www.mynursingtestprep.coman individual 4) The environment that should always be assessed is the clients immediate surroundings; extended boundaries do not apply in an ill state ANS: 3 The home environment, community, family, friends, and support system all influence health status. The balance among these variables has a net positive or negative effect on a clients health status. The effect of poor living conditions may be offset by the presence of loving family and friends. Poverty does not always have a negative effect on health. Similarly, the presence of food, shelter, and clothing does not always convey protective health, as loneliness and hopelessness may counteract these positive influences. When examining the clients environment, extended boundaries must be considered, especially when providing community-based care. PTS:1DIFifficultREF:p. 223 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 17. Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a persons level of hardiness. How can you apply this knowledge to your nursing care? 1) You cannot use this information at all. People are innately hardy or not. This is something that you must merely recognize. 2) You should encourage all people to develop some level of hardiness in order to get through difficult physical and emotional times. 3) You should assess for your own level of hardiness: If you are hardy, you will be a better nurse; if you are not, you can learn more about hardiness. 4) You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable. ANS: 4 Hardiness is a personality trait that helps many cope with stress and illness. As a personality trait, it is unlikely that you can teach or otherwise encourage this trait. Awareness of your own level of hardiness will help you understand your response to stress, but hardiness does not necessarily make you a better nurse. PTS:1DIFifficultREF:p. 229 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 18. When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do? 1) Mop the floor with an approved disinfecting solution. 2) Fold the top bed linens back to open the bed. 3) Hook up the suction machine and check to see that it is working. 4) Position the bed in its lowest position. ANS: 2 The NAP should create an open bed. The housekeeping department is almost always
www.mynursingtestprep.comresponsible for cleaning the room between patients. The nurse is responsible for hooking up and checking special equipment such as suction. The nurse would need to tell the NAP whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know whether to position the bed high or low. PTS:1DIF:ModerateREF:p. 233 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 19. When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patients planning and emotional adjustment? 1) Notify the patient and family as much in advance of the transfer as possible. 2) Send a complete copy of the patients medical records to the new facility. 3) Carefully coordinate the transfer with the long-term facility to keep it smooth. 4) Help arrange for transportation and accompany the patient to the transport vehicle. ANS: 1 Notifying the patient and family well in advance of the transfer allows them time to adjust emotionally and to make any necessary plans. A copy of the records is usually sent, and the nurse does coordinate the transfer with the receiving facility; however, that does very little to assist with the patients emotional status or planning. Someone from the hospital may accompany the patient to the car; or if the transfer is by ambulance, perhaps not. Either way, that will not help the patient and family to do the necessary planning for the transfer. PTS: 1 DIF: Moderate REF: p. 233 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 20. A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply. 1) Sick-role behavior 2) Dependence on others 3) Seeking professional care 4) Experiencing symptoms ANS: 1 The 36-year-old mother is assuming sick-role behavior because she is identifying herself as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms and realizes that illness is starting, even though she has not yet entered the stages of dependence and seeking professional care. By telling her mother of the illness, she is relieved of her normal dutiescaring for her children. Dependence on others occurs when the client accepts a diagnosis and treatment from the healthcare provider. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision that she is ill and that professional healthcare is needed. Chapter 8 Stress & Adaptation Multiple Choice
www.mynursingtestprep.comIdentify the choice that best completes the statement or answers the question. 1.When released in response to alarm, which of the following substances promotes a sense of well-being? 1) Aldosterone 2) Thyroid-stimulating hormone 3) Endorphins 4) Adrenocorticotropic hormone ANS:3 Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid- stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralocorticoids. PTS:1DIF:ModerateREF:p. 253 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2.After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing? 1) Alarm 2) Resistance 3) Exhaustion 4) Recovery ANS:3 Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place. PTS:1DIFifficultREF:p. 254 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 3.You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation? 1) Epinephrine 2) Corticotrophin-releasing hormone 3) Aldosterone 4) Antidiuretic hormone
www.mynursingtestprep.comANS:1 During the shock phase of the general adaptation syndrome, large amounts of epinephrine prepare the body to react in an emergency situation. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone. PTS: 1 DIF: Moderate REF: p. 252 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application 4.What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome? 1) Promotes fluid retention by increasing the reabsorption of water by kidney tubules 2) Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle 3) Increases the use of fats and proteins for energy and conserves glucose for use by the brain 4) Promotes fluid excretion by causing the kidneys to reabsorb more sodium ANS:1 Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium. PTS:1DIF:ModerateREF:p. 252 KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall 5.A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first? 1) Cellular inflammation 2) Exudate formation 3) Tissue regeneration 4) Vascular response ANS:4 Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate-formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase. PTS:1DIF:ModerateREF:p. 254 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 6.A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient? 1) Anger
www.mynursingtestprep.com2) Fear 3) Anxiety 4) Hopelessness ANS:3 NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely feeling anxious. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf. PTS:1DIF:ModerateREF:p. 256 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 7.A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, I hate this place; nobody knows how to take care of me or Id be home by now. Which response by the nurse is best in this situation? 1) You seem angry; whats going on that makes you hate this place? 2) Im sorry that we arent caring for you according to your expectations. 3) You were very sick; dont be angry; youre lucky to be alive. 4) You shouldnt be angry with us; were trying to help you. ANS:1 You seem angry; whats going on . . . encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry or you shouldnt be angry diminishes the patients right to be angry. PTS:1DIF:ModerateREF:p. 266 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 8.You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing? 1) Hypochondriasis 2) Somatization 3) Somatoform pain disorder 4) Malingering ANS:4 Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are
www.mynursingtestprep.comexpressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically. PTS:1DIF:ModerateREF:p. 259 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 9.After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting? 1) Reaction formation 2) Displacement 3) Denial 4) Conversion ANS:2 This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis. PTS:1DIF:ModerateREF:p. 257 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 10.A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? 1) Precrisis 2) Impact 3) Crisis 4) Adaptive ANS:4 When a patient begins to think rationally and problem-solve, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase. PTS: 1 DIF: Moderate REF: dm 259-260 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 11.A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea? 1) Monitor and record the frequency of stools on the graphic record. 2) Administer prescribed antidiarrheal medications as needed.
www.mynursingtestprep.com3) Encourage the patient to verbalize about stressors and anxiety. 4) Provide oral fluids on a regular schedule. ANS:3 The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea. PTS: 1 DIF: Moderate REF: p. 259 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 12.When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan? 1) The patient will limit his intake of fat to no more than 15% of the daily calories consumed. 2) The patient will eat three meals per day at approximately the same time each day. 3) The patient will limit his intake of sugar and salt, as well as sweet and salty foods. 4) The patient will consume no more than three alcoholic beverages a day. ANS:3 The nurse should advise the client to limit the intake of sugar and salt; limit the intake of fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals (not three meals a day); and consume no more than two alcoholic beverages per day but not necessarily every day. PTS:1DIF:ModerateREF:p. 265 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 13.At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful? 1) Decreased blood pressure 2) Decreased peripheral skin temperature 3) Increased heart rate 4) Increased respiratory rate ANS:1 Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate. PTS:1DIF:ModerateREF:dm 266-267 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension 14.The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess? 1) Depression 2)
www.mynursingtestprep.comHypochondriasis 3) Somatization 4) Malingering ANS:1 Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger. PTS:1DIF:EasyREF:p. 256 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 15.Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope 1) Could be used by the patient to hurt her 2) Might cause the patient not to trust her 3) Would distract her from focusing on the patient 4) Will function as another stressor for the patient ANS:1 When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse should be removed before entering the patients room. It is unlikely that a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely dont even notice their presence. PTS:1DIF:ModerateREF:p. 266 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis 16.A patient is in crisis. After assessing the situation, what should the nurse do first? 1) Determine the imminent cause of the crisis. 2) Intervene to relieve the patients anxiety. 3) Decide on the type of help the patient needs. 4) Ensure the safety of both the nurse and patient. ANS:4 The first goal of crisis intervention is to assess the situation. Then ensure safety of self and patient, defuse the situation, decrease the persons anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost. PTS:1DIF:ModerateREF:p. 269 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level:
www.mynursingtestprep.comApplication Multiple Response Identify one or more choices that best complete the statement or answer the question. 1.During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply. 1) Rate of metabolism decreases. 2) Liver converts more glycogen to glucose. 3) Use of amino acids decreases. 4) Amino acids and fats are more available for energy. ANS:2, 4 The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: The rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of amino acids and mobilization of fats for energy. PTS:1DIF:ModerateREF:dm 252-253 KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitive level: Comprehension 2.Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Choose all that apply. 1) The wound is most likely infected. 2) This is a vascular response to inflammation. 3) Damaged cells are being regenerated. 4) Exudate formation is occurring. ANS:2, 4 During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonly appears at surgical incisions. When a wound becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here. Chapter 9 Psychosocial Health & Illness Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which of the following is considered a strength of the nursing profession? 1) Biomedical focus 2) Psychosocial focus
www.mynursingtestprep.com3) Biopsychosocial focus 4) Physical focus ANS: 3 A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient. PTS:1DIF:EasyREF:p. 273 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. A homeless patient is admitted with an infected leg wound. According to Maslows hierarchy of needs, which nursing intervention meets one of his basic physiological needs? 1) Providing the patient with a dinner tray 2) Administering antibiotics as prescribed 3) Irrigating a wound with normal saline solution 4) Encouraging the patient to express his feelings ANS: 1 According to Abraham Maslow and his hierarchy of needs, basic physiological needs, such as food, should be addressed first. After the patients basic needs are met, the nurse can provide wound care, administer antibiotics as prescribed (safety needs), and encourage the patient to express his feelings (love and belonging or self-actualization, depending on what feelings he expresses). PTS:1DIF:ModerateREF:p. 274 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 3. Which of the following can the nurse assess using Erik Eriksons theory? 1) Moral development 2) Developmental tasks 3) Social identity 4) Self-esteem ANS: 2 Using Eriksons theory, the nurse can assess for successful completion of developmental tasks. The theory does not help the nurse assess social identity or self-esteem. However, these factors are components of developmental tasks that Eriksons theory explores. Moral development was addressed in the Kohlbergs theory. PTS:1DIF:EasyREF:p. 274 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 4. Which statement best describes self-concept? An individuals 1) Understanding of how others perceive him 2) Evaluation of himself
www.mynursingtestprep.com3) Overall view of himself 4) Perspective of his role in society ANS: 3 Self-concept is an individuals overall view of himself. The overall view includes his evaluation of himself and how he thinks others evaluate him. PTS:1DIF:EasyREF:p. 274 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 5. A 13-year-old patient is admitted to the hospital. There is no medical restriction on visitation. To help maintain the patients social identity while hospitalized, it is most important for the nurse to encourage visits by 1) Peers 2) Grandparents 3) Siblings 4) Parents ANS: 1 Peers are more important than family in maintaining social identity in this age group. PTS:1DIF:ModerateREF:p. 275 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 6. Which response by the patient demonstrates an internal locus of control? 1) My blood sugar wouldnt be out of control if my wife prepared better foods. 2) I knew I shouldnt have come to this hospital; Id be better if I hadnt. 3) God must be getting even with me for my past behavior. 4) Im just glad to be alive; the accident couldve been a lot worse. ANS: 4 People who demonstrate an internal locus of control take responsibility for their life experiences and their responses to them. This allows them to interpret unexpected events in a positive light, as the response the accident couldve been a lot worse illustrates. The other options demonstrate an external locus of control; control of the situation is attributed to external factors. PTS:1DIF:ModerateREF:p. 275 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 7. The nurse is caring for a group of patients on the medical-surgical unit. Which patient is most likely to experience the most difficulty in adapting to a change in body image? The patient 1) Who suffered a traumatic amputation of the left leg in an industrial accident 2) With hypothyroidism who has coarse, dry, thinning hair and weight gain 3) Who is obese and who underwent gastric bypass surgery
www.mynursingtestprep.com4) With peripheral vascular disease who required a wound graft ANS: 1 Theoretically, the patient who suffered a traumatic amputation in an industrial accident will most likely have more difficulty adjusting to his change in body image because the change occurred abruptly. The patients described in the other options will naturally have some difficulty adjusting to their body image change, but it should not be as great because the physical changes are more gradual, which allows for adaptation over time. PTS:1DIF:ModerateREF:dm 275-276 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 8. Which individual is most likely to have a positive body image? 1) Child who has been deaf since birth 2) Child who was born with cystic fibrosis 3) Adolescent of average appearance who had an appendectomy 4) Adult born with a spinal defect and associated paralysis of the lower body ANS: 3 The adolescent with average appearance who had an appendectomy is likely to have a positive body image because the adolescent suffered an acute, reversible illness. Those born with physical handicaps are less likely to have a positive body image because many times the handicap leaves them socially isolated. This is, of course, not to imply that no one born with a physical handicap has a positive body image; and, of course, a particular adolescents body image might suffer after an appendectomy. However, the question asks which is most likely based on theoretical knowledge of body image. PTS:1DIF:ModerateREF:dm 275-276 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 9. A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following? 1) Role strain 2) Interpersonal role conflict 3) Role performance 4) Inter-role conflict ANS: 4 The patients wife is most likely experiencing inter-role conflict, in which her role as a mother and worker are making competing demands on her. Role strain is a mismatch between role expectations and role performance. Interpersonal role conflict results when another persons idea about how a role should be performed differs from that of the person who is performing the role. Role performance is defined as the actions a person takes and the behaviors he demonstrates in performing a role. PTS:1DIFifficultREF:p. 276 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
www.mynursingtestprep.com10. Which statement best describes self- esteem? 1) View of oneself as a unique human being 2) Ones mental image of ones physical self 3) Ones overall view of oneself 4) How well one likes oneself ANS: 4 Personal identity is ones view of oneself as a unique human being. Body image is described as ones mental image of ones physical self. Self-concept is defined as ones overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect. PTS:1DIF:ModerateREF:dm 276-277 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 11. A patient undergoing fertility treatments for the past 9 months learns that despite in vitro fertilization she still is not pregnant. This patient is at risk for experiencing a crisis in which component of self-concept? 1) Body image 2) Self-esteem 3) Personal identity 4) Role performance ANS: 2 Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem. The patient is not at risk for experiencing a crisis in body image, personal identity, or role performance. PTS:1DIFifficultREF:dm 276-277 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 12. A 17-year-old 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? 1) Tell me what you mean by looking this way. 2) OK, Ill restrict your visitors until your face heals. 3) Your friends and family love you no matter what. 4) Youre young; your face will heal quickly. ANS: 1 Tell me what you mean . . . encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assume that the patient is talking about her facial wounds. Ill restrict your visitors . . . assumes that the patient is speaking about her facial wounds when she might not be. The other options are examples of false
www.mynursingtestprep.comreassurance and do not address the patients concerns. PTS: 1 DIF: Moderate REF: dm 288-289; ESG, Nursing Interventions, V2, p. 116; ESG, Supplemental Materials, Psychosocial Nursing Interventions KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 13. A patient has recently had a change in a family relationship that is greatly affecting his health. Which nursing diagnosis could you probably make for this patient? 1) Parental Role Conflict 2) Interrupted Family Processes 3) Compromised Family Coping 4) Ineffective Individual Coping ANS: 2 Interrupted Family Processes is defined as a change in a family relationship significantly affecting a patients health. Parental Role Conflict occurs when significant role confusion by a parent results in response to crises. Compromised Family Coping occurs when support from a usual family member is compromised or disabled, causing a significant health challenge. Ineffective Individual Coping occurs when the patient is unable to comprehend and effectively judge stressors. PTS:1DIFifficultREF:p. 281 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 14. The nurse is updating a care plan for a patient who has a nursing diagnosis of Anxiety. Which patient behavior might suggest that the problem is resolving? 1) Pacing in the hallway at intervals 2) Using relaxation techniques 3) Speaking rapidly when spoken to 4) Avoiding eye contact ANS: 2 Using relaxation techniques might suggest that the patients anxiety is resolving. Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the patient. The patients use of relaxation techniques indicates problem solving by the patient. PTS: 1 DIF: Easy REF: dm 288-289 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Comprehension 15. Which nursing diagnosis is categorized as a psychosocial, rather than a self- concept, diagnosis? 1) Ineffective Individual Coping 2) Situational Low Self-Esteem 3) Disturbed Personal Identity 4) Disturbed Body Image ANS: 1
www.mynursingtestprep.comIneffective Individual Coping is considered a psychosocial nursing diagnosis. It implies poor life choices, inability to use available resources, and other interactional and relationship symptoms. The term psychosocial encompasses both psychological and social factors. The other diagnoses represent primarily individual, psychological factors. They are examples of self-concept nursing diagnoses. PTS:1DIF:ModerateREF:p. 281 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Recall 16. Which statement by the nurse is best when communicating with a patient with clinical depression? 1) Its a beautiful day today; youll feel better if you look out the window. 2) Youre having a bad day; Im sure youll feel better soon. 3) Life seems overwhelming at times; would you like to discuss how youre feeling? 4) You are very lucky to have such a supportive family. ANS: 3 When caring for a patient with depression, the nurse should encourage the patient to discuss his feelings. Its a beautiful day . . . and Youre having a bad day . . . offer false reassurance. It would not be therapeutic to say, You are very lucky . . .; that is offering a judgment. PTS:1DIF:ModerateREF:p. 293 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 17. A patient who lost his job last month has now been told that his wife wants a divorce. He says, I know I dont have much to offer a woman. She wants more than what I am, and now Im not even bringing home any money. Which nursing diagnosis is most appropriate? 1) Chronic Low Self-Esteem 2) Situational Low Self-Esteem 3) Disturbed Personal Identity 4) Disturbed Body Image ANS: 2 Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of a job and a marriage). There are no data to indicate long-standing (Chronic) Low Self-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself. PTS:1DIF:ModerateREF:p. 284 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 18. The nurse is updating the care plan of a patient who must undergo a right mastectomy for breast cancer. Which nursing diagnosis should the nurse anticipate in expectation of the body changes associated with the upcoming surgery? 1)
www.mynursingtestprep.comDeficient Knowledge 2) Impaired Adjustment 3) Hopelessness 4) Grieving ANS: 4 Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associated with the expected body changes associated with the upcoming surgery, although they could certainly occur. PTS:1DIF:ModerateREF:p. 285 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 19. A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis? 1) Decision Making 2) Distorted Thought Content 3) Role Performance 4) Depression Level ANS: 4 Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis Chronic Low Self-Esteem. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem, Role Performance with Ineffective Role Performance, and Distorted Thought Content with Disturbed Personal Identity. Although the other options might contribute to the patients low self- esteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate resolution of the nursing diagnosis. Decision Making is the only outcome that does that. PTS: 1 DIF: Moderate REF: p. 293; ESG, KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 20. The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which of the following is an example of an individualized goal for that patient? 1) Distorted Thought Control 2) Anxiety Level 3) Self-Mutilation Restraint 4) No Self-Injury, Consistently Demonstrated ANS: 4 No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. The other options are examples of NOC outcomes; they are not written as goals. PTS:1DIF:ModerateREF:p. 293 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
www.mynursingtestprep.com21. A 73-year-old patient was admitted with a perforated bowel. Following surgical repair, he developed complications and required an extensive stay in the hospital. How can the medical-surgical nurse best promote self-esteem in this patient? 1) Assist the patient to ambulate in the hallway once daily. 2) Encourage the patient to participate in self-care. 3) Introduce herself to the patient if he does not know her. 4) Listen attentively when the patient speaks. ANS: 2 Encouraging the patient to his accomplish own self-care, such as bathing and brushing his teeth, encourages independence and promotes self-esteem. Assisting the patient to ambulate in the hallway prevents complications of immobility. Introducing yourself and listening attentively to the patient prevents depersonalization. PTS:1DIFifficultREF:p. 285 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 22. The nurse is developing a plan of care for a mother of three small children who has been admitted with a serious acute illness, which is likely to continue long term. The nurse writes the following intervention: Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness. The purpose of this intervention is to help 1) Promote self-esteem 2) Promote positive body image 3) Facilitate role enhancement 4) Prevent depersonalization ANS: 3 Facilitating communication between the patient and significant other regarding sharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. The intervention is not designed to promote self-esteem or positive body image or to prevent depersonalization. PTS:1DIF:ModerateREF:p. 286 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 23. A patient comes to the emergency department complaining of headache, palpitations, nausea, and dizziness. After determining that the patient is anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting? 1) Mild anxiety 2) Moderate anxiety 3) Severe anxiety 4) Panic anxiety ANS: 3
www.mynursingtestprep.comThe patient experiencing severe anxiety may experience physical symptoms including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. The patient experiencing moderate anxiety might experience a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. The patient suffering from panic anxiety might believe he has a life-threatening illness. Physical symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements. PTS:1DIF:ModerateREF:p. 278 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 24. The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He 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 says, I lie awake nights worrying about everything. He has been unable to work or care for his family for the past 6 months. What is the nurses priority after documenting this information in the nurses notes? 1) Provide emotional support for the patient using reflective listening technique. 2) Do nothing; people with duodenal ulcers typically cannot work. 3) Question the patients family about the information received from the patient. 4) Notify the primary care provider and ask for a referral to a mental health professional. ANS: 4 The nurse should involve a mental health professional immediately, because the patient is exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. Doing nothing is neglectful. Questioning the patients family about the information violates the patients right to privacy, unless the nurse obtains the patients permission to do so. PTS: 1 DIF: Difficult REF: p. 291; requires synthesis, answer not given verbatim. KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 25. An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about whether he should consent to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient? 1) Decisional Conflict 2) Death Anxiety 3) Powerlessness 4) Ineffective Denial ANS: 1 Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is uncertain about whether he should take the surgical risk. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is
www.mynursingtestprep.comsuffering from Death Anxiety at this time. Powerlessness is a perceived lack of control over a current situation; this patient is trying to exert some control over his care. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge. PTS:1DIF:ModerateREF:p. 288 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 26. Which nursing intervention specifically helps reduce a patients anxiety? 1) Teaching the importance of adequate nutrition and hydration 2) Giving clear fact pertaining to the patients circumstances 3) Promoting small-group activities to improve self-esteem 4) Monitoring the patient for the risk of suicide ANS: 2 Using clear and factual knowledge that is tailored to the patients circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promoting small-group activities to improve self-esteem, and monitoring the patient for suicide risk are interventions designed to help the patient with depression. PTS:1DIF:EasyREF:p. 289 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 27. The nurse caring for a patient admitted with severe depression identifies a nursing diagnosis of Hopelessness on the care plan. Which outcome is appropriate for this diagnosis? 1) Displays stabilization and control of mood 2) Sleeps 6 to 8 hours per night with report of feeling rested 3) Does not engage in risky, self-injurious behavior 4) Eats a well-balanced diet to prevent weight change ANS: 1 An outcome for the nursing diagnosis Hopelessness is displays stabilization and control of mood. Sleeps 6 to 8 hours per night and reports feeling rested and eats a well-balanced diet to prevent weight change are example of outcomes for the diagnosis Depressed Mood. Does not engage in risky, self-injurious behavior is an outcome for the nursing diagnosis Risk for Suicide. PTS: 1 DIF: Moderate REF: p. 293 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 28. The nurse is assessing a patient for depression. Which of the following sets of behavioral symptoms may indicate depression? 1) Preoccupation with loss, self-blame, and ambivalence 2) Anger, helplessness, guilt, and sadness 3)
www.mynursingtestprep.comAnorexia, insomnia, headache, and constipation 4) Tearfulness, withdrawal, and present substance abuse ANS: 4 Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are affective findings associated with depression. Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain, and constipation. PTS:1DIF:ModerateREF:p. 289 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 29. A frail, elderly patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. What is most important for the nurse do? 1) Recognize these symptoms as signs of normal, physiologic aging. 2) Obtain a urine specimen before notifying the primary care provider. 3) Be sure she is placed in a room occupied with another patient. 4) Interview the patient to screen for clinical depression. ANS: 4 Depression is often masked in older adults and expressed as physical and personality changes. Memory loss and confusion are also common symptoms of depression in older adults. Any one of the symptoms might occur as a result of physical illness, but the combination should prompt the nurse to suspect depression and interview and screen for it before exploring physiological causes for the symptom (as with a urine specimen). Placing the patient with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes. PTS:1DIF:ModerateREF:dm 291, 295 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application 30. An elderly patient admitted from a skilled nursing residence to a medical- surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of dehydration. Which of the following should lead the nurse to suspect that dementia, rather than depression or dehydration, is the source of the symptoms? The history and nursing observations indicate that the patient 1) Rambles, speaks incoherently, and answers questions inappropriately 2) Speaks slowly with delayed response to questions but responds appropriately 3) Awakens early in the day yet sleeps almost constantly during the day 4) Sometimes has difficulty concentrating on details of the present situation ANS: 1 In dementia, a patients language is disoriented, rambling, and incoherent and the patient responds to questions inappropriately or with near misses. Speaking slowly and being
www.mynursingtestprep.comslow to respond to verbal stimuli are signs of depression, and in depression, the patient usually answers questions appropriately. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragmented and the person awakens often during the night. Difficulty concentrating on details is a thinking pattern seen more in depression; in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment. PTS: 1 DIF: Difficult REF: p. 291 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which assessment finding(s) might suggest that the patient has low self- esteem and requires more in-depth assessment? Choose all that apply. 1) Infrequent eye contact 2) Straight posture 3) Overly critical of others 4) Careful grooming ANS: 1, 3 Assessment findings that suggest low self-esteem include avoiding eye contact and being overly critical of others. You would not need to follow up if the person displayed straight posture and careful grooming. PTS: 1 DIF: Easy REF: dm 276-277; 282-284 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 2. Which intervention(s) by the nurse might help the patient maintain a sense of personhood during hospitalization? Assume that all are culturally appropriate. Choose all that apply. 1) Addressing the patient by his first name 2) Making eye contact if it is comfortable for the patient 3) Always offering an explanation before beginning a procedure 4) Speaking to others about the patient so that the patient can hear you ANS: 2, 3 The nurse can help the patient maintain a sense of personhood by addressing him by his preferred name, which might be his first name or might be his surname with title. Using eye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the room are additional ways for the nurse to offer care that respects patient rights. Chapter 10. Family Health Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A 12-year-old patients mother recently married a man who has a 13-year- old daughter. The nurse recognizes that the patient belongs to which type of family? 1)
www.mynursingtestprep.comExtended 2) Traditional 3) Blended 4) Nuclear ANS: 3 The patient belongs to a blended family; in which two single parents marry and raise their children together. An extended family may contain grandparents, aunts, uncles, cousins, and other biological relatives. A traditional, or nuclear, family contains a husband, wife, and their children. PTS:1DIF:EasyREF:p. 301 KEY: Nursing process: N/A | Client need: PSPI | Cognitive level: Application 2. A 65-year-old patient is admitted to the hospital with heart failure. The patients best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene? 1) Involve the friend and children in the patients care, discharge planning, and home care. 2) Encourage the friend to wait until discharge to provide care for the patient at home. 3) Explain to the friend that for confidentiality reasons she cannot be involved in the patients care. 4) Encourage liberal visiting hours by the friend and the patients children. ANS: 1 The nurse can best intervene by involving the friend and the patients children in the patients care, discharge planning, and home care. The friend may or may not be able to care for the patient at home. But if planning to provide home care, the patients friend should be informed of the patients needs while in the hospital and have an opportunity to participate prior to discharge. The nurse can involve the friend with the patients consent without infringing on the patients privacy. Her name needs to be listed on the patient privacy (HIPAA) form. The nurse should also encourage liberal visiting hours by the friend and the patients children if it is beneficial for the patients recovery; however, comprehensive involvement in care is more inclusive than simply liberalizing visiting hours and therefore is the best answer. PTS:1DIF:ModerateREF:dm 301-302 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 3. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frail elderly 4)
www.mynursingtestprep.comFamily with teenagers and young adults ANS: 2 This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their children moving into phases of adulthood. In the stage of family launching young adults, the parents maintain support of young adults as they leave the security of family and the parents rediscover marriage. During the stage of family with teenagers and young adults, open communication is maintained among family members, ethical and moral values are reinforced, and there is a balance established between rules and independence among teens. PTS: 1 DIF: Moderate REF: p. 303 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 4. A 13-year-old girl is admitted to the adolescent unit with acute leukemia. The patient has a support system that includes her brother, sister, mother, father, and grandmother as well as members of her local community. Which component of her support system is considered a suprasystem? 1) The community 2) The parents 3) Her mother 4) Her sister ANS: 1 Her surrounding community is considered a suprasystem because it is larger than the family system. Subsystems within the family include the parents, mother, siblings, sister, brother, father, and grandmother; they are smaller components that fit within the family system. PTS:1DIF:ModerateREF:p. 302 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 5. The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking 2) Availability of community resources 3) Adherence to a low-fat diet 4) Importance of physical exercise ANS: 2 When teaching the family of an older adult, the nurse should include information about community resources that are available, especially when caring for chronically ill, disabled, or elderly family members. Middle-age adults typically begin experiencing signs and symptoms associated with long-standing, unhealthy behaviors. Therefore, consuming a low-fat diet and limiting the intake of alcohol and tobacco are likely appropriate topics to include in the teaching plan for a middle-aged adult. Physical exercise and activity promote the quality of life. Careful planning is necessary to ensure safety and well-being for the family member with memory loss, confusion, and
www.mynursingtestprep.comdisorientation. PTS:1DIF:ModerateREF:p. 306 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 6. Which factor is related to the increased risk of acquiring polio in the United States after the disease was thought to be eradicated? 1) Lack of health insurance 2) Bioterrorism 3) Reduced compliance with vaccinations 4) Drug resistance ANS: 3 Reduced compliance with community immunization in the United States increases the risk for diseases, such as polio, that were thought to be eradicated. For vaccines to be effective, the population needs to receive them. Bioterrorism involves the introduction of a highly infectious microbe for which there is no protection to the population. Polio is not such a threat because immunization is available. Vaccinations are available through governmental programs for those who do not have health insurance. Drug resistance has led to the reemergence of tuberculosis, which was previously cured with antibiotics. PTS:1DIF:EasyREF:p. 306 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 7. Which question helps the nurse to assess family structure? 1) Where does your family live? 2) How are family decisions made? 3) With which religious affiliation is your family associated? 4) What is your ethnic background? ANS: 2 Asking how family decisions are made helps the nurse to assess family structure. Asking about religious affiliation, ethnic background, and where the family lives provides identifying data but does not reveal lines of authority and relationships among family members. PTS:1DIF:ModerateREF:p. 308 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 8. Which family member is most likely to be disabled? 1) 60-year-old African American male 2) 65-year-old Asian male 3) 70-year-old Caucasian female 4) 75-year-old Native American female ANS: 4
www.mynursingtestprep.comSlightly more females (15.6%) than males (14.4%) reported a disability. In 2006, the prevalence of disability was lowest for persons ages 16 to 20 (6.9%) and highest for those 75 years and older (52.6%). Disability differs by ethnic group. Asians reported 6.3%, Caucasians 12.7%, African Americans 17.5%, Native Americans 21.7%, and persons of other ethnic backgrounds reported 11.9% disability. Therefore, the prevalence of disability would be highest in a female Native American who is 75 years or older. PTS:1DIFifficultREF:p. 307 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply. 1) Meeting the emotional needs of family members 2) Reinforcing ethical and moral values 3) Promoting joint decision making among parents and children 4) Being productive members of society ANS: 1, 4 Family functions outlined in the structural-functional family theory include being productive members of society, caring for elderly members, meeting physical and emotional needs of family members, and socialization of children. This model is more focused on the outcomes of family function than the process by which action occurs. Maintaining support for young adults as they leave the security of the family, reinforcing ethical and moral values, and promoting joint decision making among parents and children are examples of tasks outlined in family development theories. PTS:1DIF:ModerateREF:p. 302 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. Which of the following suggest that a family health problem may exist? Select all that apply. Family members 1) Respect each others need for privacy 2) Enact decisions made by the most powerful member 3) Do not consider a conflict resolved until everyone agrees 4) Set boundaries between family members ANS: 2, 3 Respect for privacy and clear boundaries between family members are characteristics of a healthy family. Boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. In healthy families, there is typically egalitarian distribution of power. In healthy families, it is not always necessary for all members to agree; instead, they have the ability to compromise and members feel free to disagree. PTS: 1 DIF: Moderate REF: p. 310 KEY: Nursing process: Analysis/nursing diagnosis | Client need: PSI | Cognitive level: Analysis 3. A family assessment should include the following areas. Choose all that apply. 1) Coping patterns
www.mynursingtestprep.com2) Health beliefs 3) Medical history 4) Physical exam ANS: 1, 2 Conducting a family assessment includes identifying the following: data; family composition; family history and developmental stage; environmental data; family structure; family function; health beliefs, values, and behaviors; family stressors and coping; and abuse and violence within the family. The medical history and physical exam of individuals are only relevant to the family assessment if it affects other family members. Chapter 11 Culture and Ethnicity Multiple Choice Identify the choice that best completes the statement or answers the question. 1. North American healthcare culture typically reflects which culture? 1) Asian 2) European American 3) Latino 4) African American ANS: 2 Although the demographics are changing in this recent decade with increasing Hispanic and Asian inhabitants, North American healthcare culture typically reflects the dominant (European American) culture because most healthcare providers belong to that culture. PTS: 1 DIF: Easy REF: p. 317 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? 1) A belief in taboos against narcotic use to relieve pain 2) Expectation of immediate treatment for relief of pain 3) Endurance of pain longer and report it less frequently than some patients do 4) Use of herbal teas, heat application, and prayers to manage his pain ANS: 3 In general, patients of Mexican heritage may endure pain longer and report it less frequently than some. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes and are not necessarily true for all members of a cultural group. PTS:1DIFifficultREF:p. 329 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
www.mynursingtestprep.com3. The nurse is caring for a 42-year-old Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patients discharge? 1) Ethnic background 2) Family support 3) Employment status 4) Healthcare coverage ANS: 2 The nurse should focus on the patients strengths and resources for health restoration and self-care. In this case, that is the patients family. His family can be a great support for him when he is discharged (e.g., preparing healthy meals, helping him manage exercise and treatment regimens). Although the patients ethnic background is very important to his care, discharge planning should revolve around his available resources. Insurance should not be the focus at this time, although at some point the nurse has probably obtained data about these topics. PTS:1DIF:ModerateREF:dm 320, 326 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 4. A patient who came from Central America is admitted with diabetes mellitus. The nurse is collecting biographical information. Which information provided by the patient represents his ethnicity? 1) Latino 2) Catholic 3) White 4) Teacher ANS: 1 Ethnicity refers to groups whose members share a common cultural heritage. This patient came from a Spanish-speaking country in Central America; therefore, his ethnicity is considered Latino. Catholic is his religion, white is his race, and teacher is his occupation. PTS:1DIF:ModerateREF:p. 318 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 5. A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing 1) Assimilation 2) Socialization 3)
www.mynursingtestprep.comAcculturation 4) Immigration ANS: 3 This patient is experiencing acculturation; she has accepted both her own and the new culture and has incorporated elements of both into her life. Socialization is the process of learning to become a member of a society or group. Cultural assimilation occurs when the new member gradually learns and takes on, to a great extent, the dominant cultures values, beliefs, and behaviors. Immigration is the act of moving to a new country. PTS:1DIF:ModerateREF:p. 319 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Analysis 6. Which of the following is considered a practice (as opposed to a belief or value)? 1) Always drinking water after exercise 2) Thinking often about cleanliness 3) Emphasis on success 4) Maintaining youth ANS: 1 A practice is a set of behaviors that one follows, such as always drinking water after exercise. Preoccupation with cleanliness, emphasis on success, and maintaining youth are examples of values that are dominant in United States culture. PTS:1DIF:EasyREF:p. 320 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension 7. The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the 1) Practices of the patients ethnic group 2) Patients individual cultural beliefs 3) Values of her own culture 4) Spanish-speaking community ANS: 2 The nurse cares for this patient by becoming familiar with the patients individual cultural and ethnic beliefs and values. It is helpful to become familiar with the patients ethnic group and the Spanish-speaking community; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as his ethnic group or community. The nurse should explore her own culture but not assume that the patient holds those same beliefs and practices. PTS: 1 DIF: Moderate REF: p. 320 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 8. The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present oriented? 1) I know I need to lose weight; Ill have to begin an exercise program right away. 2) If I change my diet and begin exercising, maybe I can control my blood pressure without
www.mynursingtestprep.commedications. 3) I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult. 4) I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke. ANS: 3 Knowing an action is needed but giving reasons for not beginning it just now shows a focus on the present. The patient knows that he should reduce his sodium intake, but his present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future oriented because they indicate that the patient is planning lifestyle changes that will affect his future. PTS:1DIFifficultREF:dm 321, 326 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 9. A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as 1) A punishment for immoral behavior 2) A part of life 3) Best treated with herbal teas and prayer 4) A virtue and a matter of family honor ANS: 4 Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarily apply to all members of a cultural group. PTS:1DIF:ModerateREF:dm 320-321, 326 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Comprehension 10. The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patients indigenous healthcare system and should be included in the plan of care? 1) Asking the family to bring in medals and amulets 2) Scheduling a visit from the shaman 3) Providing the patient with her favorite herbal tea 4) Requesting that the physician consult the patients acupuncturist
www.mynursingtestprep.comANS: 2 For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea and medals and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. Asians and Pacific Islanders might benefit from a visit by the acupuncturist. PTS:1DIFifficultREF:dm 323, 325 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 11. A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? 1) Use of herbs and roots 2) Application of oils and poultices 3) Burning of dried plants 4) Acupuncture ANS: 4 Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects. PTS:1DIF:ModerateREF:dm 325-326 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 12. An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states I dont want a man taking care of me. Which cultural barrier is this patient exhibiting? 1) Ethnocentrism 2) Racism 3) Sexism 4) Chauvinism ANS: 3 This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased toward their own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior. PTS:1DIF:EasyREF:p. 328 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 13. A patient who had surgery 8 hours ago has not voided. The nurse notifies the
www.mynursingtestprep.comphysician for an order to insert an indwelling urinary catheter. Which of the following statements should the nurse use to describe the procedure to the patient? 1) I need to put a Foley in you because you havent voided since your surgical procedure. 2) I need to insert a tube into your bladder to drain the urine because you havent urinated since surgery. 3) I need to catheterize you because you havent urinated since having your surgery. 4) I need to place a catheter in your bladder because you havent voided since surgery. ANS: 2 I need to insert a tube into your bladder . . . best describes the procedure for the patient because the explanation is in terms most patients will understand. The other options contain medical jargon that could confuse the patient. PTS:1DIF:ModerateREF:p. 328 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 14. A Hispanic patient is frustrated because the healthcare team does not understand the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for this patient? 1) Powerlessness 2) Impaired Verbal Communication 3) Spiritual Distress 4) Risk for Noncompliance ANS: 1 Powerlessness is the best nursing diagnosis for the patient who is unable to make healthcare personnel understand the importance of his cultural beliefs. Impaired Verbal Communication can be used for patients who do not speak or understand the healthcare personnels language. Spiritual Distress might occur because a treatment is not in agreement with the patients religious beliefs. Risk for Noncompliance can be identified when a patient fails to follow a health-promoting or therapeutic plan the healthcare provider believes they agreed to. PTS:1DIF:ModerateREF:p. 330 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 15. A patient of Scandinavian heritage is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically, without grimacing or vocalizing. The nurses thinking is an example of a/an 1) Archetype 2) Bias 3) Prejudice 4) Stereotype
www.mynursingtestprep.comANS: 1 An archetype is an example of a person or thingsomething that is recurrentand it has its basis in facts. Therefore, it becomes a symbol for remembering some of the culture specifics and is usually not negative. A bias is the tendency to see only one side of an issue, a lack of impartiality. Prejudice refers to negative attitudes toward other people that are based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on. A cultural stereotype is the unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects. Similar to biases, a stereotype may be positive or negative. PTS:1DIF:ModerateREF:dm 320-321 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 16. A patient reports experiencing gas, abdominal bloating, and diarrhea after consuming milk or cheese. Lactose intolerance might immediately be suspected if the patient is of which heritage? 1) African American 2) Mexican American 3) European American 4) Arab American ANS: 1 Lactose intolerance, caused by a deficiency of the enzyme lactase, is more commonly seen in African Americans than in the other cultural groups listed. Of course, one would assume lactose as the cause of the patients symptoms, but it would be important to rule it out. PTS:1DIF:ModerateREF:ESG,\\ KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which statement(s) about culture is/are true? Choose all that apply. 1) Culture exists on both material and nonmaterial levels. 2) Culture mainly influences food choices and special holidays. 3) Cultural customs change over time at different rates. 4) Culture is learned through life experiences shared by other cultural members. ANS: 1, 3, 4 Culture is learned through life experiences that are shared by other members of the culture, such as family members, those sharing similar religious beliefs, and people of similar cultural heritage in the same community. Culture exists at many levels that are both material and nonmaterial. Cultural customs, beliefs, attitudes, and practices are not static but change over time at different rates, depending on current events, other significant people, and social influences. Culture is all encompassing and affects everything its members think and do; it is not limited to food and holidays. Although those are visible manifestations of a culture, dietary practices and cultural calendars are not the essence of true and meaningful culture. PTS:1DIF:EasyREF:dm 317-318
www.mynursingtestprep.comKEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension 2. The nurse is caring for a patient of Japanese heritage who refuses pain medication despite the nurses explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. 1) Assess the patients pain levels at less frequent intervals. 2) Document in the patients record that the patient does not want to take opioids. 3) Utilize nonpharmacological measures to help control the patients pain. 4) Notify the primary care provider of the patients noncompliance. ANS: 2, 3 Patients of Japanese heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that they improve the healing process. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patients wishes and utilize nonpharmacological measures to control pain. The nurse should document that the patient wishes to avoid opioid use in the nurses notes. The nurse should continue to assess pain levels in this patient at the same frequency as before. She should recognize and respect his cultural beliefs and not label him as noncompliant. Note that the same intervention would be appropriate for any patient in this situation, not just a Japanese patient. Chapter 12 Spirituality True/False Indicate whether the statement is true or false. 1. Religion provides people with instruction and guidance about what to believe and what values are essential. ANS: T Religion provides instruction and guidance on beliefs, values, and codes of conduct. In contrast, spirituality is a journey that integrates life experiences and understanding. PTS:1DIF:EasyREF:p. 339 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. Spirituality occurs over time and involves the accumulation of life experiences and understanding. ANS: T Spirituality is like a journey; it occurs over time and involves the accumulation of experiences and understanding, whereas religion provides general instruction and guidance on beliefs, values, and codes of conduct. PTS:1DIF:EasyREF:dm 339-340 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A life-long journey involving accumulation of experience and understanding
www.mynursingtestprep.com4) Codes of conduct that integrate beliefs and values ANS: 1 Theology is best described as discussions and theories related to God and His relation to the world. Eschatology includes doctrines about the human soul and its relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values. PTS:1DIF:ModerateREF:p. 339 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. Which of the following is considered a religious denomination within the tradition of Christianity? 1) Buddhism 2) Jehovahs Witnesses 3) Sikhism 4) Islam ANS: 2 Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, and Islam are all religious traditions outside of Christianity. PTS:1DIF:EasyREF:dm 342-343; ESG, KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 3. Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or gods 3) Rules prohibiting alcohol consumption 4) Sacred writings that reveal the nature of the Supreme Being ANS: 4 Many of the world religions have sacred writings that are authoritative and reveal the nature of the Supreme Being. Mormons follow a strict health code, which advises healthful living. Islam means submission; therefore people of Islamic faith submit to Allah. Some religions, such as Mormon, Christian Science, Bahai, and Sikhism, prohibit alcohol consumption, but many other religions permit it. PTS:1DIF:EasyREF:p. 339 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 4. A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? 1) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2) Explore with the patient her beliefs and determine which might have caused her to make this statement. 3)
www.mynursingtestprep.comAssure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4) Comply with the patients request and assign a female nurse to care for the patient. ANS: 2 The charge nurse can best serve the patient and her staff by exploring the patients beliefs that might prevent her from being cared for by a male. There are many reasons the woman may prefer a female nurse: she may be very modest, or she may be prejudiced against male nurses, for example. Hospital policy might state that, to prevent discrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, even if this is so, before explaining this to the patient, the charge nurse should explore the patients beliefs and make special arrangements with hospital administration to uphold the patients beliefs, if possible. Telling the patient that each nurse is capable of providing care is not sensitive to the patient and her beliefs. Simply complying with the patients wishes without further investigation may alienate the nursing staff. PTS: 1 DIF: Moderate REF: dm 341-343, dm 351-352 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 5. A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patients religious affiliation, which of the following actions should the nurse take? 1) Administer the medication as prescribed. 2) Hold the medication until after Yom Kippur. 3) Explain the importance of taking the medication despite the holiday. 4) Ask the physician to change the route of administration. ANS: 4 Orthodox Jews require an alternative to the oral route of drug administration on Yom Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician to change the route of administration. Administering the medication as prescribed breaks the patients religious tradition on the holiest day of the Jewish calendar. Holding the medication until after Yom Kippur delays treatment and may cause harm to the patient; furthermore, it is not within the scope of nursing practice to hold medications that have been prescribed by a physician. The nurse should explain the importance of the medication in any case; but the nurse should not try to convince the patient to break away from his religious tradition when an alternative route of administration is available. PTS:1DIF:ModerateREF:p. 341 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 6. The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patients religion, for which religious rite should she expect to notify the hospital chaplain? 1) Anointing of the Sick 2) Baptism
www.mynursingtestprep.com3) Eucharist 4) Sacrament of Reconciliation ANS: 1 In Catholicism, those who are seriously ill might want to receive the sacrament of Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typically administered to someone who is critically ill. Baptism may be offered when infants or children of Christian parents are critically ill. PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 7. Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with 1) Islam 2) Bahai 3) Hinduism 4) Jehovahs Witness ANS: 4 Those of Jehovahs Witness faith believe that taking blood into ones body is morally wrong. Therefore, they will not consent to transfusions of whole blood or its components. Those of Islam, Bahai, and Hindu faith will, as a rule, consent to blood transfusion. PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 8. Which special consideration may the nurse need to make when caring for a female Rastafarian patient? 1) Allow the patient to wear her own clothing. 2) Provide a diet that is caffeine-free. 3) Allow the patient to wear jewelry with religious symbols. 4) Provide free-flowing water for bathing. ANS: 1 Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free- flowing water for bathing, which should be provided when possible. PTS: 1 DIF: Moderate REF: ESG, KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 9. What is the most effective action by the nurse when delivering spiritual care to a patient of the same religion as the nurse?
www.mynursingtestprep.com1) Understanding that the patient shares the same beliefs 2) Striving to meet the patients spiritual needs independently 3) Explaining her own religious beliefs to the patient 4) Developing a greater awareness of her own spirituality ANS: 4 The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patients spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient. PTS: 1 DIF: Moderate REF: p. 345 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 10. A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth ANS: 1 Muslims may want water to wash the mouth, nostrils, and hands before praying. Roman Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious items. PTS:1DIF:ModerateREF:dm 342-343, 350-351; ESG, KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 11. When performing a spiritual assessment, who is the preferred source of information? 1) Durable power of attorney 2) Next of kin 3) Patient 4) Patients clergyman ANS: 3 The patient is the preferred source of information. In the event of an emergency admission or when a patient cannot give information, the nurse can consult the next of kin or the durable power of attorney for information about the patients spirituality. Contacting the clergyman without the patients permission is a breach of patient
www.mynursingtestprep.comconfidentiality. PTS:1DIF:ModerateREF:dm 346-347; high-level question, not answered verbatim in text. KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 12. Which type of medicine do those of Hindu faith typically practice? 1) Ayurvedic medicine 2) Western medicine 3) Chiropractic medicine 4) Qigong ANS: 1 Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of hot and cold foods, which have nothing to do with temperature or degree of spiciness. People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is used to achieve healing through focus on the bodys energy centers. PTS:1DIF:ModerateREF:p. 343 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 13. A patient tells the nurse, I feel that God has abandoned me. I am so angry that I cant even pray. The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? 1) Spiritual Distress 2) Risk for Spiritual Distress 3) Impaired Religiosity 4) Moral Distress ANS: 1 This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action. PTS:1DIF:ModerateREF:p. 348 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 14. The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and not important in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement? 1)
www.mynursingtestprep.comSpiritual Support 2) Self-Esteem Enhancement 3) Values Clarification 4) Hope Inspiration ANS: 3 One of the steps of most values-clarification processes is to list values (what is important and not important in ones life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although it can indirectly contribute to development of spiritual identity. PTS: 1 DIF: Moderate REF: ESG, Standardized Language, Table Standardized Language: Using Selected NIC Interventions and Activities to Support Spirituality KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 15. The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the following actions by the nurse is appropriate? 1) Offer a prayer for healing using the nurses usual words and format. 2) Begin the prayer with Jehovah God as she always does while avoiding the name of Jesus. 3) Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer. 4) Say, What name would you like for me to use to address the Supreme Being when I am praying for you? ANS: 4 Ask how the patient prefers to address the Divine. Some people prefer the use of parental language in their prayers; for example, Father God or Divine Mother. Some use the names Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. The nurse should not assume that using the names Jesus and Jehovah God would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing God by a name, but the most supportive way to do so is to find out the name the patient wishes to use. Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually. PTS:1DIF:ModerateREF:p. 350 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. A patient has a nursing diagnosis of Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications. The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with healthcare therapy? (Choose all that apply.) The patient says
www.mynursingtestprep.com1) I will try to pray more often for stronger faith that God will heal me. 2) Let me think about it until tomorrow; I may see my way to taking those pills then. 3) You know, Ive known some very holy people who were not cured by God. 4) There is no confusion in my mind as to the right thing for me to do. ANS: 2, 3 Agreeing to consider treatment (think about it) and recognizing that sometimes faithful people are not cured both suggest that the patient is at least considering that it is all right for her to question her beliefs. Praying for stronger faith in Gods healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith. Having no confusion about the right thing to do would be evidence of problem resolution, provided the right thing to do is to take the medication. However, you need more information to know if that is what the patient means. It could just as easily mean that she is more sure than ever that she should not take the medication. Chapter 13 Experiencing Loss Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing? 1) Environmental loss 2) Internal loss 3) Perceived loss 4) Psychological loss ANS: 1 This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them. PTS:1DIF:EasyREF:p. 358 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 2. According to William Worden, which task in the grieving process takes longest to achieve? 1) Accepting that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy ANS: 1 Worden described the tasks a grieving person must achieve. They progress from an initial
www.mynursingtestprep.comnumbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task. PTS:1DIF:EasyREF:p. 359 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 3. What emotional response is typical during the Randos confrontation phase of the grieving process? 1) Anger and bargaining 2) Shock with disbelief 3) Denial 4) Emotional upset ANS: 4 During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities. PTS:1DIF:ModerateREF:p. 359 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall 4. An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate? 1) Shock and numbness 2) Yearning and searching 3) Disorganization and despair 4) Reorganization ANS: 4 According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase. PTS:1DIF:ModerateREF:p. 359 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 5. Which patient is at most risk for experiencing difficult grieving? 1) The middle-aged woman whose grandmother died of advanced Parkinsons disease 2) The young adult with three small children whose wife died suddenly in an accident 3) The middle-aged person whose spouse suffered a slow, painful death 4) The older adult whose spouse died of complications of chronic renal disease ANS: 2 Although it is impossible to predict with certainty and the grieving process is highly individual and personal, in general those who suffer a sudden loss typically have more
www.mynursingtestprep.comdifficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g., cancer) have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs. PTS: 1 DIF: Moderate REF: p. 360 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate? 1) Delayed 2) Chronic 3) Disenfranchised 4) Masked ANS: 4 Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported. PTS: 1 DIF: Moderate REF: p. 361 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 7. According to the Uniform Determination of Death Act, which bodily function must be lost to declare death? 1) Consciousness 2) Brain stem function 3) Cephalic reflexes 4) Spontaneous respirations ANS: 2 According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations. PTS:1DIF:ModerateREF:p. 362 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall 8. A patients wife tells the nurse that she wants to be with her husband when he dies. The patients respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? 1) Certainly, go ahead; your husband will most likely hold on until you return. 2) Your husband could live for days or a few hours; you should do whatever you are comfortable with.
www.mynursingtestprep.com3) You need to take care of yourself; go home and shower, and Ill stay at his bedside while you are gone. 4) Dont worry. Your husband is in good hands; Ill look out for him. ANS: 2 The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husbands bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wifes return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wifes concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death. PTS:1DIF:ModerateREF:dm 367-368 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur 1) Moments before death 2) Days to hours before death 3) 1 to 2 weeks before death 4) 1 to 3 months before death ANS: 3 Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened. PTS:1DIF:ModerateREF:p. 367 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 10. Which intervention takes priority for the patient receiving hospice care? 1) Turning and repositioning the patient every 2 hours 2) Assisting the patient out of bed into a chair twice a day 3) Administering pain medication to keep the patient comfortable 4) Providing the patient with small frequent, nutritious meals ANS: 3 A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The
www.mynursingtestprep.compatient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the bodys need for nutrition and hydration is reduced as the body begins the desiccation process. PTS:1DIFifficultREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 11. The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? An advance directive is a document 1) Specifying your healthcare intentions should you become unable to make self-directed decisions 2) Identifying the activities considered to be evidence of quality care 3) Verifying your understanding of the risks and benefits associated with a procedure 4) Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice ANS: 1 An advance directive is a group of instructions stating the patients healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patients understanding of risks and benefits associated with a procedure. An against medical advice form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient. PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension 12. A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patients condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? 1) Ill call your physician right away so he can discuss this with you. 2) You have the right to change your decision about treatment at any time. 3) Are you sure you want to change your decision? 4) We must follow whatever is written in your living will. ANS: 2 The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patients decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patients decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it. PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
www.mynursingtestprep.com13. Which dysrhythmia confirms death? 1) Asystole (absence of heart activity) 2) Pulseless electrical activity 3) Ventricular fibrillation 4) Ventricular tachycardia ANS: 1 Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment. PTS:1DIF:EasyREF:p. 365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 14. A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, I just cant make up my mind about it. Which nursing diagnosis is most appropriate for this patient? 1) Deficient Knowledge 2) Spiritual Distress 3) Decisional Conflict 4) Death Anxiety ANS: 3 This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict. PTS:1DIF:ModerateREF:dm 367-368; high-level question, not stated verbatim in text | V2, dm 168169; high-level question, not stated verbatim in text KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level: Analysis 15. Which nursing intervention should be included in the plan of care for a patient dying of cancer? 1) Encourage at least one family member to remain at the bedside at all times. 2) Follow-up with other healthcare team members during weekly meetings. 3) Avoid discussing the dying process with family (to reduce sadness). 4) Encourage family members to participate in care of the patient when possible. ANS: 4 The plan of care should include encouraging family members to help with the patients care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family
www.mynursingtestprep.comconcerns. PTS: 1 DIF: Moderate REF: dm 369-371 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 16. Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a death rattle? 1) Perform nasotracheal suctioning of secretions. 2) Turn the patient on his side and raise the head of the bed. 3) Insert a nasopharyngeal airway as needed. 4) Administer morphine sulfate intravenously. ANS: 2 If a death rattle occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a death rattle and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a death rattle. This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest. PTS:1DIF:ModerateREF:p. 376 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 17. Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will 1) Request pain medication when needed 2) Report or demonstrate satisfactory pain control 3) Use only nonpharmacological measures to control pain 4) Verbalize understanding that it may not be possible to control his pain ANS: 2 The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an as needed basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain- control medications are available and can be administered by several routes; it should be possible to control the pain. PTS: 1 DIF: Moderate REF: p. 369 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 18. When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? 1) To prevent blood from settling in the head, neck, and shoulders 2) To perform these actions more easily before rigor mortis develops 3)
www.mynursingtestprep.comTo set the mouth in a natural position for viewing by the family 4) To prevent discoloration caused by blood settling in the facial area ANS: 2 Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patients eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patients mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area. PTS: 1 DIF: Moderate REF: p. 378 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 19. How should the nurse respond to a family immediately after a patient dies? 1) Ask the family to leave the patients room so postmortem care can be performed. 2) Leave tubes and IV lines in place until the family has the opportunity to view the body. 3) Express sympathy to the family (e.g., I am sorry for your loss). 4) Tell the family that they will have limited time with their loved one. ANS: 3 The nurse should express sympathy to the family immediately after the patients death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready. PTS:1DIF:ModerateREF:p. 378 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 20. The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child? 1) Take the child to the funeral even if he is frightened. 2) Notify the physician immediately if the child shows signs of regression. 3) Spend as much time as possible with the child. 4) Provide distraction whenever the child begins to express feelings of sadness. ANS: 3 The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears. PTS:1DIF:ModerateREF:p. 380
www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 21. Which intervention should be included in the plan of care for a patient in the end-stage death process? 1) Encourage the patient to accept as much help as possible. 2) Avoid administering laxatives. 3) Wet the lips and mouth frequently. 4) Administer pain medication on an as-needed basis. ANS: 3 If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them. PTS:1DIF:ModerateREF:p. 375 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 22. Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, Tell my wife to stop hovering and go home. Im going to be fine. How should the nurse respond? 1) Your physical signs indicate that you will likely not live more than a few more days. 2) You seem very sure that you are not going to die. Please tell me more about what you are feeling. 3) It seems to me you would be feeling some anger and wondering why all this is happening to you. 4) It would be best for your family if you were able to work through this and come to accept the reality of your situation. ANS: 2 Not all patients go through all the traditional stages of grieving. It is not the nurses responsibility to move patients sequentially through each stage of the dying and grieving process with the goal that everyone ends life accepting death. It is a nursing responsibility to accept and support people where they are and help them to express their feelings. Nurses need to understand patients, not change them. In this situation, denial may be very important to this patient, as an emotional defense and coping strategy. You seem sure . . . tell me . . . what you are feeling restates what the patient has said (indicating understanding) and encourages expression of feelingsboth are supportive. Even though moving him through stages is not the goal in this situation, support does facilitate that. Telling the patient that his physical signs indicate that death is imminent is presenting truth and reality; however, the exact time of death is not always predictable. Forecasting the hour of death can have negative impact on the family as they anticipate the event with emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier
www.mynursingtestprep.comin the dying process, but not in this situation because it has already been tried with no change in the patient. Presenting reality does not support the patients needs at this time. Saying It seems to me you would be feeling some anger . . . is directed toward moving the patient from denial and suggesting he should feel something he has not yet expressed. This is not therapeutic. Saying It would be best for your family . . . presumes that the nurse knows more about what is best for the patients family than the patient himself. This statement is also judgmental. PTS: 1 DIF: Difficult REF: dm 362-363 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 23. A home health patient previously lived with her sister for more than 20 years. Although it has been over a year since her sister died, the patient tells the nurse, Its no worse now, but I never feel any relief from this overwhelming sadness. I still cant sleep a full night. The house is a mess; I feel too tired, even to take a bath. But, sometimes at night, she comes to me and I can see her plain as can be. The patients clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably 1) Grieving longer than usual because of the closeness of the relationship with her sister 2) Experiencing a depressive disorder rather than simply grieving the loss of her sister 3) Feeling guilt and worthlessness because her sister died and she is still alive 4) Interpreting the holiday as a trigger event, which is causing her to hallucinate ANS: 2 The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no correct timeline for what constitutes longer than usual grieving; however, the patients symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said that the holiday has not made her feel any worsethat is, it has not been a trigger event. PTS: 1 DIF: Difficult REF: dm 367-368 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which intervention is appropriate for a client receiving palliative care? Choose all that apply. 1) Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation 2) Administering IV dopamine to raise blood pressure of a patient with end-stage lung cancer 3) Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4)
www.mynursingtestprep.comAdministering a medication to relieve the nausea of a patient with end-stage leukemia ANS: 3, 4 Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops and administering antinausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures. PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 2. To be eligible for insurance benefits covering hospice care, a physician must certify that which of the following apply to the patient? Choose all that apply. 1) Life expectancy is not more than 6 months. 2) Life expectancy is not more than 12 months. 3) Condition is expected to improve slightly. 4) Condition is not expected to improve. ANS: 1, 4 For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6 months. PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Choose all that apply. 1) Interest in his usual activities 2) Extended regression 3) Withdrawal from friends 4) Inability to sleep 5) Intermittent sadness ANS: 2, 3, 4 The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over a long period of time. Chapter 17 Documenting & Reporting Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The clients condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1) Study the discharge plan.
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