NCLEX RN NURSING 2 EXAM 2 RATED A.

NCLEX RN NURSING 2 EXAM 2 RATED A.

A client diagnoses with a terminal illness state, "What's left for me? I feel hopeless." The nurse determines that which of the following would be the best response?

• "It makes me feel sad that you feel hopeless"
• "Sometimes people in your situation get depressed, which makes them feel

hopeless"

• "It must be difficult feeling as though there is no hope"
• "Can you think of one or two reasons to not feel so bad" Correct -c.

use of empathy communicates understanding to the client and allows him or her to explore inner feelings of hopelessness.

The nurse observes that a client hospitalized with newly diagnosed heart disease is frequently crying and stays in the room. The nurse should interpret these actions to be examples of what type of behavior? Select all that apply.

• innapropiate
• psychiatric
• psychotic
• coping
• expected Correct -4 and 5

crying indicates the client is attempting to cop with the situation in some way and is an expected behavior.

The nurse would plan to include which of the following in a biological assessment of a client? Select all that apply.

• laboratory results
• feelings of anxiety about illness
• spiritual needs during illness
• prognosis
• sleep patterns Correct -1 and 5

lab results and sleep patterns are biological assessment and may provide insight into the occurrence of psychological symptoms.

A client with terminal illness states, "if I could only live until I can walk my daughter down the aisle at her wedding, I will donate all of my money to research." The nurse reports that the client is in which phase of the grief process?

• denial
• seeking
• bargaining
• acceptance Correct -3.

bargaining is the stage in which the client attempts to bargain for more time. Denial indicates the stage in which the client denies that he or she is terminally ill. Seeking reflects the stage in which a client seeks more answers and cures. Acceptance is the stage in which the client comes to terms.

A client diagnosed with a medical illness states, "I don't enjoy my food anymore." The nurse notes during the assessment phase that this statement indicates what kind of nutritional pattern?

• Eating disruption
• Eating disorder
• Bulimia
• Compulsive disorder Correct -1.

Eating disruption indicates the client's normal eating pattern has been disturbed in some way.

As part of the admission process the nurse is conducting a social assessment. The nurse should ask which question during this part of the assessment?

• "what meds are you currently taking?"
• "Can you tell me what illnesses you have had in the past?"
• "Do you have any culturally based practices that you would like continued in the

hospital?"

• "Do your brothers or sisters have any chronic illnesses?" Correct -3.

Culturally based practices are part of a social assessment and provide information about how a client might respond to the illness based on cultural background.

A client who has a diagnosis of a chronic illness states, "I'm so tired. I can't keep on like this every day." The nurse interprets that the feeling the client is expressing can be described as which of the following.

• Atypical
• Expected
• Pathological
• Resentful Correct -2.

It is typical of clients with a chronic illness to become tired and feel as though they can't continue on this way.

The client hospitalized for five days with a medical illness says loudly, " Bring me my pain pills now!" The nurse makes which initial interpretation of the client's statement?

• This is a common response to feeling lack of control
• The response is inappropriate.
• This indicates a problem with the care delivery to the client.
• This response reflects the client's feeling of anger at the self. Correct -1.

Hospitalized clients often feel that things are out of their control and their frustration rises.

The nurse notices that a client admitted with COPD has poor eye contact and has not been eating well. The nurse then looks for additional data consistent with which potential problem?

• Hopefullness
• an eating disorder
• anxiety
• depression Correct -4.

The symptoms are indicative of possible depression and require further assessment.

What item should the nurse assess during a biological assessment to determine susceptibility to additional health problems in a client who has a medical illness? Select all that apply.

• Past meds
• recent illnesses
• spiritual needs
• cultural background
• functional abilities Correct -2 and 5

recent illnesses should be considered when conducting a biological assessment to determin impact on current illness. Functional ability may impact on the clients ability to adhere to therapy for the current illness.

A client with a recent onset of MS is observed taking part in self care. The nurse interprets the behavior to be consistent with which stage of adaptation?

• Acceptance
• Denial
• Compensation
• Indulgence Correct -1.

Acceptance indicates that the client is accepting limitation imposed by the illness and is attempting to help self as much as possible.

A client who underwent surgery for removal of a bowel tumor is exhibiting new onset of verbal outbursts and speaks aloud when no one is in the room. What should the nurse conclude that the client would benefit from next?

• Psychiatric workup
• Physical exam
• counseling session
• teaching session about the illness Correct -2.

Physical illnesses can create psychiatric symptoms and a physical examination would help to identify or rule out a physiological basis for the symptoms.

The nurse is assessing a clients coping behaviors during a psychological assessment and wishes to address factors that can contribute to depression. The nurse would ask the client about which priority items? Select all that apply

• Occupation
• Substance abuse
• Number of siblings
• Level of income
• Recent losses Correct -2 and 5

substance abuse is of primary interest as a maladaptive coping strategy and is also associated with depression. One or more recent losses can also increase risk for developing depression.

In a client newly diagnosed with amyotrophic lateral sclerosis, the nurse should antici[ate that the client may react to the diagnosis using which initial coping strategy.

• denial
• gambling
• exercise
• verbal abuse Correct -1. Denial is most accurate because it is typical and initial

stage of grief related to loss.

The nurse observes a client and family interaction. Observed behaviors include anger, rigidity, and lack of support for one another. The nurse should consider this interaction as an assessment of which family characteristic.

• Recent life changing events
• Communication patterns
• Lifestyle changes
• Community resources Correct -2.

Communication patterns within family should be assessed for flexibility and support.

A client with a medical illness tells the nurse that going to church is not a priority. Based on this info what should the nurse do at this time?

• not mention religion again
• conclude that the client does not believe in God
• Ask the client to go to church
• explore other spiritual patterns or rituals with the client Correct -4.

Exploring other spiritual patterns or rituals is therapeutic because it broadens the definition of spirituality wand what this might mean to the client.

A client who was paralyzed from severe injuries sustained during an automobile accident continually attempts to do activities beyond capability. What would be the most appropriate nursing diagnosis for this client?

• Impaired adjustment
• anxiety
• anger
• impaired skin integrity Correct -1.

Impaired adjustment refers to difficulty with adapting to the current situation.

A client tells the nurse that acupuncture helps ease the pain of terminal illness. How should the nurse react to this statement?

• Tell the client to stop
• tell the client it is illegal
• Understand that this is an appropriate intervention
• Understand that the client is not thinking clearly Correct -3.

Acupuncture as a complementary therapy can be very helpful with coping with illness.

A client with inflammatory bowel disease has exacerbations when job responsibility's become heavy or when family conflict occur at home. The nurse determines that this client would benefit from instruction that focuses on which of the following?