Exam 13: Psychosocial Health Illness

The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which is an example of an individualized goal for that patient?

A client who is 45 years of age has a history of anxiety and comes into the emergency department with chest pain. The patient is diagnosed with a myocardial infarction (MI). The patient tells the nurse, "This is the most ridiculous thing I've ever heard of. I eat well, exercise, and am too young to have a heart attack." Which reaction does the nurse recognize the patient is most likely experiencing?

The nurse on a psychiatric unit is providing care for a client with severe depression. The client states, "I just cannot go on. It is hopeless for me, and there is no end in sight. My family would be better off without me burdening them." For which condition does nurse recognize this client as being most likely at risk?

Which interventions by the nurse might help the patient maintain a sense of personhood during hospitalization? Select all that apply.

The nurse is updating a plan of care for a patient who with a nursing diagnosis of Anxiety. Which patient behavior indicates to the nurse that the problem is resolving?

The nurse is providing care for several patients on a medical-surgical unit. To which patient statement is the nurse most alerted for making a mental health referral?

A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which Nursing Outcomes Classification (NOC) outcome is essential for this nursing diagnosis?

An adolescent patient is admitted to the hospital. The nurse is aware the patient has no medical restriction on visitation. Which group of potential visitors is it most important for the nurse to encourage to help maintain the patient's social identity while hospitalized?

An older adult patient is admitted from a skilled nursing residence to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. The patient has a medical diagnosis of Dehydration. Which finding leads the nurse to suspect dementia, rather than depression or dehydration, as the source of the symptoms?

The nurse is providing care for patient who comes to the emergency department experiencing headache, palpitations, nausea, and dizziness. After determining that the patient has tachycardia and trembling, the nurse suspects anxiety. Which level of anxiety does the nurse recognize?

The nurse is providing care for a patient with cancer who is receiving chemotherapy. Based on Maslow's Hierarchy of Needs, which nursing intervention is the first priority?

The nurse understands the necessity of focusing nursing care on the entire person. Which focus is considered most appropriate for the nursing profession?

The nurse is working with a group of clients who recently experienced health alterations that impacted physical and psychosocial functioning. When the nurse addresses self-concept, which statement best describes self-esteem?

A frail, older adult patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. Which is the most important action for the nurse?

An adolescent female patient sustained facial fractures and a 6-inch laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her "looking this way." Which statement by the nurse is most appropriate?

The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. The patient is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells the nurse that he is often "short of breath" and states, "I lie awake nights worrying about everything." The patient has been unable to work or care for family for the past 6 months. Which is the nurse's priority after documenting this information in the nurses' notes?

The nurse is developing a plan of care for a client with anxiety. Which are appropriate nursing interventions the nurse can use for assisting the client in reducing anxiety? Select all that apply.

The nurse is providing care for a patient with a history of depression. The patient states, "Sometimes I just don't believe in using all the medications the doctor orders for me, so I use a lot of over-the-counter herbal medications." Which is the most appropriate response by the nurse?

A patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his spouse misses work whenever the children are ill. The spouse is becoming increasingly distressed over the situation. Which experience does the nurse identify?

An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about consenting to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient?