307 fundamentals: Unit 6 exam
13. In caring for the patient's spiritual needs, the nurse asks 20 questions to assess the patient's relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using? a. The spiritual well-being scale b. The FICA assessment tool c. Belief tool d. Hope scale
A
A nurse is assessing a group of adolescents. Which person is most likely to have the highest self-esteem? a. Latino adolescent female who has strong ethnic pride b. Caucasian boy who lives below federal poverty level c. African-American adolescent male who has severe acne d. Adolescent who was suspended twice from high school
A
14. A male patient in stable condition is in the intensive care unit (ICU) and is asking to see his spouse and two daughters. What should the nurse do? a. Allow only 5 to 10 minutes with the family. b. Allow the wife and daughters to visit at the patient's request. c. Allow the two daughters to visit, and let the wife visit when they leave. d. Allow the wife and one daughter to enter the ICU but not the other daughter
B
7. A nurse is caring for a Hindu patient. Which action will the nurse take? a. Allow time to practice the Five Pillars b. Allow time to practice Blessingway. c. Allow time for Holy Communion. d. Allow time for purity rituals.
D
. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. Which response by the nurse will be most effective? a. "Sexually transmitted infections and unwanted pregnancy are a real risk. Let's discuss what you think is the best method for protecting yourself." b. "Having sexual interaction with both males and females places you at higher risk for STIs. To protect yourself, you need to decide which orientation you are." c. "Your current friends are leading you to make poor choices. You should find new friends to hang out with." d. "I think it's best to notify your parents. They know what's best for you and can help make sure you practice safe sex.
a
15. The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, "I just don't feel like going to work. I have no energy, and I can't eat or sleep." The patient shows no interest in taking part in the care by saying, "What's the use?" Which response by the nurse is best? a. It sounds like you have lost hope. b. It sounds like you have lost energy. c. It sounds like you have lost your appetite. d. It sounds like you have lost the ability to sleep.
a
17. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient saying that God has left and there is no reason for living. b. A patient refusing treatment on the Sabbath. c. A patient having a folk healer in the room. d. A patient praying to Allah
a
18. A nurse is providing spiritual care to patients. Which action is essential for the nurse to take? a. Know one's own personal beliefs. b. Learn about other religions. c. Visit churches, temples, mosques, or synagogues. d. Travel to other areas that do not have the same beliefs.
a
8. The nurse is caring for a patient with a chronic illness who is having conflicts with beliefs. Which health care team member will the nurse ask to see this patient? a. The clergy b. A psychiatrist c. A social worker d. An occupational therapist
a
A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic? a. Ask the patient what concerns she may have about the vaccination. b. Inquire about how many sexual partners she has had in the past year. c. Remind her that her mother knows best and that she should respect her parents' wishes. d. Promote the importance of the vaccine, and recommend that the patient get the vaccine as soon as possible.
a
A male patient states, "I'm such a loser. I only had that job for a month." Which outcome criteria will the nurse add to the patient's care plan? a. The patient will verbalize two life areas in which he functions well. b. The patient will find new employment before the next clinic visit. c. The patient will confront a former boss about previous work problems. d. The patient will identify two reasons why he is considered a bad employee.
a
A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. Which nursing principle does the nurse's action best demonstrate? a. Facilitation of normal mourning b. Pain-management technique c. Grief evaluation d. Palliative care
a
A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect? a. Physical aggression and sleep disturbances b. Many peers and no drug usage c. Panic attacks and anorexia d. Anxiety and depression
a
A nurse is assessing a patient's self-concept. Which area should the nurse assess first? a. Role performance b. Vital signs c. Anxiety d. Morals
a
A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, "I feel happier, but my sex drive is gone." Which nursing diagnosis has the highest priority? a. Sexual dysfunction b. Ineffective coping c. Risk for self-directed violence d. Deficient knowledge about contraception
a
A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of-life care? a. During assessment b. During planning c. During implementation d. During evaluation
a
A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask? a. Have you noticed any changes in the way you feel about yourself? b. What is your favorite sex position with men and with women? c. Do you think your partner is attractive? d. Why do you like men over women?
a
A nurse is caring for a patient with dyspareunia. In which order will the nurse provide care, starting with the first step? 1. Determine which signs and symptoms of dyspareunia the patient has. 2. Mutually decide upon goals and objectives for dyspareunia. 3. Ask the patient if the dyspareunia is improving. 4. Develop a nursing diagnosis for the patient. 5. Use resources to help resolve the problem. a. 5, 3, 1, 4, 2 b. 1, 4, 2, 5, 3 c. 3, 1, 4, 2, 5 d. 4, 2, 5, 3, 1
b
A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up? a. "I have lost 12 pounds on this diet." b. "I use the diaphragm to prevent pregnancy." c. "I use a contraceptive cream with my diaphragm." d. "I know this provides a barrier over the cervical opening."
a
A nurse is providing postmortem care. Which action will the nurse take? a. Leave dentures in the mouth. b. Lower the head of the bed. c. Cover the body with a sterile sheet. d. Remove all tubes for an autopsy.
a
A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient? a. Writing in a journal b. Drinking alcohol to go to sleep c. Exercising vigorously rather than sleeping d. Avoiding talking with friends and family members
a
A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend? a. Condom b. Diaphragm c. Spermicide d. Oral contraceptive
a
A trauma survivor is requesting sleep medication because of "bad dreams." The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. "Are you reliving your trauma?" b. "Are you having chest pain?" c. "Can you describe your phobias?" d. "Can you tell me when you wake up?"
a
A verbally abusive partner has told a significant other many negative comments over the years. In the crisis center, the nurse would anticipate that the patient may have which selfconcept deficits? a. Body image b. Role confusion c. Rigidity d. Yearning
a
The mother of a child who died recently keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? a. Normal b. End-of-life c. Abnormal d. Complicated
a
The nurse in an addictions clinic is working with a patient on priority setting before the patient's discharge from residential treatment. Which goal is a priority at this time? a. Identifying local self-help groups before being discharged from the program b. Stating a plan to never be tempted by illicit substances after discharge c. Staying away from all triggers that cause substance abuse d. Recognizing personal areas of weakness to grow stronger
a
1. A nurse is evaluating a patient's spiritual care. Which areas will the nurse include in the evaluation process? (Select all that apply.) a. Review the patient's view of the purpose in life. b. Ask whether the patient's expectations were met. c. Discuss with family and friends the patient's connectedness. d. Review the patient's self-perception regarding spiritual health. e. Impress on the patient that spiritual health is permanent once obtained.
a, b, c, d
A nurse is assessing a patient's self-concept. Which areas will the nurse include? (Select all that apply.) a. Identity b. Body image c. Coping behaviors d. Significant others' support e. Availability of insurance
a, b, c, d
Spiritual distress has been identified in a patient who has been diagnosed with a chronic illness. Which interventions will the nurse add to the care plan? (Select all that apply.) a. Offer to pray with the patient. b. Avoid time with the support group. c. Have the patient avoid church attendance. d. Develop activities to heal body, mind, and spirit. e. Teach relaxation, guided imagery, and meditation.
a, d, e
An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.) a. Plan sexual activity around a time when the couple feels rested. b. Encourage intimate touching, such as hugging and kissing. c. Use extra lubrication to decrease discomfort. d. Take pain medication before intercourse. e. Avoid alcohol and tobacco. f. Eat well-balanced meals.
a, e, f
1. A co-worker asks the nurse to explain spirituality. What is the nurse's best response? a. It has a minor effect on health. b. It is awareness of one's inner self. c. It is not as essential as physical needs. d. It refers to fire or giving of life to a person.
b
11. A nurse makes a connection with the patient when providing spiritual care. Which type of connectedness did the nurse experience? a. Intrapersonal b. Interpersonal c. Transpersonal d. Multipersonal
b
16. The patient is having a difficult time dealing with an AIDS diagnosis. The patient states, "It's not fair. I'm totally isolated from God and my family because of this. Even my father hates me for this. He won't even speak to me." What should the nurse do? a. Tell the patient to move on and focus on getting better. b. Use therapeutic communication to establish trust and caring. c. Assure the patient that the father will accept this situation soon. d. Point out that the patient has no control and that he or she must face the consequences
b
2. A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. General adaptation syndrome b. Post-traumatic stress disorder c. Acute stress disorder d. Alarm reaction
b
5. After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, "No way, I'm not crazy." What is the nurse's best response? a. "Many times disasters can create mental health problems, so you really should participate with your family." b. "Seeking this kind of help does not mean that you have a mental illness; it is a shortterm problem-solving technique." c. "Don't worry now. The psychiatrists are well trained to help." d. "This will help your family communicate better."
b
6. A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events
b
9. The nurse is caring for a patient with a terminal disease. The nurse sits down and lightly touches the patient's hand. Which technique is the nurse using? a. "Doing for" b. Establishing presence c. Offering transcendence d. Providing health promotion
b
A 9-year-old is proudly telling the nurse about mastering the yellow belt in a martial arts class. Which developmental stage is the child exhibiting? a. Initiative versus guilt b. Industry versus inferiority c. Identity versus role confusion d. Autonomy versus shame and doubt
b
A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV vaccine? a. Protects against human immunodeficiency virus (HIV) b. Protects against cervical cancer c. Protects against chlamydia d. Protects against pregnancy
b
A nurse hears the following comments from different patients. Which patient comment does the nurse identify as faith? a. I go to church every Sunday. b. I believe there is life after death. c. I have something to look forward to each day. d. I get a feeling of awe when looking at the sunset.
b
A nurse is assessing a patient for possible altered self-concept. Which assessment finding is consistent with altered self-concept? a. Appropriately dressed with clean clothes b. Hesitant to express opinions c. Independent attitude d. Holds eye contact
b
A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse's religious and ethical values are strongly opposed. How should the nurse best handle the situation? a. Attempt to educate the patient about the consequences of abortion. b. Refer the patient to a family planning center or another health professional. c. Continue to care for the patient, and limit conversation as much as possible. d. Inform the patient that, because of immoral issues, another nurse will have to care for her
b
A nurse is caring for a patient who is dealing with the developmental task known as initiative versus guilt. The nurse is providing care to which patient? a. A 3-week-old neonate b. A 5-year-old kindergarten student c. An 11-year-old student d. A 15-year-old high school student
b
A nurse is caring for a postoperative mastectomy patient. Which action is a priority for increasing self-awareness? a. Solving problems for the patient before developing insight b. Using communication skills to clarify family and patient expectations c. Telling the patient that it will be fine because many others have survived d. Rotating nursing personnel in the patient's care, so the patient can talk to many people
b
A nurse is completing a history on a patient with role conflict. Which finding is consistent with role conflict? a. A patient is unsure about job expectations in a fast-paced company. b. A patient has to travel for work and misses children's birthdays. c. A patient feels less of a man after a leg amputation. d. A patient loses a job from the company's downsizing.
b
A nurse is evaluating a patient's self-concept. Which key indicator will the nurse use? a. Drug abuse history b. Nonverbal behavior c. Personal journal entries d. Posts on social media
b
A nurse is preparing a community class about sexually transmitted infections. Which primary group will the nurse focus on for this class? a. Bisexual women b. Men who have sex with men c. Youths between the ages of 24 and 27 d. Pregnant women and their partners
b
A nurse is reviewing a patient's history. Which priority finding will alert the nurse to assess the patient for possible sexual dysfunction? a. Takes vacations out of the country b. Takes antianxiety medication c. Takes exercise classes d. Takes afternoon naps
b
A nurse is teaching a patient about self-concept. Which information from the patient indicates the nurse needs to follow up about components of self-concept? a. One component is identity. b. One component is coping. c. One component is body image. d. One component is role performance
b
A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene? a. Elevating head of bed b. Making the patient eat c. Giving mouth care every 2 to 4 hours d. Keeping skin clean, dry, and moisturized
b
A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session? a. It is recommended for girls 6 to 9 years old. b. It is recommended for females ages 11 to 26. c. It is recommended that booster injections be given. d. It is recommended to receive four required injections.
b
A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting? a. Dietary changes b. Recent parental death c. Playmate moved away d. Sibling was sick 2 days
b
A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. "Let's call 911 because this freshman student is suicidal." b. "Give the freshman student this list of university and community resources." c. "I recommend that you help the freshman student start packing bags to go home." d. "You must make an appointment for the freshman student to obtain medications."
b
A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? a. Perceived loss b. Situational loss c. Maturational loss d. Uncomplicated loss
b
A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes on her labia. The patient is distraught because her partner must have cheated on her. Which response by the nurse is most effective in establishing an open rapport with a patient? a. Share a story. b. Inform the patient that all encounters are confidential. c. Encourage the patient to break up with her partner for cheating. d. Tell the patient that she must be honest about every sexual experience she has had.
b
An Orthodox Jewish rabbi has been pronounced dead. The nursing assistive personnel respectfully ask family members to leave the room and go home as postmortem care is provided. Which statement from the supervising nurse is best? a. "I should have called a male colleague to handle the body." b. "Family members stay with the body until burial the next day." c. "I wish they would go home because we have work to do here." d. "Family will quietly leave after praying and touching the rabbi's head."
b
Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? a. Delegate complex nursing tasks to nursing assistive personnel. b. Strengthen friendships outside the workplace. c. Write for 10 minutes in a journal every day. d. Use progressive muscle relaxation.
b
During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing? a. Denial b. Anger c. Bargaining d. Depression
b
The nurse is caring for an Islam patient who wants a snack. Which action by the nurse is most appropriate? a. Offers a ham sandwich b. Offers a beef sandwich c. Offers a kosher sandwich d. Offers a bacon sandwich
b
The nurse is leading a seminar about menopause and age-related changes. Which response from a group member indicates the nurse needs to follow up? a. "Hormones of sexual regulation decrease with aging." b. "Orgasms are no longer achievable after menopause." c. "The excitement phase is prolonged as we age." d. "As men age, their erection may be less firm."
b
Which individual is most likely to need the nurse's assistance in coping with identity confusion? a. A 49-year-old male with stable employment b. A 35-year-old recently divorced mother of twins c. A 22 year old in the third year of college d. A 50-year-old self-employed woman
b
Which patient is most in need of a nurse's referral to adoption services? a. A woman considering abortion for an unwanted pregnancy b. An infertile couple religiously opposed to artificial insemination c. A woman who suffered miscarriage during her first pregnancy d. An infertile couple who has been attempting conception for 3 months
b
While gathering an adolescent's health history, the nurse recognizes that the patient began to act out behaviorally and engaged in risky behavior when the patient's parents divorced. Which information will the nurse gather to determine situational low self-esteem? a. How long the parents were married b. How the patient views behaviors c. Why the parents are divorcing d. Why the patient is acting out of control
b
A nurse is documenting end-of-life care. Which information will the nurse include in the patient's electronic medical record? (Select all that apply.) a. Reason for the death b. Time and date of death c. How ethically the family grieved d. Location of body identification tags e. Time of body transfer and destination
b, d, e
"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? a. Providing curative therapy b. Promoting spirituality c. Facilitating mourning d. Eradicating grief
c
1. In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors
c
10. The nurse and the patient have the same religious affiliation. Which action will the nurse take? a. Must use a formal assessment tool to determine patient's beliefs. b. Assume that both have the same spiritual beliefs. c. Do not impose personal values on the patient. d. Skip the spiritual belief assessment.
c
12. The patient is admitted with chronic anxiety. Which action is most appropriate for the nurse to take? a. Focus on finding quick remedies for the anxiety. b. Realize that the patient's only goal is relief of the anxiety. c. Look at how anxiety influences the patient's ability to function. d. Help the patient realize that there is little hope of relief from anxiety.
c
3. The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? a. Primary b. Secondary c. Tertiary d. Quad
c
A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is the female nurse experiencing? a. Normal grief b. Perceived grief c. Complicated grief d. Disenfranchised grief
c
A nurse grimaces while changing a patient's colostomy bag. Which effect will the nurse's behavior most likely have on the patient? a. Assist recovery by using honest communication. b. Motivate the patient to increase physical activity. c. Promote development of a negative body image. d. Develop a kind nickname for the colostomy bag.
c
A nurse is teaching a patient how to meditate. Which information from the patient indicates effective learning? a. I will lie on the floor. b. I will breathe quickly. c. I will focus on an image. d. I will do this for 10 minutes every day.
c
A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal secretions. The nurse suggests using water-soluble lubricants. Which component of PLISSIT is the nurse using? a. P b. LI c. SS d. IT
c
A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene? a. "Avoiding alcohol use will enhance your sexual functioning." b. "You need to tell your partner how you feel about sex and any fears you may have." c. "You do not need to worry about getting a sexually transmitted infection at this point in your life." d. "Using pillows and taking pain medication if needed before having sexual intercourse often help alleviate pain and improve sexual functioning."
c
A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote? a. Time management b. Reminiscence c. Hope d. Faith
c
An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. Which response by the nurse will help establish a trusting relationship? a. "Don't worry. It's just a phase you will grow out of." b. "Those are abnormal impulses. You should seek therapy." c. "At your age, it is normal to be curious about both genders." d. "Having questions about sexuality is normal but if these sexual activities make you feel bad you should stop."
c
An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.
c
Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory? a. Numbing b. Reorganization c. Yearning and searching d. Disorganization and despair
c
The nurse is admitting a patient to the hospital. The patient is a very spiritual person but does not practice any specific religion. How will the nurse interpret this finding? a. This indicates a strong religious affiliation. b. This statement is contradictory. c. This statement is reasonable. d. This indicates a lack of hope.
c
The nurse is caring for a patient who is an agnostic. Which information should the nurse consider when planning care for this patient? a. The patient is devoid of spirituality. b. The patient does not believe in God The nurse is caring for a patient who is an agnostic. c. The patient believes there is no known ultimate reality. d. The patient finds no meaning through relationship with others.
c
The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. Which response by the nurse is best? a. "You should have your blood drawn today to see if you were infected." b. "If you have the virus, you will have flu-like symptoms in 6 months." c. "Highly active antiretroviral therapy has been shown effective in slowing the disease process." d. "I will set you up with a support group to help you cope with dying within the next 10 years."
c
The nurse is caring for an older-adult patient. Which technique will the nurse use to enhance an older-adult patient's self-concept? a. Discussing current weather b. Encouraging patients to sing c. Reviewing old photos with patients d. Allowing patients extra computer time
c
4. A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? a. Singing b. Massaging back c. Listening to music d. Using sensory peaceful words
d
7. A nurse is caring for a patient with stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? a. Select nursing interventions and promote patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions and achieve expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.
d
A cancer patient asks the nurse what the criteria are for hospice care. Which information should the nurse share with the patient? a. It is for those needing assistance with pain management. b. It is for those having a terminal illness, such as cancer. c. It is for those with completion of an advance directive. d. It is for those expected to live less than 6 months
d
A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Teach the teen about the food pyramid. b. Administer antidiarrheal medications with meals. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.
d
A nurse is caring for a dying patient. One of the nurse's goals is to promote dignity and validation of the dying person's life. Which action will the nurse take to best achieve this goal? a. Take pictures of visitors. b. Provide quiet visiting time. c. Call the organ donation coordinator. d. Listen to family stories about the person
d
A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death? a. Redness of skin b. Clear-colored urine c. Tense muscles tone d. Cheyne-Stokes breathing
d
A nurse is developing a drinking prevention presentation for adolescents. Which areas should the nurse include in the teaching session? a. Stressful life events and scholarships b. Very high self-esteem and work failure c. Health problems and avoidance of conflict d. Stress management and improving self-esteem
d
A nurse is teaching a patient about self-concept. Which information from the patient indicates a correct understanding of the teaching? a. Self-concept is how a person feels about others. b. Self-concept is how a person thinks about others. c. Self-concept is how a person feels about oneself. d. Self-concept is how a person thinks about oneself
d
A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient's family. What is the primary rationale for the nurse's action? a. The nurse is not as knowledgeable as the coordinator. b. The nurse is uncomfortable asking the family. c. The nurse does not want to upset the family. d. The nurse is following a federal law.
d
A palliative team is caring for a dying patient in severe pain. Which action is the priority? a. Provide postmortem care for the patient. b. Support the patient's nurse in grieving. c. Teach the patient the stages of grief. d. Enhance the patient's quality of life.
d
A patient cancels a scheduled appointment because the patient will be attending a Shivah for a family member. Which response by the nurse is best? a. "When families come together for end-of-life decisions, it provides connections." b. "We will reschedule so the appointment does not fall on the Sabbath." c. "Missionary outreach is so important for spiritual comfort." d. "I'm so sorry for your loss."
d
A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the ostomy is physically unattractive. Which initial nursing intervention will be most effective in helping this patient resume sexual activity? a. Inform the patient about a support group for people with colostomies. b. Reassure the patient that lots of people resume sex the same week the colostomy is placed. c. Teach the patient about intimate activities that can be done to incorporate the ostomy. d. Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy.
d
A patient's father died a week ago. Both the patient and the patient's spouse talk about the death. The patient's spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and gets choked up most of the time. How should the nurse interpret these findings as the basis for a follow-up assessment? a. The patient is dying and the spouse is angry. b. The patient is ill and the spouse is malingering. c. Both the patient and the spouse are likely in denial. d. Both the patient and the spouse are likely grieving.
d
A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem? a. Contact the health care provider to discontinue pain medication. b. Administer enemas twice daily for 7 days. c. Massage the patient's abdomen. d. Use a laxative
d
An adult son is adjusting to the idea of his chronically ill parents moving into his family home. The community health nurse is assessing the adult son for potential stressors secondary to the new family living arrangement. Which stressor will the nurse assess for in this adult son? a. Role confusion b. Role ambiguity c. Role performance d. Role overload
d
In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan? a. Prepare the body for autopsy. b. Prepare the body for cremation. c. Allow male Muslims to care for the body after death has occurred. d. Allow female Muslims to care for the body after death has occurred.
d
The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide? a. Store in a warm lit space. b. Use massage oils for lubrication. c. Rinse and reuse the condom if needed. d. Hold onto the condom when pulling out.
d
Two 50-year-old men are discussing their Saturday activities. The first man describes how he tutors children as a volunteer at a community center. The other man says that he would never work with children and that he prefers to work out at the gym to meet young women to date. Which developmental stage is the second man exhibiting? a. Mistrust b. Inferiority c. Generativity d. Self-absorption
d
