition and asks the nurse, “Am I going to die?” What response by the nurse is best?

The night nurse reports that the preoperative client scheduled for the cystectomy and ileal conduit was awake much of the night and that, when sleeping, the client was restless. What assessment supports the nurse’s assumption that the client’s sleep disturbance was likely due to anxiety?