Fundamentals PrepU Final Exam
You are the pediatric nurse caring for Beth, a 13-month-old who is admitted with a respiratory infection. Her mother says she wants her child to develop in the best way possible. She asks you, "What kind of self-concept should Beth have at her age?" Your best answer is which of the following? a) "She has developed no self-concept at this age." b) "The differences between self and others are strong at this age." c) "She has a beginning differentiation of self and non-self." d) "Her sense of self is very consolidated at this age."
"She has a beginning differentiation of self and non-self." Explanation: The newborn has no self-concept at birth. In late infancy, a baby starts to differentiate between self and non-self. In childhood, differences between self and others are strong. During adolescence one's sense of self becomes very consolidated. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1497.
A new mother is discussing her 6-month-old infant's sleep habits and expresses concern about the infant obtaining too much sleep. The mother reports the infant's circadian cycle as listed above. The best statement by the nurse is: a) "You need to awaken your infant during the 2400 to 0600 time period." b) "Your infant is actually obtaining too little sleep for one day." c) "Your infant requires more time asleep during the day hours." d) "Your infant is obtaining the average hours of sleep per day for an infant."
"Your infant is obtaining the average hours of sleep per day for an infant." Explanation: Infants usually require 14 to 20 hours of sleep per day. This infant is obtaining 14 hours of sleep each day. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1083.
A new mother calls the pediatric nurse to talk to the nurse about her baby who sleeps "all day long." The nurse informs the new mother that an infant requires how many hours of sleep? a) 8 to 9 hours of sleep each day b) 9 to 12 hours of sleep each day c) 12 to 14 hours of sleep each day d) 14 to 20 hours of sleep each day
14 to 20 hours of sleep each day Explanation: The pediatric nurse informs the new parent that on the average, infants require 14 to 20 hours of sleep each day. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1083.
Upon assessment of a patient being evaluated at the headache clinic, the patient informs the nurse that her headaches started when she started experiencing marital problems. The patient reports that each time she and her husband have a fight, she develops a headache and loses her appetite for several days. Which of the following best defines the physiologic symptoms? a) A psychosomatic disorder b) Fear c) Anxiety d) A coping mechanism
A psychosomatic disorder Explanation: A psychosomatic disorder is a real illness caused by psychological influences. The patient's fight with her husband causes emotions that lead to physical symptoms. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fear is a cognitive response to a known threat. Anxiety is often managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1526.
An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of a) Adaptation b) Valuation c) Reaction d) Evaluation
Adaptation Explanation: Adaptation is generally considered a person's capacity to flourish and survive, even with diversity. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1522.
A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which of the following stress-reduction techniques should the nurse use with this client? a) Discourage family from interacting with the client. b) Advocate on behalf of the client to others. c) Avoid discussing the client's condition with client's family. d) Avoid referring the client to other organizations.
Advocate on behalf of the client to others. Explanation: The nurse should advocate on behalf of the client to others. If need be, the nurse should refer the client and his family to organizations or people who provide post-discharge assistance. The nurse should keep the client and the client's family informed about the client's condition and encourage the family members to interact with the client. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation p. 1538.
A nurse is caring for a client diagnosed with sleep apnea. What should the nurse do in order to promote sleep in the client? a) Provide good ventilation in the room. b) Encourage deep breathing exercises. c) Avoid sedatives for sleeping. d) Encourage the client to lose weight.
Avoid sedatives for sleeping. Explanation: The nurse should avoid sedatives in the client because sedatives may depress respiration. The client with sleep apnea already has decreased ventilation and low blood oxygenation; the condition may become worse if the respiration is further depressed by sedatives. Losing weight is a long-term measure and is not applicable in this case. Encouraging deep breathing exercises and providing good ventilation may help the client, but they are secondary measures. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1090.
A student nurse studying human anatomy knows that the following is a structure of the large intestine: a) Duodenum b) Cecum c) Jejunum d) Ileum
Cecum Explanation: The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 38: Bowel Elimination, p. 1299.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? a) Denial b) Acceptance c) Bargaining d) Anger
Correct response: Anger Explanation: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 43: Loss, Grief, and Dying, p. 1549.
During a physical examination, the patient reports that he is a marathon runner when the nurse inquires about the patient's level of physical activity. The nurse identifies running as which type of exercise? a) Isotonic exercise b) Isometric exercise c) Passive exercise d) Isokinetic exercise
Correct response: Isotonic exercise Explanation: Isotonic exercise involves muscle shortening and active movement, such as running, walking, and cycling. Isometric exercise involves muscle contraction without shortening of muscle fibers. Passive exercise is performed by the nurse, family member, or therapist, and the patient's muscles do not exert the effort. Isokinetic exercise involves muscle contractions with resistance, such as weight training. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1012
In the United States, what belief is the hospice movement based on? a) Meaningful living during terminal illness is best supported in the home. b) Meaningful living during terminal illness requires technologic interventions. c) Meaningful living during terminal illness is meant to prolong physiologic dying. d) Meaningful living during terminal illness is best supported in designated facilities.
Correct response: Meaningful living during terminal illness is best supported in the home. Explanation: The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness and that it is best supported in the home, free from technologic interventions to prolong physiologic dying. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 43: Loss, Grief, and Dying, p. 1551.
The nurse adjusts a patient's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action? a) Push the patient to the opposite side of the bed. b) Pull the patient to the edge of the bed to which the patient will be turning. c) Move the patient to edge of the bed opposite the side that patient will be turning. d) Push the patient to the edge of the bed to which the patient will be turning.
Correct response: Move the patient to edge of the bed opposite the side that patient will be turning. Explanation: When turning a patient in bed, the nurse would use a friction-reducing sheet to pull the patient to the edge of the bed that is opposite the side the patient will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual patient. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1056.
A nurse is ambulating a patient who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall? a) The nurse should rock his or her pelvis out on the opposite side of the patient. b) The nurse should grasp the gait belt and pull the patient's body backward away from his or her body. c) The nurse should place his or her feet close together with one foot in front of the other. d) The nurse should gently slide the patient down his or her body to the floor.
Correct response: The nurse should gently slide the patient down his or her body to the floor. Explanation: The nurse should place feet wide apart, with one foot in front and rock pelvis out on the side nearest the patient. The nurse should grasp the gait belt and support the patient by pulling his or her weight backward against his or her body and then gently sliding the patient down his or her body to the floor, protecting the patient's head. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1039
A 78-year-old woman has recently moved to an assisted-living facility. Within the patient's documented medication regimen is a dose of an antianxiety medication each evening at bedtime as a sleep aid. The nurse would recognize that this medication carries a risk of which of the following? a) Seizures b) Night terrors c) Dependence d) Respiratory depression
Dependence Explanation: Many pharmacologic sleep aids carry a risk for physical and psychological dependence. Respiratory depression is not a common risk of these medications and they are not associated with night terrors or seizure activity. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1100.
A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis. a) Fear of rejection by others related to colostomy and altered self-image b) Altered role performance related to inability to cope with visitors c) Disturbed body image related to colostomy as evidenced by avoidance of colostomy d) Altered self-esteem related to colostomy and poor self-image
Disturbed body image related to colostomy as evidenced by avoidance of colostomy Explanation: Disturbed body image possesses the clinical cues of behaviors of avoidance, monitoring, or acknowledgement of one's body. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1501.
A nurse introduces herself to a visually impaired client, addresses the client by name, speaks to the client respectfully, and explains all the nursing activities. The nurse is implementing health promotion with this client by which mechanism? a) Helping in positive self-evaluation b) Aiding goal formulation c) Identifying strengths d) Fostering a sense of self
Fostering a sense of self Explanation: By treating the client respectfully and personally, the nurse is fostering a sense of self. The nurse pays special attention to the client's individuality and emotional needs by explaining all the nursing activities, which will promote the client's self-concept. To implement health promotion by identification of strengths, the nurse would assist the client in identifying and cultivating his personal strengths such as a nice smile, hobbies, and strong health maintenance patterns. The nurse would assist the client in positive self-evaluation by focusing on positive attributes and pointing out accomplishments that deserve positive feedback. The nurse assists the client in goal formulation by identifying the desired outcome. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1500.
The nurse is helping a patient with musculoskeletal alterations to perform range-of-motion exercises. In what order would the nurse perform the exercises for the patient? a) From the head and down one side of the body at a time. b) From the head, to the arms, to the legs. c) From the arms, to the head, to the legs. d) From the feet, to the arms, to the head.
From the head and down one side of the body at a time. Explanation: The nurse would perform range-of-motion exercises working on the joints from the head, going down the side of the body to the feet, and then moving to the other side of the body, proceeding in the same manner. Performing the exercises from head to toe, one side at a time, promotes efficient time management and an organized approach to the task. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1067.
A client whose arm was amputated after a motor vehicle accident is in shock by the loss. Which intervention would be most appropriate for the nurse to implement for this client? a) Help the client to continue changing patterns of behavior b) Help the client to express thoughts and feelings about the loss c) Emphasize the ned for the client to accept the loss and begin reorganization d) Help the client mobilize normal support systems like family and friends
Help the client mobilize normal support systems like family and friends Explanation: The nurse should help the client mobilize normal support systems like family and friends because the client is in a state of shock. During the protest phase, the nurse should help the client to express thoughts and feelings about the loss. During the disorganization phase, the nurse should help the client to accept the reality of the loss and begin reorganization. During the reorganization phase, the nurse should help the client to continue changing patterns of behavior. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 43: Loss, Grief, and Dying, p. 1548.
Which of the following gaits is characterized by one leg being dragged and swung forward by hip motion? a) Festinating b) Hemiplegic c) Spastic d) Waddling
Hemiplegic Explanation: A hemiplegic gait occurs when one leg is paralyzed or neurologically damaged, so that the leg is dragged or swung around to propel it forward. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1018.
An 80-year-old patient experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the patient? a) Low-Fowler's b) Protective supine c) High-Fowler's d) Semi-Fowler's
High-Fowler's Explanation: A high-Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The patient's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1032
The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from one hour ago. The nurse assesses the stage of non-rapid eye movement (NREM) sleep, which the client exhibits as Stage a) I. b) IV. c) III. d) II.
I. Explanation: Easy arousal from sleep and involuntary muscle jerking which may awaken the client are signs of Stage I NREM. In the other stages the client becomes increasingly more difficult to arouse and does not exhibit involuntary muscle jerking. In Stage IV NREM, the client's pulse, respirations, and blood pressure decrease, and muscles are relaxed. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1083.
A 35-year-old women comes to the local health center with a large mass is her right breast, she has felt the lump for about a year but was afraid come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient? a) Self-esteem disturbance b) Altered family process c) Ineffective individual coping d) Ineffective denial
Ineffective individual coping Explanation: Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case the patient was unable to access health care even when she was aware the disorder could be life threatening. Self-esteem disturbance, Altered family process, and Ineffective denial are all nursing diagnoses that are often associated with breast cancer, but her ineffective individual coping has created a significant safety risk and is therefore the most appropriate nursing diagnosis. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1536.
A nurse is explaining the effect of a prescribed medication and the different phases of sleep to an insomniac client. Which of the following statements is true for non-rapid eye movement (REM) sleep? a) It is called slow wave sleep. b) It is called active sleep. c) It is called paradoxical sleep. d) It is the deepest stage of sleep.
It is called slow wave sleep. Explanation: Non-rapid eye movement sleep, which progresses through four stages, is also called slow wave sleep because during this phase, electroencephalographic (EEG) waves appear as progressively slower oscillations. The REM phase of sleep is referred to as paradoxical sleep because the EEG waves appear similar to those produced during periods of wakefulness but it is the deepest stage of sleep. NREM sleep is characterized as quiet sleep and REM sleep as active sleep. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1082.
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be a) Bloody b) Soft semi-formed c) Liquid consistency d) Mucus filled
Liquid consistency Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 38: Bowel Elimination, p. 1325.
A nurse integrates knowledge of developmental levels and their influence on self-concept when planning client care. The nurse would expect a client in which developmental stage to begin to examine the meaning of self? a) Young adult b) Adolescent c) Preschooler d) Older adult
Older adult Explanation: Older adults begin to examine the meaning of self. They begin to look at the meaning of life in relation to roles previously discarded. The preschooler's sense of self is more defined than that of a toddler but is still undergoing development. Preschoolers often imitate adult roles, but do not question or examine the meaning of self. Adolescents are in the process of defining their identity and self-concept. They do not examine the meaning of self. Early adulthood involves forming intimate relationships, choosing a career, establishing a home base, and starting a family. Young adults are still in the process of experiencing new events and roles. They do not commonly engage in examination of the meaning of self. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1510.
A nurse is performing an abdominal assessment of a patient before administering a large-volume cleansing enema. Which of the following assessment techniques would be performed last? a) Auscultation b) Palpation c) Inspection d) Percussion
Palpation Explanation: The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 38: Bowel Elimination, p. 1307.
As an occupational health nurse at an oil refinery on the Gulf coast of Texas you are doing patient education with a man in his mid-forties. The patient is being seen after having been exposed to a chemical spill at the refinery. What type of stressor has this patient been exposed to? a) Physical b) Psychosocial c) Physiologic d) Psychiatric
Physical Explanation: Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. These facts make the other options incorrect. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1531.
A nurse is caring for a client with sleep apnea. Which nursing intervention would be most appropriate to prevent hypoxia in the client? a) Provide a back massage before sleep b) Provide milk before sleeping c) Provide relief for nasal congestion d) Encourage physical exercises
Provide relief for nasal congestion Explanation: The nurse should provide relief for nasal congestion in the client to prevent hypoxia. Physical exercise may have an indirect beneficial effect on sleep apnea by reducing the client's weight. Providing milk before sleep helps to promote sleep but is not helpful in cases of sleep apnea. Providing a back massage before sleep does not have any effect on sleep apnea. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1089.
An elderly client at a health care facility dies after a prolonged illness. Which of the following is a psychological reaction associated with the different stages of grief? a) Difficulty breathing b) Refusal to accept death c) Tightness in the throat d) Behaving in a morbid manner
Refusal to accept death Explanation: The most common psychological reaction is shock and disbelief or the refusal to accept that a loved one is about to die or has died. Some grieving people report physical symptoms such as difficulty breathing or tightness in the throat, whereas some people show signs of pathologic grief through morbid behaviors. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 43: Loss, Grief, and Dying p. 1568.
A nurse has been caring for a client who is being treated for physical assault that had occurred a year ago. Upon inquiring if the incident caused any stress to the client, the client replies that he no longer feels any emotion about the incident. Which stage of stress is the client currently experiencing? a) Resistance stage b) Exhaustion stage c) Alarm stage d) Primary stage
Resistance stage Explanation: The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress. The primary stage is not related to stages of stress and is applicable for stress prevention. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1525.
A client states to you, "I am not smart enough to learn how to take of my mother, and I just don't think I can do it." This is an example of a) Self-perception b) Self-expectation c) Self-knowledge d) Social self
Self-knowledge Explanation: Self-knowledge or self-awareness involves the basic understanding of oneself, a cognitive perception. It is consciousness of one's abilities: cognitive, affective, and physical. Self-concept is the way a person thinks about himself or herself whereas self-perception is how a person explains behavior based on self-observation. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1493.
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Newborns a) Sleep 16 to 17 hours per day b) Are inactive when awake c) Will nap two times per day d) Have shorter periods of REM sleep
Sleep 16 to 17 hours per day Explanation: Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1085.
A nurse is meeting with a young woman who has recently lost her mother, her job and moved with her husband to a new city. She is complaining of acute anxiety and depression. What does the nurse knows that would be helpful to this patient? a) Adaptation often fails during stressful events and results in homeostasis. b) Stress is a part of our lives and eventually this young woman will adapt c) Acute anxiety and depression are seldom associated with stress. d) Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease.
Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. Explanation: Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic and hormonal measures, stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. Option A is incorrect, when adaptation fails, the result is disease. Option B is incorrect, if a person is overwhelmed by stress they may never adapt. Option C is incorrect, acute anxiety and depression is frequently associated with stress. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation, p. 1523.
A client begins snoring and is sleeping lightly. The stage of sleep is a) Stage 3 b) Stage 2 c) Stage 1 d) Stage 4
Stage 2 Explanation: Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 34: Rest and Sleep, p. 1083.
The nurse is assisting a patient with limited mobility to turn in bed. After successfully turning the patient to the side, where would the nurse place an additional pillow? a) Under the patient's feet. b) Supporting the patient's back. c) In front of the patient's abdomen. d) Under the patient's head.
Supporting the patient's back. Explanation: The nurse would place the pillow under the patient's back to provide support and help maintain the proper position. More than one pillow under the patient's head is not necessary. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1056
A patient who has died an unexplained death has numerous catheters and drainage tubes in place and is being prepared for an autopsy. In providing care to the body after the patient has been pronounced dead, how shall the nurse manage the tubes prior to the autopsy? a) The nurse will remove all tubes and send the tubes to the autopsy procedure with the body. b) The nurse will remove all tubes and discard in isolation trash receptacles. c) The nurse will remove all catheters in blood vessels and leave drains and urinary catheters in place. d) The nurse will not remove any tubes from the body.
The nurse will not remove any tubes from the body. Explanation: If an autopsy is to be performed, any tubes that were in place should not be removed. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 43: Loss, Grief, and Dying, p. 1567.
A client visits a health care facility after his spouse's death. The client is quite depressed and feels very lonely. The nurse asks him to confront the reality and be emotionally strong. What type of strategy is the nurse following in this case? a) Therapeutic coping strategy b) Non-therapeutic coping strategy c) Negative coping strategy d) Sensory manipulation strategy
Therapeutic coping strategy Explanation: Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. People use non-therapeutic coping strategies such as mind- and mood-altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain using sensory stimuli. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 42: Stress and Adaptation p. 1537-1539.
Which of the following factors is related to developmental changes in bowel habits for elderly clients? a) Milk products cause constipation in lactose intolerance b) Increase in dietary fiber can decrease peristalsis c) The elderly should peel fruits before eating d) Weakened pelvic muscles lead to constipation
Weakened pelvic muscles lead to constipation Explanation: Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increaseing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in the elderly. Peeling fruit does not impact bowel habits in the elderly. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 38: Bowel Elimination, p. 1301.
A patient with uncontrolled hypertension experienced a stroke 1 week ago, leading to significant motor losses. A successful and normal adaptive response to these new limitations is evident if the patient: a) refuses to participate in physiotherapy. b) changes the subject when the nurse addresses activities of daily living (ADLs). c) exhibits signs of grief. d) repeatedly states, "It is what it is."
exhibits signs of grief. Explanation: Grief is a normal response to a recent deformity or limitation. Changing the subject and refusing treatment would be considered maladaptive responses. Stating that "it is what it is" may possibly signal resignation and defeat, neither of which is associated with an adaptive response. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1502.
A physician orders a large volume cleansing enema for a patient postabdominal surgery. What is one of the usual outcomes of this procedure? a) It removes hardened fecal impactions from the rectum. b) It softens and facilitates the removal of intestinal polyps. c) It provides an outlet for diarrhea to be funneled into a collection unit. d) It stimulates peristalsis and provides a passageway for gas to escape.
t removes hardened fecal impactions from the rectum. Explanation: Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction, preventing involuntary escape of fecal material during surgical procedures, promoting visualization of the intestinal tract by radiographic or instrument examination, and helping to establish regular bowel function during a bowel training program. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 38: Bowel Elimination, p. 1319.
Choice Multiple question - Select all answer choices that apply. You are the nurse who is assessing Melissa Barnes, a 25-year-old patient, for information about her personal identity. Which of the following verbalizations to Melissa would help solicit the needed information? Choose all that apply. a) "How would you describe yourself to others?" b) "What words would your best friend use to describe you?" c) "What is your favorite color?" d) "Tell me a little bit about yourself." e) "Make a list of 10 labels that you believe identify yourself."
• "How would you describe yourself to others?" • "What words would your best friend use to describe you?" • "Make a list of 10 labels that you believe identify yourself." Explanation: Personal identity describes an individual's conscious sense of who he or she is. "How would you describe yourself to others?" is a good way to get a description of self-concept. Having the patient think of labels or words that describe him/her is another good way to get information about self-concept. The patient's favorite color tells you nothing about self-concept and "Tell me a little bit about yourself" is far too broad to get any specific information. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1501.
Choice Multiple question - Select all answer choices that apply. You are working on the rehabilitation unit today and caring for Jan Krane, a 19-year-old, who suffered a traumatic amputation of her left hand 6 days ago. You are assessing her for adaptive responses to her physical deficits. Which of the following statements by Jan indicate an adaptive response? a) "I am okay with this now." b) "I am not going to any of the rehab classes." c) "I don't believe this has happened to me." d) "I am so angry that this has happened to me." e) "I am not worth anything to anybody now."
• "I am so angry that this has happened to me." • "I don't believe this has happened to me." • "I am okay with this now." Explanation: The patient exhibits signs of adaptive behavior by showing grief and mourning (shock, disbelief, denial, anger, guilt, acceptance). The patient shows signs of maladaptive behavior by continuing to deny and to avoid dealing with the deformity or limitation, engaging in self-destructive behavior, and talking about feelings of worthlessness or insecurity. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self Concept, p. 1503.
Choice Multiple question - Select all answer choices that apply. Today you are caring for Betsy Carpenter, a 62-year-old woman, who is admitted for a hip replacement related to osteoarthritis. Mrs. Carpenter expresses distress about the aging process and how it affects her appearance. You have identified "disturbed body image" as a nursing diagnosis for Mrs. Carpenter. Which of the following teaching topics would be appropriate nursing interventions for this diagnosis? a) Identification of depression b) Yoga to maintain joint flexibility c) Exercising to maintain muscle mass d) Proper nutrition e) Measures for basic skin care
• Exercising to maintain muscle mass • Proper nutrition • Measures for basic skin care • Yoga to maintain joint flexibility Explanation: Some basic interventions for a diagnosis of disturbed body image for an older adult include teaching preventive self-care measures that reduce discomforting signs of aging (e.g., exercise, which maintains muscle mass and joint flexibility; proper nutrition; and basic hygiene and skin care measures). Teaching this patient about how to identify depression may be appropriate, but is not an intervention for disturbed body image. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 41: Self-Concept, p. 1512.
Choice Multiple question - Select all answer choices that apply. A nurse is teaching an elderly patient how to use a walker. Which of the following instructions ensures accurate use of this device? Select all that apply. a) Stand between the back legs of the walker. b) Step forward with your right foot supporting weight on your legs. c) Move the walker forward 12 to 18 inches and set it down. d) Keep arms relaxed at the side. e) Line up the top of the walker with the crease on the inside of your wrist. f) Place your hands on the grips and flex your elbows about 10 degrees.
• Stand between the back legs of the walker. • Keep arms relaxed at the side. • Line up the top of the walker with the crease on the inside of your wrist. Explanation: Regardless of the type of walker used, the patient stands between the back legs of the walker with arms relaxed at the side, the top of the walker should line up with the crease on the inside of the patient's wrist. When the patient's hands are placed on the grips, elbows should be flexed about 30 degrees (Mayo, 2007). Have the patient move the walker forward 6 to 8 inches and set it down, making sure all four feet of the walker stay on the floor. Then, tell the patient to step forward with either foot into the walker, supporting himself or herself on his or her arms. Follow through with the other leg. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 33: Activity, p. 1041.
