TEST 6 MF

What philosophy for handling stress can nurses encourage patients to adopt?

"Accept what can't be changed, change what can't be accepted."

Which of the following questions would be helpful in eliciting data about the effects of stress during a health history?

"How does your body feel when you are upset?"

A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which of the following statements?

"I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

A nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which of the following statements, if made by the client, would indicate an understanding of the instructions?

"I will not sleep on my right side."

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that:

"The medication causes the pupil to constrict and will lower the pressure in the eye."

Age range of the Autonomy vs. Shame & Doubt stage of Erikson's theory

1 - 3 years (toddler)

The family of a client with increasing dementia asks the nurse how to convince one sibling who refuses to acknowledge their elderly mother's personality change. Which information would the nurse address in teaching the family about personality change in dementia? Select all that apply. 1. Loss of interest in surroundings 2. Lack of consideration for others 3. Difficulty learning new things 4. Disregard for the concept of time 5. Inability to do things in sequence 6. Decreased performance of daily activities

1 and 2. Clients with dementia often manifest a loss of interest in their surroundings, a lack of consideration for others, and a tendency to be self-absorbed as manifestations of a personality change. Having difficulty learning new things and the loss or disregard for the concept of time are cognitive changes that occur in dementia. The inability to do things in an orderly sequence and the decreased performance of daily activities indicate the functional changes seen in clients with dementia.

1. The nurse is asking a client in the psychiatric crisis unit specific questions about recent substance use. Which assessment finding could indicate to the nurse that the client is experiencing mild to moderate delirium? 1. Time and place disorientation 2. Impaired abstract thinking 3. Persistent memory disturbance 4. Changes in personality

1. 1. Clients with delirium experience disorientation to time, then place, and then person. Impaired abstract thinking and noted changes in personality are characteristics of dementia. Persistent memory disturbance is associated with an amnestic disorder.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. The nurse would prepare to position the client:

On bedrest in a semi-Fowler's position

The nurse is providing health teaching for a client using herbal compounds such as valerian for sleep. What points need to be included?

1. Should not be used indefinitely 2. May interfere with prescribed medications 3. Over time they can lead to further sleep problems 4. Are not regulated by the Food and Drug Administration (FDA)

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

1. To avoid activities that require bending over 3. To place an eye shield on the surgical eye at bedtime 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort

A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crisis is she experiencing?

Situational

Age range of the Initiatiion vs. Guilt stage of Erikson's theory

3 - 5 years (preschool)

Age range of the Identity vs. Identity Confusion stage of Erikson's theory

10 - 20 years (puberty)

Nuclear Family

married adult man and woman and their children living in the same household

multigenerational families

several generations living together in one residence

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially?

Instillation of mineral oil or diluted alcohol

Age range of the Intimacy vs. Isolation stage of Erikson's theory

20's & 30's (young adult)

Which patient is handling stress by using the defense mechanism termed displacement?

A mother who is angry at her husband shouts at the kids to "keep quiet."

The nurse notices that a client with dementia about to eat his dinner picks up his spoon, looks at it, puts it down, and then picks up his fork, looks at it, and puts it back on the table. He sits staring at the utensils and his dinner. How does the nurse interpret this behavior? 1. A risk for altered nutrition 2. A disruption in metabolic functioning 3. A disturbance in executive functioning 4. A potential sensory-motor deficit

3. The client's inability to initiate activities or perform routine tasks are examples of the loss of the ability to think and reason abstractly; hence, a disturbance or interference in the client's executive functioning has occurred. This behavior does not indicate a problem with nutrition or with metabolic or sensory-motor functioning.

4. The home health nurse notices that the elderly, diabetic client she sees every week is starting to demonstrate some difficulty answering questions about her chronic disease strategies and self-management activities. Which action would the nurse take to validate her suspicion of the client having cognitive changes and possibly the beginning stages of dementia? 1. Speak to the doctor about ordering cardiac diagnostic studies. 2. Petition the insurance company for a weekly home health aide. 3. Request that another nurse visit and perform a mental status exam. 4. Arrange to speak to a family caregiver as soon as possible.

4. 4. By speaking to the consistent family caregiver, that person may be able to validate for the nurse the presence of the slow and progressive changes that occur in the early stages of dementia. In the early stages of dementia, the client will have recurrent memory impairment and will attempt to hide these cognitive losses. Communication with the physician would be for the purpose of sharing the nurse's assessment findings, not to request a cardiac workup. The need for a possible home health aide can be addressed when speaking to the caregiver, rather than acting without family consultation. There is no need to request that a different home health nurse perform the mental status assessment. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 13650-13655). Lippincott Williams & Wilkins. Kindle Edition.

Older adults are cautioned about the use of nonprescription sleeping medications because these medications can:

Lead to further sleep disruption even when they initially seemed to be effective. Over-the-counter medications for sleep often cause more problems than benefits. The other answers are incorrect.

8. Which intervention should help a client diagnosed with Alzheimer's disease perform activities of daily living? 1. Have the client perform all basic care without help. 2. Tell the client morning care must be done by 9 a.m. 3. Give the client a written list of activities he's expected to do. 4. Encourage the client and give ample time to complete basic tasks. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 13689-13693). Lippincott Williams & Wilkins. Kindle Edition.

4. Clients with Alzheimer's disease respond to the effect of those around them. A gentle, calm approach is comforting and nonthreatening, and a tense, hurried approach may agitate the client. The client has problems performing independently. The inherent expectations of deadlines and activity lists may lead to frustration. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 13695-13697). Lippincott Williams & Wilkins. Kindle Edition.

5. A nurse is caring for a client with delirium. Which nursing intervention has the highest priority? 1. Providing a safe environment 2. Offering recreational activities 3. Providing a structured environment 4. Instituting measures to promote sleep

5. 1. The nurse's highest priority when caring for a client with delirium is to ensure client safety. Offering recreational activities, providing a structured environment, and promoting sleep are all appropriate interventions after safety measures are in place.

Age range of the Industry vs. Inferiority stage of Erikson's theory

6 years to puberty (school-age)

Age range of the Integrity vs. Despair stage of Erikson's theory

60's and older (older adult)

what age are most infants become attached to their primary caregivers and are developing trust

8 months

Which of the following medications are the safest to administer to adults needing assistance in falling asleep?

Benzodiazepines The safest group of drugs is the benzodiazepenes. They facilitate the action of the neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal.

Age range of the Generativity vs. Stagnation stage of Erikson's theory

40's & 50's (middle age)

A nurse is assigned to care for a client with a detached retina. Which finding would the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision

A nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as:

A sensorineural hearing loss that occurs with aging

Regarding the request for organ and tissue donation at the time of death, the nurse needs to be aware that: A. Specially educated personnel make requests. B. Requests are usually made by the nurse caring for the patient at the time of death. C. Only patients who have given prior instruction regarding donation become donors. D. Professionals need to be very selective in whom they ask for organ and tissue donation.

A. Specially educated personnel make requests. Individuals specially trained in requesting organ donations facilitate the process. They are skilled in talking compassionately to people who have suffered a tragic, sudden loss and have answers to many questions that people have regarding the donation process.

The client is receiving an eyedrop and an eye ointment to the right eye. The nurse should:

Administer the eyedrop first, followed by the eye ointment.

A client, while driving, hits a small child crossing the road. The child survives with some minor bruises and cuts. The client feels very stressed and is depressed when thinking of the child's injury. Which of the following techniques should the nurse implement in this case?

Alternative thinking

The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question?

Atropine sulfate (Isopto Atropine)

The nurse walks into the client's room and finds her sobbing uncontrollably. When the nurse asks what the problem is, the client responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this client's care plan the nurse notes a nursing diagnosis of "Ineffective coping related to stress." What is the best outcome you can expect for this client?

Client will adapt relaxation techniques to reduce stress.

Healthy development of the Industry vs. Inferiority stage

Belief in own abilities

When discussing his concerns with the nurse, the client discloses that when he comes home from work, he plays with his pet dog and this makes him feel relaxed. His friends make fun of him because of this, however. The nurse explains that this is perfectly normal and is not a cause of worry. In this case, how is the client relieving stress?

By adopting an alternative lifestyle

Healthy development of the Intimacy vs. Isolation stage

Capacity for reciprocol relationships

A nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

Complaints of a burst of black spots or floaters

To assist an adult client to sleep better, the nurse recommends which of the following?

Consuming a small glass of warm milk at bedtime A small glass of milk relaxes the body and promotes sleep. Alcohol, large meals, and exercising all within 1 to 2 hours of bedtime have insomnia-producing effects and may, in fact, stimulate wakefulness. Large meals could also produce indigestion.

A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?

Coping mechanism

Healthy development of the Integrity vs. Despair stage

Create creativity and productivity and the capacity to care for others

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops, knowing that the purpose of this medication is to:

Dilate the pupil of the operative eye.

Tasks of the Industry vs. Inferiority stage of Erikson's theory

Direct energy to mastering knowledge and intellectual skills. Inferiority creates feeling incomplete and unproductive

The children of a woman 60 years of age are distraught at her apparent lack of recovery following a stroke several weeks earlier. The client's daughter has frequently directed harsh criticism toward the nurses, accusing them of a substandard effort in rehabilitating her mother despite their best efforts. What defense mechanism may the client's daughter be exhibiting?

Displacement

The nurse is gathering a sleep history from a client who is being evaluated for obstructive sleep apnea. What common symptom will the client most likely report?

Excessive daytime sleepiness The client will awake with a headache. The other options may exist, but headache is the most common complaint

Tasks of the Intimacy vs. Isolation stage of Erikson's theory

Form intimate relationships. Health friendships lead to intimacy, otherwise isolation may result

Tasks of the Generativity vs. Stagnation stage of Erikson's theory

Generativity is achieved through helping the younger generation develop and lead useful lives. Stagnation results from not having done anything to help the next generation

A nurse working on an oncology floor often sits with her clients in a calm, quiet, dimly lit environment and describes a walk along the ocean's shore. The nurse provides details of the walk and verbally paints a picture for the client. Which of the following best defines this form of stress management?

Guided imagery

The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system?

Heart rate of 102 beats/minute

Healthy development of the Identity vs. Identity Confusion stage

Identify sense of sense of self and plan to actualize potential

A client sustains a chemical eye injury from a splash of battery acid. The nurse prepares the client for which immediate measure?

Irrigating the eye with sterile normal saline

The nurse finds a client sleepwalking down the unit hallway. An appropriate intervention the nurse implements is:

Lightly tapping the client on the shoulder and leading him or her back to bed. The nurse should not startle the client but should gently awaken the client and lead him or her back to bed. Sleepwalkers are unaware of their surroundings. Asking them what they are doing is not helpful. The nurse may or may not need assistance. Startling the client may result in injury. Blocking the walkway with chairs may result in injury.

A nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which of the following would most likely be prescribed for the client?

Low-sodium diet

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching?

My grandmother told me that babies sleep better on their stomachs." Babies should sleep on their backs, not their stomachs, as a SIDS preventative. Babies should not be put to bed with a bottle. Due to nighttime feedings, new moms should be encouraged to temporarily place a cradle near where they sleep and know that they will have to get up during the night to feed the baby.

A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?

Non-therapeutic coping strategy

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to:

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

When analgesics are ordered for a client with obstructive sleep apnea (OSA) following surgery, the nurse is most concerned about:

Opioids Clients with obstructive sleep apnea are particularly sensitive to opioids. Thus the risk of respiratory depression is increased. The nurse must recognize that clients with OSA should start out receiving very low doses of opioids.

A nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by:

Pulling the pinna up and back

Healthy development during the Initiation vs. Guilt stage

Purposeful behavior and ability to evaluate own behavior

To validate the suspicion that a married male client has sleep apnea, the nurse first:

Questions the spouse if she is awakened by her husband's snoring. Asking the spouse would be a starting place to determine if a client has sleep apnea. This may lead to determining whether more tests are needed. The client would not know if he experiences sleep apnea. CPAP is a treatment for sleep apnea. Although this is a diagnostic tool, the first thing the nurse would do is question the spouse.

Tasks of the Integrity vs. Despair stage of Erikson's theory

Reflection Integrity achieve if positive Gloom, doubt, and despair if negative

A nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse takes which appropriate action?

Reports the finding to the registered nurse (RN)

Tasks of Erikson's Trust vs. Mistrust stage

Sets the stage for life-long expectations. Achieved trust ensures view that the world will be a good and pleasant place

A nurse is caring for a client who is hearing-impaired and takes which approach to facilitate communication?

Speaks in a normal tone

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Stand in front of the client.

While obtaining an initial assessment of a client, the nurse gathers information about the client's stress history. What would the nurse collect as subjective data?

Structured interview

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?

Sympathetic nervous system

Cold temperatures and loud noises are stressors to one person but not another. Why does this occur?

The perception and effects of stressors are highly individualized.

Which of the following group of terms best describes anxiety?

Unknown cause, emotional, apprehensive

The nurse prepares the client for ear irrigation as prescribed by the health care provider. In performing the procedure, the nurse:

Warms the irrigating solution to 98° F

blended families that for are at risk for

altered family function as members maintain or break ties to previous marriage

Extended Family

expands the other family structures to include grandparents, aunts, etc.

Various physiologic mechanisms within the body respond to internal changes in order to maintain relative constancy in the internal environment. The state that results is called:

homeostasis

Communal Family

number of members who share a common bond, such as religious affiliation or economic need; can be short term ex. young adults living together in college

Single-Parent Family

one parent and one or more children.

Cohabitated Family

people living together without the formal or legal bond of marriage

the development of which initiative is developed at what age

preschool

important focus for caregivers of toddlers and preschoolers is

protection from harm

The client is a child age 5 years hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of ...

regression

nontraditional families

same-sex parents who established a functioning household may have children

what age group develops autonomy

toddler and preschooler

Which of the following are considered internal stressors? Select all that apply.

• Fear • Illness • Hormonal change

Which of the following behaviors represent effective coping mechanisms? (Select all that apply.)

• Setting limits with family members who upset you • Learning relaxation techniques • Taking a vacation

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse takes which action immediately?

Applies ice to the affected eye

Erikson's stages of psychosocial development

1. Trust vs. Mistrust 2. Autonomy vs. Shame & Doubt 3. Initiative vs. Guilt 4. Industry vs. Inferiority 5. Identity vs. Identity Confusion 6. Intimacy vs. Isolation 7. Generativity vs. Stagnation 8. Integrity vs. Despair

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS), the best position in which to place the baby after nursing is

1. Supine 2. Side lying Research demonstrates that the occurrence of SIDS is reduced with these two positions. Placing the infant prone has been implicated as a cause of SIDS. Fowler's position is a semi-sitting position and has not been discussed in the prevention of SIDS.

The nurse recognizes that a client is experiencing insomnia when the client reports

1.Difficulty staying asleep 2.Extended time to fall asleep 3.Feeling tired after a night's sleep These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia. Falling asleep at inappropriate times is indicative of narcolepsy.

2. The nurse is explaining the symptoms of dementia to a military family member who has not seen his mother in 15 months. Which characteristics of dementia of the Alzheimer's type would the nurse address in her teaching session? Select all that apply. 1. Experiences an impending sense of doom 2. Forgets that food is cooking on the stove 3. Becomes lost walking on her own street 4. Unable to write and to sign her name 5. Begins to fear using public transportation 6. Unable to understand new information

2. 2, 3, 4, and 6. Common symptoms of dementia of the Alzheimer's type include forgetting things such as cooking food and where specific items were placed, becoming lost in one's own neighborhood, being unable to write or even sign one's name to a document, and being unable to understand new information. A client experiencing an impending sense of doom and fearing public transportation is most likely dealing with a panic attack with agoraphobia.

3. During an interaction with the spouse of a client with Alzheimer's disease, the nurse is asked the following question: "What exactly is Alzheimer's disease?" Which is the correct explanation for the nurse to tell the spouse? 1. " Often, Alzheimer's disease is a combination of several common autoimmune diseases that attack and shrink brain tissue." 2. " It is a brain disease that results from the development of abnormal structures called neurofibrillary tangles found in the person's brain." 3. " The disease is a genetic disease that changes a person's brain tissue, causing it to deteriorate due to an accumulation of excessive fluid." 4. " A biological and psychosocial component of undiagnosed moderate depression is causing a steady decline in daily performance."

3. 2. People with Alzheimer's disease have a disease of the brain where abnormal structures composed of twisted protein fibers (neurofibrillary tangles) are found within the nerve cells. These neurofibrillary tangles attack the inside of the neurons. The possible link of autoimmune diseases to Alzheimer's disease as well as the genetic errors identified on chromosomes 14, 19, and 21 along with biological and neurochemical problems are currently being investigated. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 13637-13641). Lippincott Williams & Wilkins. Kindle Edition.

The nurse has taught a family about the medication donepezil (Aricept). The nurse determines that teaching was successful when the family makes which statement? 1. " We will need to figure out a schedule to get dad's weekly blood work done." 2. " When dad's Alzheimer's disease worsens, he will need to stop taking this drug." 3. " This drug may slow down dad's pulse, since he has preexisting heart disease." 4. " Aricept acts like a diuretic medication, so dad should take it in the morning."

9. 3. Donepezil has the potential to cause bradycardia in clients with cardiac disease. Weekly blood work is not necessary for clients on donepezil. Donepezil can be used for mild, moderate, or severe Alzheimer's disease. Donepezil does not act like a diuretic; it can cause urinary retention, and the client may have difficulty passing his urine.

Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient? A. Older adults have usually sustained many losses in life, which influence the current loss. B. Older adults with a poor memory experience grief less intensely. C. Older adults generally handle loss better because they have more experience with it. D. Social support is less important because an older adult's circle of friends has become smaller.

A. Older adults have usually sustained many losses in life, which influence the current loss. Older adults have usually sustained more losses because they have lived longer. For people at any age, each loss influences the way one responds to subsequent losses. The loss of a social network makes it more important to find resources and sources of social support for grieving older adults. Sometimes many losses overpower a person's coping resources instead of making him or her stronger.

When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to: A: Form a sense of identity. B: Create intimate relationships. C: Separate from parents and live independently. D: Achieve positive self-esteem through experimentation.

A: Form a sense of identity.

The nurse can increase a patient's self-awareness through which of the following actions? (Select all that apply.) A: Helping the patient define her problems clearly B: Allowing the patient to openly explore thoughts and feelings C: Reframing the patient's thoughts and feelings in a more positive way D: Have family members assume more responsibility during times of stress

A: Helping the patient define her problems clearly B: Allowing the patient to openly explore thoughts and feelings C: Reframing the patient's thoughts and feelings in a more positive way

Based on knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will: A: Increase his self-esteem with mastery of a new skill. B: Accept changes in his appearance and physical endurance. C: Experience success in role transitions and increased responsibilities. D: Appreciate his body appearance and function.

A: Increase his self-esteem with mastery of a new skill.

A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of situational low self-esteem. Which of the following nursing interventions would be best to address self-esteem? A: Offer independent decision-making opportunities B: Review previously successful coping strategies C: Provide a quiet environment with minimal stimuli D: Support a dependent role throughout treatment

A: Offer independent decision-making opportunities

An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. The nurse's approach should be based on an understanding of which of the following: A: Patients need support in dealing with the loss of a body part. B: The patient's family should take the lead role in providing support. C: The nurse should explain that breast tissue is not essential to life. D: The patient should focus on the cure of the cancer rather than loss of the breast.

A: Patients need support in dealing with the loss of a body part.

A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as "I'm such a failure...I can't do anything right." The best nursing response would be to: A: Remain with the patient until he or she stops crying. B: Tell the patient that is not true and that every person has a purpose in life. C: Review recent behaviors or accomplishments that demonstrate skill ability. D: Reassure the patient that you know how he is feeling and that things will get better

A: Remain with the patient until he or she stops crying.

The patient is admitted with chronic back pain. The nurse who is caring for this patient should a. Focus on finding quick remedies for the back pain. b. Look at how pain influences the patient's ability to function. c. Realize that the patient's only goal is relief of the back pain. d. Help the patient realize that there is little hope of relief from chronic pain.

ANS: B Do not just look at the patient's back pain as a problem to solve with quick remedies, but rather look at how the pain influences the patient's ability to function and achieve goals established in life (not just pain relief). Mobilizing the patient's hope is central to a healing relationship.

In caring for the patient's spiritual needs, the nurse understands that a. Establishing presence is part of the art of nursing. b. Presence involves "doing for" the patient. c. A caring presence involves listening to the patient's wishes only. d. The nurse must use her expertise to make decisions for the patient.

ANS: A Establishing presence is part of the art of nursing. Presence involves "being with" a patient versus "doing for" a patient. Demonstrate a caring presence by listening to the patient's concerns and willingly involving family in discussions about the patient's health. Show self-confidence when providing health instruction, and support patients as they make decisions about their health.

The nurse is admitting a patient who is a member of the Seventh Day Adventist religion. The physician has written an order for specific tests to be done the next day, which is Saturday. The nurse should a. Discuss the patient's beliefs about the Sabbath. b. Order the tests without questioning. c. Inform the physician that the tests cannot be performed. d. Reorder the tests for Sunday.

ANS: A It is essential to consider cultural differences and explore personal preferences when determining nursing interventions to enhance spiritual well-being. Some Seventh Day Adventists may not mind having tests on the Sabbath. Others might. Ordering the tests without questioning may lead to patient refusal later and to wasted resources as well as spiritual distress for the patient. Informing the physician that the tests cannot be performed is premature without speaking with the patient first. It is not in the realm of the nurse to reorder tests. Some tests may be critical and may need to be done on the Sabbath.

In assessing the spiritual health of her patients, the nurse understands that a. Spiritual beliefs change as patients grow and develop. b. Spiritual health in older adults leads to peace and acceptance of others. c. Older adults often express spirituality by focusing on themselves. d. The basis of beliefs among older people is focused on one or two factors.

ANS: A Spiritual beliefs change as patients grow and develop. Health spirituality in older adults leads to peace and acceptance of self. However, older adults often express their spirituality by turning to important relationships and giving of themselves to others. Beliefs among older people vary based on many factors, such as gender, past experience, religion, economic status, and ethnic background.

A complex concept that is unique to each individual; is dependent upon a person's culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples' lives is called a. Spirituality. b. Religion. c. Self-transcendence. d. Faith.

ANS: A Spirituality is a complex concept that is unique to each individual; is dependent upon a person's culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples' lives. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Self-transcendence is the belief that there is a force outside of and greater than the person. Faith allows people to have firm beliefs despite lack of physical evidence.

The word spirituality derives from the Latin word spiritus, which refers to breath or wind. Today, spirituality is a. Awareness of one's inner self and a sense of connection to a higher being. b. Less important than coping with the patient's illness. c. Patient centered and has no bearing on the nurse's belief patterns. d. Equated to formal religious practice and has a minor effect on health care.

ANS: A Today, spirituality is often defined as an awareness of one's inner self and a sense of connection to a higher being, to nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals achieve the balance needed to maintain health and well-being and to cope with illness. It positively affects and enhances health, quality of life, health promotion behaviors, and disease prevention activities. Nurses need an awareness of their own spirituality to provide appropriate and relevant spiritual care to others. The concepts of spirituality and religion are often interchanged, but spirituality is a much broader and more unifying concept than religion. The human spirit is powerful, and spirituality has different meanings for different people.

When evaluating a patient's risk for spiritual crises, which of the following are part of the evaluation process? (Select all that apply.) a. Review the patient's self-perception regarding spiritual health. b. Review the patient's view of his/her purpose in life. c. Discuss with family and associates the patient's connectedness. d. Ask whether the patient's expectations are being met. e. Impress on the patient that spiritual health is permanent once obtained.

ANS: A, B, C, D One critical thinking model for spiritual health evaluation lists the evaluation process as including a review of the patient's self-perception regarding spiritual health, the patient's view of his/her purpose in life, discussion with the family and close associates about the patient's connectedness, and determining whether the patient's expectations are being met. Attainment of spiritual health is a lifelong goal.

Spiritual distress has been identified in a patient who has been diagnosed with AIDS. Upon evaluating the following interventions, which are appropriate for the diagnosis of Spiritual distress? (Select all that apply.) a. Develop activities to heal body, mind, and spirit. b. Assess for potential suicide. c. Offer to pray with the patient. d. Teach relaxation, guided imagery, and meditation. e. Have patient avoid church attendance.

ANS: A, C, D Interventions that are appropriate for the nursing diagnosis of Spiritual distress include (1) helping the patient develop/identify activities to heal body, mind, and spirit; (2) offering to pray with the patient; and (3) teaching relaxation, guided imagery, and medication. Assessing for potential suicide would be appropriate for the nursing diagnosis of Hopelessness. Attendance at church should be encouraged.

The nurse is caring for a patient who claims that he does not believe in God, nor does he believe in an "ultimate reality." The nurse realizes that this patient a. Is devoid of spirituality. b. Is an atheist/agnostic. c. Finds no meaning through relationships with others. d. Believes that what he does is meaningless.

ANS: B Some individuals do not believe in the existence of God (atheist) or believe that there is no known ultimate reality (agnostic). This does not mean that spirituality is not an important concept for the atheist or the agnostic. Atheists search for meaning in life through their work and their relationships with others. Agnostics discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.

Which of the following statement about religion and spirituality is true? a. Religion is a unifying theme in people's lives. b. Spirituality is unique to the individual. c. Spirituality encompasses religion. d. Religion and spirituality are synonymous.

ANS: B Spirituality is a complex concept that is unique to each individual. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. People from different religions view spirituality differently. Although closely associated, spirituality and religion are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice.

In discussing spiritual well-being, the nurse identifies that the vertical dimension involves a. The positive relationships and connections people have with others. b. The transcendent relationship between a person and God. c. Confidence in something for which there is no proof. d. Providing an attitude of something to live for and look forward to.

ANS: B The concept of spiritual well-being is often described as having two dimensions. The vertical dimension supports the transcendent relationship between a person and God or some other higher power. The horizontal dimension describes positive relationships and connections people have with others. Faith provides confidence in something for which there is no proof. When a person has the attitude of something to live for and look forward to, hope is present.

The nurse and the patient have the same religious affiliation. Because of this, the nurse a. Can assume that they have the same spiritual beliefs. b. Should not impose her personal values on the patient. c. Must use an assessment tool to assess the patient's beliefs. d. Can skip the spiritual belief assessment.

ANS: B The nurse can use an assessment tool or direct an assessment with questions based on principles of spirituality, but it is important not to impose personal value systems on the patient. This is particularly true when the patient's values and beliefs are similar to those of the nurse because it then becomes very easy to make false assumptions. It is important to conduct the spiritual belief assessment; conducting an assessment is therapeutic because it expresses a level of caring and support.

The patient is having a difficult time dealing with his AIDS diagnosis. He states, "It's not fair. I'm totally isolated from my family because of this. Even my father hates me for this. He won't even speak to me." The nurse needs to a. Assure the patient that his father will accept his situation soon. b. Use therapeutic communication to establish trust and caring. c. Point out that the patient has no control and that he has to face the consequences. d. Tell the patient, "If your father can't get over it, forget it. You have to move on."

ANS: B The nurse needs to use therapeutic communication to establish trust and a caring presence because providing spiritual care requires caring, compassion, and respect. The nurse should not offer false hope. The nurse should help the patient maintain feelings of control. The nurse should encourage renewing relationships if possible and establishing connections with self, significant others, and God.

The nurse is caring for a patient who is terminally ill with very little time left to live. The patient states, "I always believed that there was life after death. Now, I'm not so sure. Do you think there is?" The nurse states, "I believe there is." The nurse has attempted to a. Strengthen the patient's religion. b. Provide hope. c. Support the patient's agnostic beliefs. d. Support the horizontal dimension of spiritual well-being.

ANS: B When a person has the attitude of something to look forward to, hope is present. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. This is not evident here. Agnostics believe that there is no known ultimate reality. This would indicate a lack of belief in life after death. The horizontal dimension of spiritual well-being describes positive relationships and connections people have with others. In this case, the patient is more concerned with the vertical dimension, which supports the transcendent relationship with God or some other higher power.

The nurse is caring for a patient who is in the final stages of his terminal disease. The patient is very weak but refuses to use a bedpan, and wants to get up to use the bedside commode. What should the nurse do? a. Explain to the patient that he is too weak and needs to use the bedpan. b. Insert a rectal tube so that the patient no longer needs to actively defecate. c. Enlist assistance from family members if possible and assist the patient to get up. d. Put the patient on a bedpan and stay with him until he is finished.

ANS: C Establishing presence is part of the art of nursing. Presence involves "being with" a patient versus "doing for" a patient. Demonstrate a caring presence by listening to the patient's concerns and willingly involving family in discussions about the patient's health. The nurse should support patients as they make decisions about their health. If at all possible, the nurse should encourage the patient to maintain as much independence as possible. Inserting a rectal tube involves "doing for" instead of "being with." Placing the patient on the bedpan is against the patient's wishes and is another form of "doing for."

The nurse creates a referral to pastoral care when he/she realizes that the patient is in need of a. Psychiatric care. b. Return to religious affiliation. c. Spiritual care. d. Transfer to the psychiatric unit.

ANS: C Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships, as well as a relationship with a higher being or life force. The patient may need psychiatric care and may be transferred to the psychiatric unit, but referral to pastoral care will not provide that. Return to a religious affiliation may follow a return to spiritual health.

When caring for a terminally ill patient, the nurse should focus on the fact that a. Spiritual care is possibly the least important nursing intervention. b. Spiritual needs often need to be sacrificed for physical care priorities. c. The nurse's relationship with the patient allows for an understanding of patient priorities. d. Members of the church or synagogue play no part in the patient's plan of care.

ANS: C The nurse's relationship with the patient allows the nurse to understand the patient's priorities. Spiritual priorities do not need to be sacrificed for physical care priorities. When a patient is terminally ill, spiritual care is possibly the most important nursing intervention. If the patient participates in a formal religion, involve in the plan of care members of the clergy or members of the church, temple, mosque, or synagogue.

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 his care. The nurse should a. Not be concerned about self-harm because the patient has not indicated any desire toward suicide. b. Ignore individual patient goals until the current crisis is over. c. Encourage the patient to purchase over-the-counter sleep aids to help him sleep. d. Assess the potential for suicide and make appropriate referrals.

ANS: D A decreased appetite and level of energy and not wanting to be involved in care are signs of hopelessness. The nurse should assess for risk of the patient harming himself or others. The nurse should set goals that are important to the patient. Recommending good sleep hygiene habits is more appropriate than giving over-the-counter sleep aids.

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements a. Are contradictory. b. Indicate a strong religious affiliation. c. Indicate a lack of faith. d. Are reasonable.

ANS: D These statements are reasonable and are not contradictory. Many people tend to use the terms spirituality and religion interchangeably. Although closely associated, these terms are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a person has the attitude of something to live for and look forward to, hope is present.

The patient is in the intensive care unit (ICU), which has strict posted visiting hours and limits the number of visitors to two per patient at any one time. The patient is asking to see his wife and two daughters. The nurse should a. Tell the patient that they will be allowed to visit at the appropriate time. b. Allow the wife and one daughter to enter the ICU, but not the other daughter. c. Allow the two daughters to visit, and let the wife visit when they leave. d. Allow the wife and daughters to visit at the patient's request.

ANS: D Use of support systems is important in any health care setting. When patients depend on family and friends for support, encourage them to visit the patient regularly. As long as no interference with active patient care is involved, there is no reason to limit visitation.

Healthy development during the Autonomy vs. Shame and Doubt stage

Ability to express oneself and cooperate with others

Healthy development of the Integrity vs. Despair stage

Accept that one's life is unique and worthwhile

What is the term for the change that takes place in response to a stressor?

Adaptation

5.What are prevailing characteristics of narcolepsy? Select all that apply. 1) Involuntary 2) Cataplexy 3) Hallucinations 4) Temporary paralysis

Answer: 1) Involuntary 2) Cataplexy 3) Hallucinations 4) Temporary paralysis Rationale: The person with narcolepsy experiences a sudden, uncontrollable urge to sleep lasting from seconds to minutes, even though the person sleeps well at night. The person cannot avoid the "sleep attacks" but awakens easily. Narcolepsy is characterized by involuntary episodes of sleepiness, slurred speech, slackening of the facial muscles, a feeling of impending weakness of the knees, paralysis, and hallucinations. Some have other symptoms, such as cataplexy, a sudden loss of muscle tone usually triggered by an emotional event (e.g., laughter, surprise, or anger), but most only have hypersomnia.

4.What is the hormone that promotes sleep? 1) Melatonin 2) L-tryptophan 3) Progesterone 4) Oxytocin

Answer: 1) Melatonin Rationale: The levels of melatonin, which is the natural hormone that promotes sleep, decline in the latter decades of life. It is produced at night by the pineal gland in the brain.

8.Which of the following is a common, normal emotional response to a stressor? 1) Depression 2) Fear 3) Anxiety 4) Panic

Answer: 3) Anxiety Rationale: Anxiety is a common emotional response to a stressor. Depression is a prolonged feeling of sadness. Fear is a specific, cognitive response to a known threat. Panic is an unreasonable and irrational response to a stressor.

1.Which of the following would be an abnormal assessment finding for an older adult that the nurse would document and report to the primary care provider? Decreased: 1) Reaction time 2) Short-term memory 3) Intellectual ability 4) Cognitive processing speed

Answer: 3) Intellectual ability Rationale: There should be no loss of intellectual ability. An elderly person can learn, although learning takes longer. Reaction time slows as we age, and it is also normal to have a decline of short-term memory, although long-term memory loss is not as common. Cognitive processing speed declines with age. This includes slower computational skills and reduced speed for problem-solving, but this does not imply that intellect is impaired.

2.The nurse in the hospital has a prescription to administer medication at 0400 to Mrs. Giovanni. Mrs. Giovanni is asleep when the nurse enters the room. She is difficult to arouse and confused. Identify the stage of sleep Mrs. Giovanni was likely in when the nurse awakened her. 1) Stage II 2) Stage III 3) Stage IV 4) REM

Answer: 3) Stage IV Rationale: Stage IV is the deepest sleep and the most restorative. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep, and if awakened, the person may appear confused and react slowly.

6.How would the nurse be able to identify the person with narcolepsy from one with seizures? 1) Episodes are short in duration. 2) Episodes come on suddenly. 3) The patient can be aroused from the episode. 4) The patient loses voluntary control of his muscles.

Answer: 3) The patient can be aroused from the episode. Rationale: The patient with narcolepsy can be aroused from the sleep episode. A person with seizure activity is unresponsive to stimulus and does not resolve in relationship to arousing. Narcolepsy and seizures are triggered suddenly. Both involve involuntary control of motor function with paralysis and cataplexy. Typical seizures last less than 8 minutes. Most narcoleptic episodes are also brief with microactivity lasting only a few minutes. Infrequently, the uncontrollable urge to sleep goes on for up to an hour.

3.Depression, hyperthyroidism, hypothyroidism, pain, and sleep apnea are examples of: 1) disorders that are provoked by sleep. 2) conditions known as parasomnias. 3) conditions that cause secondary sleep disorders. 4) disorders associated with narcolepsy.

Answer: 3) conditions that cause secondary sleep disorders. Rationale: Secondary sleep disorders occur when a disease causes alterations in sleep stages or in quantity of sleep. Depressed people may spend more time in bed; however, in general, they have difficulty falling asleep, experience less slow-wave (deep) sleep, spend less time in REM sleep, awaken early, and have less total sleep time. An increase in thyroid secretion causes an increase in stage III and IV sleep. Hypothyroidism causes a decrease in those stages. Hyperthyroidism creates increased metabolic rate, making it difficult to fall asleep. Acute pain and chronic pain interfere with sleep. They inhibit sleep, increase arousals during sleep, and cause longer awake intervals during the night. During periods of sleep apnea, O2 level in the blood drops, and the CO2 level rises, causing the person to wake up frequently.

5.A nurse is admitting a 75-year-old patient to the nursing unit, accompanied by his son. Using a life span approach to care, which of the following is essential for the nurse to do? 1) Increase the room temperature. 2) Speak slowly and use short sentences. 3) Direct admission questions to the patient's son. 4) Ask the patient if he has had any falls in the past year.

Answer: 4) Ask the patient if he has had any falls in the past year. Rationale: Falls are a major source of morbidity in hospitalized patients. On admission, nurse should ask all older adults (age 65 and older) if they have had any falls in the past year. Although it is true that some older adults may like a warm temperature, this is not universally true; it would need to be assessed for each individual. Speaking slowly and using short sentences is recommended for patients with learning or hearing disabilities; however, the nurse cannot assume that all older adults have either of these. The best assessment data usually are obtained from the patient. The nurse should interview other family members only if the patient is not communicating clearly; the nurse has not yet assessed that in this scenario.

1.The duration of sleep is regulated by the: 1) electrical impulses transmitted to the cerebellum. 2) person's innate biorhythms. 3) amount of sleep a person usually requires. 4) reticular activating system.

Answer: 4) reticular activating system. Rationale: In the morning, with an increase in environmental light, the hypothalamus is signaled to induce gradual arousal from sleep. The reticular formation is then activated by the stimuli from the cerebral cortex. The reticular formation is responsible for maintaining wakefulness. Together, the reticular formation and cortical neurons are called the reticular activating system (RAS). The RAS regulates the duration of sleep.

Question: A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

Answer: a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

Question: A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.

Answer: a. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

Question: A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? a. Stage I NREM sleep b. Stage II NREM sleep c. Stage IV NREM sleep d. REM sleep

Answer: a. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility.

Question: To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.

Answer: a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

Question: A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c .Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis.

Answer: b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

Question: A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c. It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage.

Answer: c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

Question: A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.

Answer: d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

Question: A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism b. A patient with coronary artery disease c. A patient who has gastroesophageal reflux (GERD) d. A patient who is HIV positive e. A patient who is taking corticosteroids for arthritis f. A patient with a urinary tract infection

Answer: a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

Question: A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia b. A patient with Parkinson disease who is taking dopamine c. An elderly patient taking diuretics for congestive heart failure d. A patient who is taking antibiotics for an ear infection e. A patient who is prescribed antidepressants f. A patient who is taking low-dose aspirin prophylactically

Answer: b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

Question: A nurse assesses a patient's body temperature in the late afternoon as 37.2°C (99°F). What would be the nurse's best action related to this slight elevation in temperature? a. Assess the patient for infection. b. Record the temperature as a normal finding. c. Call the physician for an order for antipyretics. d. Decrease the room temperature.

Answer: b. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm.

Question: A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. REM behavior disorder b. Narcolepsy c. Enuresis d. Sleep apnea

Answer: b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

Question: A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.

Answer: c. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increases both REM and NREM sleep.

Question: A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? a. Ineffective Coping: Multiple Stressors of New Job b. Sleep Deprivation: Difficulty Falling Asleep c. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern d. Risk for Injury: Activity Intolerance/Sleep Deprivation

Answer: c. When assessment data point to a sleep problem that is amenable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined.

Question: A nurse working the night shift in a pediatric unit observes a 10-year-old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? a. Bruxism b. Cataplexy c. Restless leg syndrome d. Somnambulism

Answer: d. Somnambulism (sleepwalking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding of one's teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.

Question: A nurse formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.

Answer: a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?

Anticipatory guidance

The nurse incorporates what priority nursing intervention into a plan of care to promote sleep for a hospitalized client?

Avoid awakening client for nonessential tasks Hospitals and extended care facilities usually do not adapt care to an individual's sleep-wake cycle preferences. The nurse should attempt to avoid awakening sleeping clients for nonessential tasks to try and preserve their sleep cycles.

A client with Ménière's disease is experiencing severe vertigo. The nurse instructs the client to do which of the following to assist in controlling the vertigo?

Avoid sudden head movements.

A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflect a helpful understanding of patient self-care at the end of life? A. "Learning to accept that you can't perform some activities anymore will bring you more acceptance and peace." B. "Which activities are most important to you, and how can you continue to do them?" C. "People in your life want to help you with things; allow them to do what they want for you." D. "Spending more of your time resting or reading will conserve your energy."

B. "Which activities are most important to you, and how can you continue to do them?" Even seriously ill people want to carry on with life, doing what they can to maintain their identity and purpose. They know best how to regulate their energy and wishes for how to spend their time.

A family member of a recently deceased patient talks casually with the nurse at the time of the patient ' s death and expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to this family member? A. Denial B. Anticipatory grief C. Dysfunctional grief C. Yearning and searching

B. Anticipatory grief If a person has been anticipating a loss for some time, he or she may have already experienced many of the emotions (sadness, shock) commonly associated with death.

Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care? A. Practice honesty with everyone, telling patients about their illness, even if the news is not good. B. Ask family members if they prefer to help with the care of the body after death. C. Provide postmortem care at the time of death to relieve family members of this difficult job. D. Value patient self-determination, understanding that each person makes his or her own decisions.

B. Ask family members if they prefer to help with the care of the body after death. Giving people options in caregiving allows them to honor their cultural beliefs. Although western health care practices place a high value on honesty, people from some cultural backgrounds regard being told the "truth" as harmful.

The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not believe the treatments will make any difference, does not ask about her progress, and missed two chemotherapy sessions. Based on the above assessment data, the nurse gathers more information to consider making which of the following nursing diagnoses? A. Anxiety B. Hopelessness C. Spiritual distress D. Complicated grieving

B. Hopelessness The patient exhibits signs and symptoms of hopelessness. Manifestations of hopelessness include withdrawing, not following through with recommended treatment, and losing confidence that anything she does will be of help.

The nurse suggests that a patient receive a palliative care consultation for symptom management related to anxiety and increasing pain. A family member asks the nurse if this means that the patient is dying and is now "in hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) A. Hospice and palliative care are the same thing. B. Palliative care is for any patient, any time, any disease, in any setting. C. Palliative care strategies are primarily designed to treat the patient's illness. D. Palliative care interventions relieve the symptoms of illness and treatment.

B. Palliative care is for any patient, any time, any disease, in any setting. D. Palliative care interventions relieve the symptoms of illness and treatment. Palliative care is not reserved for people who are at the end of life. The goal of palliative care is to help relieve the burdens of illness at any time along the continuum of that illness.

A nurse is providing postmortem care. Which action is the priority? A. Locating the patient's clothing B. Providing culturally and religiously sensitive care in body preparation C. Transporting the body to the morgue as soon as possible to prevent body decomposition D. Providing all postmortem care to protect the family of the deceased from having to see the body

B. Providing culturally and religiously sensitive care in body preparation At the end of life religious and cultural expectations are important for the lasting memories held by the family about the way their loved one's death occurred. Sensitive care contributes to feelings of closure, appropriateness of the death rituals, and fulfilled family obligations.

An appropriate nursing diagnosis for an individual who experiences confusion in the mental picture of his physical appearance is: A: Acute confusion. B: Disturbed body image. C: Chronic low self-esteem. D: Situational low self-esteem.

B: Disturbed body image.

Several staff members complain about a patient's constant questions such as "Should I have a cup of coffee or a cup of tea?" and "Should I take a shower now or wait until later?" Which interpretation of the patient's behavior helps the nurses provide optimal care? A; Asking questions is attention-seeking behavior. B: Inability to make decisions reflects a self-concept issue. C: Dependence on staff must be stopped immediately. D: Indecisiveness is aimed at testing how the staff reacts.

B: Inability to make decisions reflects a self-concept issue.

In planning nursing care for an 85-year-old male, the most important basic need that must be met is: A: Assurance of sexual intimacy. B: Preservation of self-esteem. C: Expanded socialization. D: Increase in monthly income.

B: Preservation of self-esteem.

The nurse asks the patient, "How do you feel about yourself?" The nurse is assessing the patient's: A: Identity. B: Self-esteem. C: Body image. D: Role performance.

B: Self-esteem.

Tasks of the Autonomy vs. Shame & Doubt stage of Erikson's theory

Begin asserting independence. Realize their will and discern their behavior is their own. Shame and doubt occur if restrained too much or punished too harshly.

You have identified three nursing diagnoses for a patient who is having anxiety and hopelessness as a result of a loss. Which general approach do you take to prioritize the nursing diagnoses? (Select all that apply.) A. Use family members and physician orders as primary resources for prioritizing your actions. B. Address the nursing diagnosis that most affects the medical diagnosis. C. Ask the patient to identify the most distressing D. symptom and first address that diagnosis. D. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses.

C. Ask the patient to identify the most distressing D. symptom and first address that diagnosis. D. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses. When you are prioritizing nursing diagnoses, first get the patient's sense of the most important issue. Some patients do not fully understand the physiology or relationship among diagnoses. For example, one patient does not understand that pain contributes to a decreased appetite or depression. Your nursing knowledge along with the patient's perceptions help you determine the diagnosis with the highest priority.

Which approach to helping grieving people is most consistent with postmodern grief theories? A. Help the patient identify the tasks to be accomplished during his or her grief. B. Encourage people to recognize stages of grieving in anticipation of what is to come. C. Listen carefully to a person's story of how his or her grief experience is unfolding. D. Offer general grief timelines to help the person know when a phase will pass.

C. Listen carefully to a person's story of how his or her grief experience is unfolding. Postmodern grief interventions focus on the uniqueness of the patient's story that unfolds and "writes" itself as the person lives through the experience of loss.

A self-care goal you set when caring for dying and grieving patients includes: A. Learning not to take losses so seriously. B. Limiting involvement with patients who are grieving. C. Maintaining life balance and reflecting on the meaning of your work. D. Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to care for these patients.

C. Maintaining life balance and reflecting on the meaning of your work. Maintaining life balance is very important for emotional, spiritual, and physical well-being. Withdrawing or not seeing one's work with grieving people as serious does not help maintain balance but rather may contribute to numbing feelings.

A patient diagnosed with major depressive disorder has a nursing diagnosis of chronic low self-esteem related to negative view of self. Which of the following would be the most appropriate cognitive intervention by the nurse? A: Promote active socialization with other patients B: Role play to increase assertiveness skills C: Focus on identifying strengths and accomplishments D: Encourage journaling of underlying feelings

C: Focus on identifying strengths and accomplishments

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease

A family member asks a home care nurse what he should do if the patient's serious chronic illness worsens even with increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life? A. Encourage the family member to think more positively about the patient's new therapy B. Avoid the discussion because it has to do with medical, not nursing, diagnoses C. Initiate a discussion about advance directives with the patient, family, and health care team D. Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present

D. Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present If you ask the patient first what he or she believes is best, you know how to discuss that option in more detail and give realistic ways of reaching that desired goal. Discussing other possible options after the patient's preference helps family members know and understand the patient's wishes.

A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing? A. Delayed B. Anticipated C. Exaggerated D. Disenfranchised

D. Disenfranchised This woman's friends are not fully acknowledging the value of her pregnancy because of the short length of time the woman was pregnant or because, by comparison, the loss seems less than losing a child after birth. The loss does not seem "legitimate." Thus the woman does not experience sympathy from others and feels disenfranchised.

A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic communication with this patient? A. Younger patients are usually less talkative about their diagnosis. B. All patients benefit by talking about their feelings with another person. C. Avoid discussing illness-related topics with quiet patients. D. Remain alert for signals that the patient wants to discuss his illness.

D. Remain alert for signals that the patient wants to discuss his illness. Make no presumptions about this patient other than the fact that he is not yet ready to talk about his situation. However, stay alert for a time when he might want to talk to you. Some people do not work through their problems by talking to others.

Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? A: "What's the special occasion?" B: "You must be feeling better today." C: "This is the first time I have seen you look this good." D: "I see that you've combed your hair and put on makeup."

D: "I see that you've combed your hair and put on makeup."

When caring for an 87-year-old patient, the nurse needs to understand that which of the following most directly influences the patient's current self-concept: A: Attitude and behaviors of relatives providing care B: Caring behaviors of the nurse and health care team C: Level of education, economic status, and living conditions D: Adjustment to role change, loss of loved ones, and physical energy

D: Adjustment to role change, loss of loved ones, and physical energy

Based on knowledge of Erikson's stages of growth and development, the nurse plans her nursing care with the knowledge that old age is primarily focused on: A: Intimacy versus Isolation. B: Autonomy versus Shame and Doubt. C: Generativity versus Self-Absorption. D: Ego Integrity versus Despair.

D: Ego Integrity versus Despair.

The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks' post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? A: Self-care deficit, toileting B: Deficient knowledge regarding resources for the visually impaired C: Disturbed body image D: Risk for situational low self-esteem

D: Risk for situational low self-esteem

Which intervention is appropriate to include on a care plan for improving sleep in the older adult?

Decrease fluids 2 to 4 hours before sleep By decreasing fluids 2 to 4 hours before sleep, it is less likely that the client will awaken because of a need to urinate. Limiting naps during the day will help improve nighttime sleep. The client should sleep until the same time each morning. Exercising in the evening can make falling asleep more difficult.

The nurse is developing a plan of care for a client experiencing narcolepsy. Which intervention is appropriate to include on the plan?

Encourage client to take one or two 20-minute naps during the day Brief daytime naps of no longer than 20 minutes help reduce subjective feelings of sleepiness. Carbohydrates can increase sleepiness. Limiting fluids will not help the client with narcolepsy, nor will energy preservation.

What nursing measure promotes sleep in school-aged children?

Encourage quiet activities prior to bedtime. Encouraging quiet activities before bedtime helps prepare children for sleep. Evening exercise and watching television can make falling asleep more difficult. Children may sleep better with a night light in the room

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?

Exhaustion stage

A nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications will need to be administered for the rest of your life.

Tasks of the Initiation vs. Guilt stage of Erikson's theory

Face challenges that require active, purposeful, responsible behavior. Guilt occurs if the child is irresponsible and made to feel too anxious

Tasks of the Identity vs. Identity Confusion stage of Erikson's theory

Finding out who they are, what they are about, where they are going in life. Health exploration achieves positive identity otherwise, may be confusion

The nurse is sure to implement strategies to reduce noise on the unit particularly on the ______ night of admission, when the client is especially sensitive to hospital noises.

First The client is most sensitive to noise in the hospital setting on the first night because everything is new. This represents sensory overload, which interferes with sleep and decreases rapid eye movement (REM) as well as total sleep time

The nurse teaches a client taking phenytoin (Dilantin), an anticonvulsant, that this group of medications causes which symptom of a sleep problem?

Increased daytime sleepiness The anticonvulsants can cause increased daytime sleepiness because they decrease REM sleep time. They do not cause nocturia, increased awakenings, or increased difficulty falling asleep.

The nurse is caring for a client who is experiencing stress while weighing two good job offers. The nurse suggests that the client use therapeutic coping strategies. What does the suggestion of the nurse imply?

It means the client is asked to seek professional assistance.

A 65-year-old client has experienced the death of a parent and a family pet in one month. Which of the following is a coping mechanism that demonstrates adaptation?

Joining the local gardening club

Betaxolol hydrochloride (Betoptic SR) eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side effects of this medication?

Monitoring blood pressure

The client reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs in which sleep phase?

REM sleep The dreams of REM sleep are vivid and elaborate. The other answers are incorrect.

A nurse teaches a client deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique?

Relaxation

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention?

Seek assistance from family and friends

Healthy development of the Trust and Mistrust stage

Sense of trust in self and others

A client visits a health care facility with complaints of work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case?

Sensory manipulation technique

A client has been brought to the health care facility with accident-related injuries. During the initial interview, the client becomes agitated, upset and is unable to answer any more of the nurse's questions. What does the nurse conclude about the condition of the client?

The client's mind is preparing for a fight-or-flight response as he relates the incident.

The nurse at the student health center is seeing a group of nursing students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What does guided imagery involve?

The mindful use of a word, phrase, or visual image which allows one's self to be distracted and temporarily escape from stressful situations.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones

While providing care to a client, the client states, "I can't do anything. I'm just so useless." Which technique would the nurse suggest to help the client gain control over negative thoughts?

Use supportive internal messages

factors that affect bonding for infant and newborns

availability of both parents flexibility of schedules feelings about the birth comfort in parenting role emotional responsiveness financial security other demands, as caring for another child

Age range for the Trust vs. Mistrust stage in Erikson's theory

birth to 12 months (infant)

Blended Family

children who live with one birth parent and one nonbirth parent as well as any offspring of the nonbirth parent