Unit 4 Questions-K & E Chapters 20,22,23,39 (Self/Development)

In planning any health program for elderly adults, the nurse will implement Eriksons theory of task development. The nurse realizes that in this stage of life, the successful completion of the task allows the person to 1. have a feeling of satisfaction from past accomplishments. 2. make connections with the younger generation. 3. wish he or she could live life over again. 4. live out his or her last years in physical health.

Correct Answer: 1 Rationale 1: Eriksons task of this developmental stage is integrity versus despair. People who develop integrity accept their lives with a sense of wholeness and satisfaction with their past accomplishments. Rationale 2: Making connections with the younger generation is part of the task of the middleadult age group. Rationale 3: People who despair often believe they made poor choices during life and wish they could live life over. Rationale 4: Physical health is not part of psychosocial development.

The nurse is planning to assess a clients family relationships. What questions should the nurse ask to obtain this information? Standard Text: Select all that apply. 1. How do you spend your free time? 2. What is your home like? 3. Who is most important to you? 4. How well do you feel you accomplish what is expected of you? 5. Whom do you seek out for help?

Correct Answer: 2, 4 Rationale 1: The question How do you spend your free time? is a question to assess work and social roles. Rationale 2: The question What is your home like? is an appropriate question for the nurse to ask to assess a clients family relationships. Rationale 3: The question Who is most important to you? is a question to assess work and social roles. Rationale 4: The question How well do you feel you accomplish what is expected of you? is an appropriate question for the nurse to ask to assess a clients family relationships. Rationale 5: The question Whom do you seek out for help? is a question to assess work and social roles.

A community health nurse is planning adult health education classes. According to Eriksons stages of development, the nurse should address which task with this age group? 1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation

Correct Answer: 4 Rationale 1: This task is appropriate for the 6 to 12year-old schoolage child. Rationale 2: This task is appropriate for the adolescent 12 to 20 years old. Rationale 3: This task is appropriate for the 18- to 24yearold young adult. Rationale 4: Adulthood, age 25 to 65 years, is characterized by the central task of generativity versus stagnation. Positive resolution is indicated by creativity, productivity, and concern for others. Negative resolution is characterized by self-indulgence, self-concern, and lack of interests and communication.

While assisting in a community health project for middle-aged adults, the nurse attempts to identify members of the community who have been successful in the tasks identified by Erikson. What characteristic should the nurse identify in the community members? 1. Ability to have satisfaction in their volunteer activities 2. Ability to find an acceptable social group 3. Satisfaction with rearing children 4. Ability to manage a home

Correct Answer: 1 Rationale 1: Erikson identifies this stage as generativity versus stagnation. Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors. Rationale 2: This option identifies tasks associated with the young adult stage. Rationale 3: This option identifies tasks associated with the young adult stage. Rationale 4: This option identifies tasks associated with the young adult stage. Global Rationale:

A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a sitting position. In which process should the nurse identify that this child is lagging? 1. Growth 2. Development 3. Height 4. Behavior

Correct Answer: 2 Rationale 1: Growth is physical change and increase in size. Rationale 2: Development is an increase in the complexity of function and skill progression. It is the behavioral aspect of growththe persons ability to walk, talk, and run, for example. Rationale 3: Height is one of the indicators of growth. Rationale 4: Behavior is a component of the developmental stage.

An occupational health nurse is providing a hypertension screening at a local manufacturing plant. Among the employees, the nurse should focus on which population? 1. Males and females, equally 2. African American males 3. Asian American females 4. White females

Correct Answer: 2 Rationale 1: Hypertension is a problem for males and females equally. Rationale 2: Hypertension is a major problem for young African American adults, particularly men. The causes for this are unknown. Rationale 3: Hypertension is not a major problem for Asian American females. Rationale 4: Hypertension is not a major problem for White females.

A parent tells the nurse that his child is quite creative and learning how to pretend with almost anything in the house. According to Piaget, the nurse realizes this child is demonstrating which stage/phase? 1. Tertiary circular reaction: stage 5 2. Inventions of new means: stage 6 3. Preconceptual phase 4. Concrete operations phase

Correct Answer: 2 Rationale 1: Stage 5, 12 to 18 months, is characterized by discovery of new goals and ways to attain goals. Rituals are important in this stage. Rationale 2: Stage 6, inventions of new means, is from 18 to 24 months. The significant behavior is identified by interpretation of the environment by mental image. Make-believe and pretend-play are in use during this stage. Rationale 3: The preconceptual phase, 2 to 4 years, is when the child uses an egocentric approach to accommodate the demands of an environment. Rationale 4: The concrete operations phase, 7 to 11 years, is where the child is able to solve concrete problems and begins to understand relationships such as size and right and left, and is cognizant of viewpoints.

A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates 1. role confusion. 2. body image disturbance. 3. fear of success. 4. lack of education.

Correct Answer: 2 Rationale 1: Role confusion would be indicated if the client did not have a clear indication of what role to fulfill in life or how to fulfill a chosen role. Rationale 2: The most likely interpretation of this finding is that the client continues to see himself as fat, which is a body image disturbance. Rationale 3: The nurse would need more information to make this conclusion. Rationale 4: More information is needed to come to this conclusion.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 22 Question 1 The nurse is providing pre-employment physicals to a group of adults, aged 30 to 40. In which generation should the nurse categorize these adults? 1. Baby Boomers 2. Generation X 3. Generation Y 4. Millennials

Correct Answer: 2 Rationale 1: The Baby Boomers were born in the years 1945 to 1964. Rationale 2: Generation X includes individuals born in the years 1965 to 1978. Rationale 3: Generation Y includes individuals born between the years 1979 and 2000. Rationale 4: Millennials were born between the years 1979 and 2000.

A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. The nurse identifies which nursing diagnosis as appropriate for the client at this time? 1. Chronic Low Self-Esteem 2. Ineffective Role Performance 3. Disturbed Body Image 4. Parental Role Conflict

Correct Answer: 2 Rationale 1: The client is experiencing fatigue and inadequacy with the current situation, and not long-term low self-esteem. Rationale 2: The client has many role expectations that could be in conflict. The client is expected to maintain the home, care for the family, and earn money. The clients symptoms of fatigue and inadequacy indicate Ineffective Role Performance. Rationale 3: The client is not experiencing and alteration in perception of body image. Rationale 4: The client is not experiencing an issue with parenting.

A school nurse is bringing a group of students to a nursing home for a social exchange project. Before the students arrive, the nurse reminds them to do what when speaking to the residents? 1. Speak as loud as they can. 2. Speak into the residents ears. 3. Write out what they want to say on a piece of paper. 4. Speak distinctly, while facing the residents.

Correct Answer: 4 Rationale 1: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 2: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 3: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 4: Hearing loss in the elderly is greater in the higher frequencies than the lower ones. Older adults with hearing loss usually hear speakers with low, distinct voices best, and it is always appropriate to speak while facing a target.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 23 Question 1 A nurse is working with a group of clients in a community center, all over the age of 85. How should the nurse classify this group of clients? 1. Young-old 2. Middle-old 3. Old-old 4. Elite-old

Correct Answer: 3 Rationale 1: Those of age 65 to 74 years are referred to as the young-old. Rationale 2: Those of age 75 to 84 are the middle-old. Rationale 3: Those of age 85 to 100 are the old-old. Rationale 4: Individuals over 100 are considered the elite-old.

The nurse is reviewing the four stages of development in Westerhoffs spiritual theory. In which order should the nurse review these stages to match the life cycle? Standard Text: Click and drag the options below to move them up or down. Choice 1. Owned faith Choice 2. Affiliative faith Choice 3. Experienced faith Choice 4. Searching faith

Correct Answer: 4, 2, 1, 3 Rationale 1: Puts faith into personal and social action and is willing to stand up for what the individual believes even against the nurturing community is Stage 4. Rationale 2: Actively participates in activities that characterize a particular faith tradition; experiences awe and wonderment; feels a sense of belonging is Stage 2. Rationale 3: Experiences faith through interaction with others who are living a particular faith tradition is Stage 1. Rationale 4: Through a process of questioning and doubting own faith, acquires a cognitive as well as an affective faith is Stage 3.

A nurse is preparing an education program on safety concerns for elderly adults living in their own homes. To address the sensory changes in this age group, what should the nurse recommend to this group? 1. Have carbon monoxide detectors that are checked on a scheduled basis. 2. Place a list of emergency numbers near the phone. 3. Install telephones that use a blinking light instead of a ringer. 4. Ask someone to do their cooking for them.

Correct Answer: 1 Rationale 1: A decreased or absent sense of smell adds to the safety issues of this age group. Because of this, and if the elderly persons home has natural gas appliances or furnace, a carbon monoxide detector would alert the person of any gas leaks or problems present. Rationale 2: Emergency numbers by the phone is a good idea, but does not address sensory changes. Rationale 3: Telephones that utilize a blinking light are used for people who are significantly hearing impaired. Rationale 4: It is not necessary for someone to do cooking for this age group, although they may be inclined to use more salt due to decreased sense of smell and taste.

A rare malignancy will require the amputation of an adolescent clients leg. The client refuses the surgery, stating: I would rather die than have my leg amputated. What information should the nurse use to plan future interventions for this client? 1. The knowledge that adolescents are very concerned about body image 2. Concern about need for education regarding the danger of delaying surgery 3. The fact that the parents will have the ultimate decision about surgery 4. The ability of the adolescent to understand medical terminology

Correct Answer: 1 Rationale 1: Adolescents are very concerned about body image and will make decisions based upon peer or media opinion even if it puts their health at risk. The nurses further interventions should be planned with this thought in mind. Rationale 2: Although the client may need further education, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention. Rationale 3: Even though the parents will make the ultimate decision, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention. Rationale 4: Although there may be a problem with the client understanding medical terminology, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention.

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident? 1. Ask the resident for advice in setting up an activity in the dayroom. 2. Keep the resident too busy to dwell in the past. 3. Dont allow the resident to talk about minor concerns. 4. Meet with the social worker to plan all of the clients care.

Correct Answer: 1 Rationale 1: Asking the client for advice in setting up an activity in the dayroom validates the clients usefulness and worth. Rationale 2: Reminiscence therapy is a standard therapy used with older clients. Rationale 3: The nurse and staff should listen carefully to client concerns. Rationale 4: Clients should be encouraged to be a part of the planning of their care.

A group of middle-aged clients is inquiring about nutritionrelated health problems inherent in their age group. In order to best address these concerns of this specific age group, the nurse should take which action? 1. Provide information, including a website, regardingage specific diet plans. 2. Give all clients a handout on diets recommended by the ADA. 3. Tell the clients to check with their physician before dieting. 4. Have them write to the U.S. Department of Agriculture for more information.

Correct Answer: 1 Rationale 1: Decreased metabolic activity and decreased physical activity mean a decrease in caloric needs. This particular age group must be educated regarding nutrition, exercise, and the relationship of nutrition and exercise to chronic diseases such as diabetes mellitus and heart problems. Rationale 2: This option does not necessarily address the concerns of this specific age group. Rationale 3: Although this information is not incorrect, is the nurses responsibility to provide general information, education, and sources for clients seeking improvement in their nutrition that would include but not be limited to encouragement to check with their physician before dieting. Rationale 4: Although encouraging the individuals to write for information is not incorrect, in this situation it is the nurses responsibility to provide information, education, and resources for clients seeking improvement in their nutrition.

A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Eriksons theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments

Correct Answer: 1 Rationale 1: Erikson viewed the developmental choice of the middle-aged adult as generativity versus stagnation. Generativity is defined as concern for establishing and guiding the next generation. This could be accomplished through a mentor program with school-age children. Rationale 2: Peer socialization is a task of the young adult and adolescent. Rationale 3: Finding civic responsibility is a task of the young adult and adolescent. Rationale 4: Taking inventory of past accomplishments is the task of the older adult.

A parent brings her baby in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age? 1. The child does not cry when the parent allows the nurse to hold the child. 2. The child shows mistrust when strangers approach. 3. The child becomes willful when disciplined. 4. The child does not play with other children.

Correct Answer: 1 Rationale 1: In the infancy years (birth to 18 months), the childs central task is to form trust or mistrust with people. Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust. Rationale 2: Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust. Negative resolution would indicate mistrust, withdrawal, and estrangement. Rationale 3: Willfulness and defiance are negative indicators of the early childhood stage. Rationale 4: Playing with other children is part of the self-esteem and self-expression of the early childhood years.

An elderly client who has had a stroke is ready for hospital discharge. How should the gerontological nurse case manager support this clients independence? 1. Allow the client to be actively involved in all decisions made. 2. Make arrangements based on what the nurse feels is in the best interest of the client. 3. Work closely with the social worker and physician to make the decisions necessary for the client. 4. Set up a meeting with the family members so decisions can be made.

Correct Answer: 1 Rationale 1: Nurses need to acknowledge the older clients ability to think, reason, and make decisions. Most elders are willing to listen to suggestions and advice, but they do not want to be ordered around. It would be quite appropriate to include the physician or primary care provider, social worker, as well as the family in the decision-making process, but always and foremost, to include the client. Rationale 2: Nurses need to acknowledge the older clients ability to think, reason, and make decisions. This option does not reflect an understanding of the clients right to autonomy. Rationale 3: This option does not reflect an understanding of the clients right to autonomy. It would be quite appropriate to include the physician or primary care provider, social worker, as well as the family in the decision-making process, but always and foremost, to include the client. Rationale 4: This option does not reflect an understanding of the clients right to autonomy. Nurses need to acknowledge the older clients ability to think, reason, and make decisions. It would be quite appropriate to include the physician or primary care provider, social worker, as well as the family in the decision-making process, but always and foremost, to include the client.

The nurse is completing an assessment to determine an older patients development of moral reasoning. Which observation indicates that the client has developed moral reasoning as anticipated? 1. Considers relationships as well as justice in moral decisions 2. Approaches moral decisions based upon the consequences to self 3. Follows societys rules of conduct in response to the expectations of others 4. Bases moral judgments on connectedness to others and the value of relationships

Correct Answer: 1 Rationale 1: Older adults begin to make moral decisions that are consistent with the theories of both Kohlberg and Gilligan. Older men consider relationships, as well as justice, in moral decisions, and older women add justice to the factors they consider in moral situations. Rationale 2: Approaching moral decisions based upon the consequences to self does not exemplify development of moral reasoning for the older adult client. Rationale 3: Following societys rules of conduct in response to the expectations of others is a belief of Kohlberg; however, this does not demonstrate the development of moral reasoning for an older adult. Rationale 4: Basing moral judgments on connectedness to others and the value of relationships is a belief of Gilligan, who identified this approach to moral behavior in women.

A college-age client shares that he is struggling with feelings of both independence and dependence regarding his family. The nurse recognizes this as which stage of development, according to Roger Gould? 1. Stage 2 2. Stage 3 3. Stage 4 4. Stage 5

Correct Answer: 1 Rationale 1: Roger Gould studied adult development and described seven stages. Stage 2 (ages 1822) is where individuals have established autonomy, feel it is in jeopardy, and feel they could be pulled back into their families. Rationale 2: Roger Gould studied adult development and described seven stages. Stage 3 (ages 2228) is when individuals feel established as adults and autonomous from their families. They see themselves as well defined, but still feel the need to prove themselves to their parents. Rationale 3: Roger Gould studied adult development and described seven stages. Stage 4 (ages 2934) is when marriage and careers are well established. Individuals question what life is all about and wish to be accepted as they are, no longer finding it necessary to prove themselves. Rationale 4: Roger Gould studied adult development and described seven stages. Stage 5 (ages 3543) is a period of self-reflection. Individuals question values and life itself. They see time as finite, with little time left to shape the lives of adolescent children.

Which statement made by a new mother would indicate to the nurse that there is potential for lowered self-esteem due to role ambiguity? 1. I dont know if I know how to be a mom. 2. My husband will be a stay-at-home dad while I work. 3. Im so disappointed that this baby is not a girl. 4. I havent even finished the babys room.

Correct Answer: 1 Rationale 1: Role ambiguity occurs when expectations are unclear or a person does not know how to fulfill the role. In this case, the clearest indication of role ambiguity is I dont know if I know how to be a mom. Rationale 2: Even though the husband staying at home while the mother works may not be the expected role assignment, there is no ambiguity in the arrangement. Rationale 3: Disappointment that the baby is not a girl is not specific to role ambiguity. Rationale 4: Not having the room finished is not specific to role ambiguity.

A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter on a daily basis. Remembering the growth and development characteristics of the adolescent, how should the nurse respond to this client? 1. You should feel very proud for understanding and using your meter. 2. Think of using the meter as one of your daily chores. 3. Maybe you could make a game out of the daily use of your meter. 4. Its too bad if you dont want to use the meter, its just something youll have to do.

Correct Answer: 1 Rationale 1: School-age children (612 years) are in the preadolescent period, where the peer group begins to increasingly influence behavior. The nurse must allow time and energy for the school-age child to pursue hobbies and school activities and should recognize and support the childs achievement. Play and social activity are more important in the preschool-age child as new experiences and social roles are tried during play. Rationale 2: This phrase does not support the childs growth and development. Rationale 3: This phrase does not support the childs growth and development. Rationale 4: This phrase does not support the childs growth and development.

During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the clients 1. personal identity. 2. body image. 3. role performance. 4. self-esteem.

Correct Answer: 1 Rationale 1: Self-concept consists of personal identity, body image, role performance, and self-esteem. Personal identity consists of name, sex, age, race, ethnic origin or culture, occupation or roles, talents, and other situational characteristics. Rationale 2: Body image is perception of size, appearance, and functioning of the body. Rationale 3: Role performance relates to how a person fulfills his or her own expectations of role. Rationale 4: Self-esteem is a judgment of ones own worth.

A nurse is working in a community of factory workers and is planning an educational session for wellness, targeting the young adult group. In order to address one of the health problems of this group, the nurse plans to: 1. help the group become more aware of marketing efforts by tobacco companies. 2. tell this group that smoking is unacceptable. 3. make sure the group is aware of the increased risk of liver disease and cancer of the esophagus. 4. counsel the group regarding addiction.

Correct Answer: 1 Rationale 1: Smoking is a type of drug abuse prevalent in this age group, which can lead to lung cancer and cardiovascular disease. The nurses role regarding smoking is to serve as a role model by not smoking, provide educational information regarding the dangers of smoking (not just tell or counsel about it), help make smoking socially unacceptable, suggest resources such as hypnosis, and assist with lifestyle training and behavior modification to clients who desire to stop smoking. Rationale 2: The nurses role regarding smoking does not include making judgment statements. Rationale 3: There is not current research to support the role of tobacco in the development of liver and esophagus cancers. Rationale 4: The nursing role in this situation is to educate, not counsel.

A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? 1. Temperament 2. Physical characteristics 3. Environment 4. Culture

Correct Answer: 1 Rationale 1: Temperament is the way individuals respond to their external and internal environment and sets the stage for the interactive dynamics of growth and development. Rationale 2: Physical characteristics include eye color and potential height and do not affect how children interact, for the most part. Rationale 3: Environment includes family, religion, climate, culture, school, community, and nutrition and would not play as big of a role in how the child responds to peers as temperament does. Rationale 4: Culture is part of environmental factors.

Which statement should the nurse make first when assessing a clients self-concept? 1. Describe yourself as a person. 2. Tell me about your family. 3. Describe what you do when you have free time. 4. Tell me about the work you do.

Correct Answer: 1 Rationale 1: The first information the nurse gathers when assessing self-concept should focus on the clients personal identity (Describe yourself as a person). Rationale 2: Tell me about your family assesses role performance. Rationale 3: What do you do when you have free time assesses social role. Rationale 4: Tell me about the kind of work do you do assesses work role.

The nurse and client had set the following expected outcome: At the next clinic visit, the client will report participation in three activities to increase self-esteem. At todays visit, the client is unable to meet the stated outcome. What should be the nurses next action? 1. Explore the possible reasons for not meeting the outcome. 2. Reevaluate the accuracy of the outcome statement. 3. Collaborate with the client to write a new expected outcome. 4. Identify new interventions to help the client achieve the outcome.

Correct Answer: 1 Rationale 1: The nurses first action should be to explore possible reasons the outcome was not met. Rationale 2: Reevaluating the accuracy of the outcome statement would be the second step. Rationale 3: Collaborating with the client to write a new expected outcome would not be the nurses next step. Rationale 4: Identifying new interventions to help the client achieve the outcome would not be the nurses first step.

A nursing student has just received an evaluation that indicates difficulties with time management and prioritization in the care of clients. How should the student react to this input? 1. Take the feedback seriously and use it to guide personal growth. 2. Blame the studentfaculty relationship as the basis of the evaluation. 3. Dismiss the evaluation as invalid. 4. Consider the feedback carefully but not change practice patterns.

Correct Answer: 1 Rationale 1: The student should take the feedback seriously and use it to guide personal growth. Issues with time management and prioritization are common with students and should be addressed. The student should introspectively look at the situation and use it for growth. Rationale 2: Blaming the studentfaculty relationship for the poor review reflects projection of the students beliefs onto the situation. Rationale 3: Dismissing the feedback reflects projection of the students beliefs onto the situation. Rationale 4: Considering the feedback but not using it to change personal practice reflects projection of the students beliefs onto the situation.

An elderly client comes to the clinic for follow-up after a long hospitalization. When the client asks about increasing strength and endurance, what should the nurse respond? 1. Your muscles can be strengthened, which might help you function better. 2. It wont matter if you exercise. At your age, theres little room for improvement. 3. Once muscle mass is decreased, theres nothing that can be done for strength improvement. 4. Maybe you should think about going to a nursing home. At least the people there will be able to help with your needs.

Correct Answer: 1 Rationale 1: There is evidence that an older adults muscles can be strengthened through exercise and training, with concomitant improvements in functional status. Rationale 2: It would be inappropriate for the nurse to assume that there is no room for improvement. Rationale 3: Physical changes associated with the aging process are normal, but not something that cant be improved upon. Rationale 4: There is evidence that an older adults muscles can be strengthened through exercise and training, with concomitant improvements in functional status. It would be inappropriate for the nurse to suggest that the client is a suitable candidate for long-term care.

The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ? 1. Encourage the client to set attainable goals, even if small. 2. Help the client choose a significant goal, even if it is time consuming. 3. Devise a set of goals from which the client can pick. 4. Advise the client to avoid goals that will require too much effort.

Correct Answer: 1 Rationale 1: When attempting to reinforce client strengths, it is important to help the client set attainable goals, even if the goals are small at first. Rationale 2: If the goal is too long range, the client may lose sight of the goal before it is attained. Rationale 3: Devising goals should be a team effort between the client, significant others, and the nurse. Rationale 4: The goal should not be so effortless that it is not important to the client.

The nurse is assessing a childs growth and development. What questions should the nurse ask the parents that demonstrate an understanding of the factors that affect growth and development processes? Standard Text: Select all that apply. 1. How tall the parents are 2. Whether noises seem to bother their child 3. How many ounces of formula their child drinks daily 4. What their yearly income is 5. Whether their child will receive daycare services

Correct Answer: 1, 2, 3 Rationale 1: The genetic inheritance of an individual is established at conception. It remains unchanged throughout life, and determines such characteristics as gender and physical characteristics (e.g., eye color, potential height). Rationale 2: Temperament sets the stage for the interactive dynamics of growth and development. Rationale 3: Adequate nutrition is an essential component of growth and development. Rationale 4: Although adequate family income allows for sufficient nutrition, housing, and other needs, it is not generally considered a factor affecting growth and development. Rationale 5: Being cared for by individuals other than ones parents is not generally considered as a factor unless care is neglected by whoever is responsible.

The nurse working in a community health office that is often frequented by young adults is assessing clients for suicide. Which factors should the nurse identify as indicating a problem in this area? 1. Decreased interest in work 2. Weight loss 3. Depression 4. Brain dysfunction, including tumors 5. Sleep disturbances

Correct Answer: 1, 2, 3, 5 Rationale 1: The nurses role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including decreased interest in work roles. Rationale 2: The nurses role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including weight loss. Rationale 3: The nurses role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including depression. Rationale 4: Brain tumors are not an indicator for suicide. Rationale 5: The nurses role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including sleep disturbances.

The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? Standard Text: Select all that apply. 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities

Correct Answer: 1, 2, 4 Rationale 1: Selecting a mate is a task appropriate for this age group. Rationale 2: Rearing children is a task appropriate for this age group. Rationale 3: Achieving civic responsibility is a task of the middle-aged adult. Rationale 4: Finding a congenial social group is a task appropriate for this age group. Rationale 5: Developing adult leisure-time activities is a task of the middle-aged adult.

The nurse is confident that a young adult has successfully achieved psychosocial development. What observations about the client did the nurse make to come to this conclusion? Standard Text: Select all that apply. 1. Discusses plans to expand his exercise routine to include running 2. Is optimistic about finding a new job 3. Volunteers weekly at the local senior center 4. Recognizes that professional sports may be enjoyed but does not aspire to participating 5. May be too bald to play Santa Claus

Correct Answer: 1, 2, 4 Rationale 1: The psychosocial development of a young adult would include keeping good health habits. Rationale 2: The psychosocial development of a young adult would include the ability to cope with stressors appropriately. Rationale 3: The psychosocial development of a middle-aged adult would include pursuing charitable and altruistic activities. Rationale 4: The psychosocial development of a young adult would include having a realistic self-concept. Rationale 5: The psychosocial development of a middle-aged adult would include accepting his aging body.

A client with an acute, serious illness has been hospitalized. Upon entering the room, the nurse observes the client praying. The client states to the nurse: I dont know how people manage to get through difficult times without their faith. Its where I get my strength. With which theorist should the nurse associate this clients belief? 1. Fowler 2. Westerhoff 3. Gilligan 4. Kohlberg

Correct Answer: 2 Rationale 1: Fowlers theory describes the development of faith as a force that gives meaning to a persons life. Rationale 2: Westerhoff describes faith as a way of being and behaving that evolves from an experienced faith guided by parents and others during a persons infancy and childhood to an owned faith that is internalized in adulthood. For the client who is ill, faith provides strength and trust. Rationale 3: Gilligan is not a spiritual theorist. Rationale 4: Kohlberg is not a spiritual theorist.

The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlbys attachment theory during this presentation? Standard Text: Select all that apply. 1. Use the attachment figure as security 2. Desire to be near the attachment figure 3. Plan to separate from the attachment figure 4. Return to the attachment figure when threatened 5. Express anxiety when the attachment figure is absent

Correct Answer: 1, 2, 4, 5 Rationale 1: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include using the attachment figure as a security base. Rationale 2: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include the desire to be near the attachment figure. Rationale 3: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory do not include a plan to separate from the attachment figure. Rationale 4: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include returning to the attachment figure when threatened. Rationale 5: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include expressing anxiety (separation anxiety) when the attachment figure is absent.

A client approaching middle age asks for information to keep mentally sharp. What should the nurse explain about the cognitive abilities of the middle-aged client? Standard Text: Select all that apply. 1. Reaction time stays much the same. 2. Memory is maintained during this time. 3. Learning declines and cannot be completed. 4. Problem-solving ability is maintained during this time. 5. Cognitive and intellectual abilities change very little at this time.

Correct Answer: 1, 2, 4, 5 Rationale 1: The middle-aged adults cognitive and intellectual abilities change very little. Reaction time during the middle years stays much the same. Rationale 2: The middle-aged adults cognitive and intellectual abilities change very little. Memory is maintained during middle adulthood. Rationale 3: The middle-aged adults cognitive and intellectual abilities change very little. Learning continues and can be enhanced with motivation. Rationale 4: The middle-aged adults cognitive and intellectual abilities change very little. Problemsolving ability is maintained during middle adulthood. Rationale 5: The middle-aged adults cognitive and intellectual abilities change very little.

A group of older clients is interested in living options available in the community when they may need some assistance with their daily needs. What should the nurse suggest as possibilities to meet these needs? 1. Adult foster care 2. Group homes 3. Retirement villages 4. Long-term care facilities 5. Adult day-care centers

Correct Answer: 1, 2, 5 Rationale 1: Adult foster care offers services to individuals who can care for themselves but require some form of supervision for safety purposes. Rationale 2: Group homes offer services to individuals who can care for themselves but require some form of supervision for safety purposes. Rationale 3: Retirement villages provide social support, but do not provide assistance with medication and activities of daily living (ADLs). Rationale 4: Long-term care facilities provide all care when elderly persons are no longer able to care for themselves; they are not considered assistance living. Rationale 5: The older adult who lives at home can attend a daycare center that provides health and social services to the older person. While the older adult is at daycare, the caregiver has a respite from the daily care. Global Rationale:

The nurse is completing a spiritual assessment with a middle-aged client. What should the nurse recognize as expected characteristics of moral development in this client? Standard Text: Select all that apply. 1. Uses religion for comfort 2. Seeks religious explanations for death 3. Compares characteristics of various religions 4. Questions the purpose of religion in ones life 5. Relies upon spiritual beliefs to help with illness

Correct Answer: 1, 2, 5 Rationale 1: In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. Rationale 2: In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with death. Rationale 3: Comparing characteristics of various religions is a characteristic of an earlier stage of development. Rationale 4: Questioning the purpose of religion in ones life is a characteristic of an earlier stage of development. Rationale 5: In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness.

After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms. According to Freud, what should the nurse realize as being the cause of this behavior? Standard Text: Select all that apply. 1. Anxiety created by conflicts 2. Activation of the conscience 3. Conflict between the ids impulses 4. Immediate pleasure and gratification 5. Underlying motivation for development

Correct Answer: 1, 3 Rationale 1: Defense mechanisms or adaptive mechanisms are the result of anxiety created by the conflicts due to social and environmental restrictions. Rationale 2: Activation of the conscience is a function of the superego. Rationale 3: Defense mechanisms or adaptive mechanisms are the result of conflicts between the ids impulses. Rationale 4: Immediate pleasure and gratification is a function of the id. Rationale 5: The underlying motivation for development is the libido.

The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears mismatched clothing. What should be the nurses response to this concern? 1. Dont worry, day-care workers are accustomed to that sort of thing. 2. This is normal and the preschooler is just practicing skills needed later in life 3. I am glad you brought that to our attention. I will make a note for her pediatrician. 4. You should have better control of the child now if you have any hope of controlling the child during the teenage years.

Correct Answer: 2 Rationale 1: Even though day-care workers are accustomed to this stage, the option given discounts the parents worry and does not give them any information that the preschooler is normal. Rationale 2: The nurse should accept that the parents are concerned and then tell them that this is normal behavior at this age. Preschoolers often begin to exert independence and to practice picking out clothing, cooking with play toys, and parenting dolls. Rationale 3: The only reason to notify the pediatrician would be to report this normal behavior. Rationale 4: Because this is a normal behavior, there are no issues about controlling the preschooler when older.

The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? Standard Text: Select all that apply. 1. Promote safety. 2. Promote mental health. 3. Improve quality of life. 4. Promote spiritual health. 5. Promote growth and development.

Correct Answer: 1, 3 Rationale 1: Miller developed the Functional Consequences Theory in 1990. Functional consequences are age-related changes, actions that have placed the client at risk for illness or injury, and risk factors for disease. The nurse should design interventions that promote safety. Rationale 2: In the Nursing Theory of Successful Aging developed by Flood, the client experiences spiritual connections and a sense of meaning and worth. Nurses must target interventions for the older adult in the promotion of mental health throughout the aging process. Rationale 3: Miller developed the Functional Consequences Theory in 1990. Functional consequences are age-related changes, actions that have placed the client at risk for illness or injury, and risk factors for disease. The nurse should design interventions that improve the clients quality of life. Rationale 4: In the Nursing Theory of Successful Aging developed by Flood, the client experiences spiritual connections and a sense of meaning and worth. Nurses must target interventions for the older adult in the promotion of spiritual health throughout the aging process. Rationale 5: The Theory of Thriving asserts that nurses must intervene to promote the older adults growth and development.

The nurse concludes that a young adult client is completing developmental tasks within Havighursts early adulthood age period. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Taking on civic responsibility 2. Developing adult leisure-time activities 3. Getting started in an occupation 4. Relating oneself to ones spouse as a person 5. Managing a home

Correct Answer: 1, 3 Rationale 1: Taking on civic responsibilities is one of Havighursts early adulthood tasks. Rationale 2: Developing adult leisure-time activities is not a part of the middleage period. Rationale 3: Getting started in an occupation is one of Havighursts early adulthood tasks. Rationale 4: Relating oneself to ones spouse as a person is not a part of the middleage period. Rationale 5: Managing a home is one of Havighursts early adulthood tasks.

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? Standard Text: Select all that apply. 1. I hate my hair. 2. Life is wonderful! 3. My hips are too big. 4. I wish I had that nose job 2 years ago. 5. It is awesome that I got that promotion at work.

Correct Answer: 1, 3, 4 Rationale 1: Specific self-esteem is how much one approves of a certain part of oneself. The client hating her hair demonstrates an issue with specific self-esteem. Rationale 2: Stating that life is wonderful indicates healthy global self-esteem. Rationale 3: Specific self-esteem is how much one approves of a certain part of oneself. The client stating that her hips are too big demonstrates an issue with specific self-esteem. Rationale 4: Specific self-esteem is how much one approves of a certain part of oneself. The client wishing that a nose job was done 2 years ago demonstrates an issue with specific self-esteem. Rationale 5: Being successful at work indicates healthy specific and global self-esteem.

An adult client who has been a successful writer in the past has been experiencing low self-esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes? Standard Text: Select all that apply. 1. The client joined a library book club. 2. The client counted the number of rejection letters she received from publishers. 3. The client states that she no longer reads Facebook to compare her life with her friends lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition.

Correct Answer: 1, 3, 4, 5 Rationale 1: Joining a book club demonstrates spending time with positive supportive people. Rationale 2: Counting the number of rejection letters is focusing on the negative and will not help improve self-esteem. Rationale 3: Avoiding comparisons with other people helps develop self-esteem. Rationale 4: Helping others will help develop the clients self-esteem. Rationale 5: Having success will help develop the clients self-esteem

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? Standard Text: Select all that apply. 1. Growth involves physical change and increase in size. 2. Skills and function increase with growth. 3. Most humans experience a similar pattern of growth. 4. Being able to adapt to ones environment is an indicator of growth. 5. Childrens growth is monitored by height, weight, bone size, and dentition.

Correct Answer: 1, 3, 5 Rationale 1: Growth is physical change and increase in size. Rationale 2: Development is an increase in the complexity of function and skill progression. Rationale 3: The pattern of physiologic growth is similar for all people. Rationale 4: Development skills include the ability to adapt to ones environment. Rationale 5: Growth can be measured quantitatively. Indicators of growth include height, weight, bone size, and dentition.

The nurse is determining a clients level of psychosocial development according to Eriksons stages. Place the developmental tasks in order according to Eriksons stages of psychosocial development. Standard Text: Click and drag the options below to move them up or down. Choice 1. Expressing ones own opinion Choice 2. Guiding others Choice 3. Asserting independence Choice 4. Working well with others

Correct Answer: 1, 4, 3, 2 Rationale 1: Expressing ones own opinion is a behavior in the infancy stage of trust vs. mistrust. Rationale 2: Guiding others is a behavior in the middle-aged adult stage of generativity vs. stagnation. Rationale 3: Asserting independence is a behavior in the adolescence stage of identity vs. role confusion. Rationale 4: Working well with others is a behavior in the early school years stage of industry vs. inferiority.

A group of elderly women come to the community center for exercise classes taught by the community health nurse. This activity will help lead to which outcome for these clients? 1. Reverse the effects of aging and cure pain. 2. Slow bone density loss and decrease muscle atrophy. 3. Eliminate the risk for osteoporosis. 4. Prevent pathologic fractures.

Correct Answer: 2 Rationale 1: Exercise and proper nutrition will not reverse the effects of aging, nor will they eliminate the risk for osteoporosis. Rationale 2: Programs of physical activity and proper nutrition will slow bone density loss and decrease muscle atrophy and stiffness that occurs with aging. Rationale 3: Exercise and proper nutrition will not reverse the effects of aging, nor will they eliminate the risk for osteoporosis. Rationale 4: Pathologic fractures occur spontaneously, without a fall or trauma to the bone. Many are a result of low bone density or tumor.

The nurse can identify movement into Kohlbergs postconventional level when the client, after being asked about work, makes which statement? 1. Oh, the work isnt so bad anymore. Im getting close to retirement. 2. Work is fine, but my family and friends are so much more important to me. 3. Ive done a good job for the company. Im proud of my years there. 4. I dont like to talk about work when Im not there.

Correct Answer: 2 Rationale 1: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. A statement about work not being so bad shows a complacency about work that is not reflective of the postconventional level. Rationale 2: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. Movement from a law-and-order orientation to a social contract orientation requires that the individual move to a stage in which rights of others take precedenceas in the statement that work is OK, but family and friends are more important. Rationale 3: Stating that the person has pride about work and the time spent doing it would be an example of Eriksons stage of integrity versus despair. Rationale 4: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. A statement about not wanting to talk about work shows complacency about work that is not reflective of the postconventional level.

A client who has a terminal diagnosis has been using her time to help family members deal with her impending death. Among her activities, she collected pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? 1. Body transcendence versus body preoccupation 2. Ego transcendence versus ego preoccupation 3. Ego differentiation versus work-role preoccupation 4. Integrity versus despair

Correct Answer: 2 Rationale 1: Body transcendence versus body preoccupation calls for the individual to adjust to decreasing physical capacities and at the same time maintain feelings of well-being. Rationale 2: Ego transcendence is the acceptance without fear of ones death as inevitable. This acceptance includes being actively involved in ones own future beyond death. Peck proposes that there are three developmental tasks during old age, in contrast to Eriksons oneintegrity versus despair. Rationale 3: Ego differentiation versus work-role preoccupation maintains that an adults identity and feelings of worth are highly dependent on that persons work role. Rationale 4: Erikson proposed integrity versus despair, not Peck.

A nurse who works in a long-term care facility has noticed that one of the residents has been showing signs of impaired cognitive and selfcare abilities over the last 2 weeks. The nurse should 1. remember that memory loss is a normal, age-related change. 2. investigate for possible physiologic problems. 3. instruct the staff to be extra attentive, as this person needs more assistance. 4. inform the residents family that the resident probably has some form of dementia.

Correct Answer: 2 Rationale 1: Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal and be investigated. Rationale 2: Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal and be investigated. Rationale 3: This option does not address the loss of function the client is experiencing. Rationale 4: This option is premature and not within the scope of nursing practice.

Which nursing intervention would be helpful when caring for a client who has negative self-esteem? 1. Find a way to praise the client during each encounter. 2. Design a series of small successes for the client. 3. Correct the client when negativity arises. 4. Tell the client how much easier life would be with positive self-esteem.

Correct Answer: 2 Rationale 1: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem. Rationale 2: Clients who have negative self-esteem may have a history of failures and disappointments. Designing a series of small successes for the client will help foster a more positive attitude. Rationale 3: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem. Rationale 4: The client likely already knows how much better life would be with positive self-esteem, so reiterating that fact would not be helpful.

An elderly client comes to the clinic after checking his blood pressure several times in the local discount store. The nurse checks the blood pressure and finds that it is 146/80. What should the nurse say to this client? 1. Having blood pressure a little high is normal at your age. Yours is fine. 2. Ill recheck this in a while, but your systolic pressure is too high. 3. Well wait and see what the doctor says, but I doubt he will be concerned. 4. You should be on medicine for high blood pressure.

Correct Answer: 2 Rationale 1: Current evidence indicates that a systolic pressure of greater than 140 mm Hg is as problematic in older adults as in younger ones and should be treated. Rationale 2: Isolated systolic hypertension was considered to be normal in older adults and was frequently not treated. Now, evidence indicates that a systolic pressure of greater than 140 mm Hg is as problematic in older adults as in younger ones and should be treated. Rationale 3: Current evidence indicates that a systolic pressure of greater than 140 mm Hg is as problematic in older adults as in younger ones and should be treated. Rationale 4: It would be up to the physician or primary care provider whether or not to treat. The nurse does not make this decision.

During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the clients reluctance to share information? 1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt.

Correct Answer: 2 Rationale 1: Documenting that the client is not cooperative labels the client for all other health care provider interactions. Rationale 2: The nurse should always consider that there could be a cultural implication of behavior. Rationale 3: Assuming that the client has something to hide labels the client for all other health care provider interactions. Rationale 4: Asking a second nurse to sit in on the next interview may make the client feel more intimidated.

A nurse is working with clients in an assisted living facility. In the past month, there have been several deaths among the residents and their spouses. In helping the remaining residents deal with these deaths, the nurse understands that adjustment may be easier for which resident? 1. A resident who spent most of her days attending to her partner who is now deceased 2. A resident who had a wide circle of friends, besides her spouse 3. A resident who was not inclined to participate in any activities offered at the facility 4. A resident who started to become more dependent on the nursing staff at the facility

Correct Answer: 2 Rationale 1: Independence established prior to the loss of a mate makes adjustment easier. Rationale 2: Independence established prior to the loss of a mate makes adjustment easier. A person who had meaningful relationships and friendships or economic security, ongoing interests in the community or private hobbies, and a peaceful philosophy of life copes more easily with bereavement. Rationale 3: Not participating in functions offered may indicate feelings of inadequacy or insecurity after a death has occurred. Rationale 4: Becoming more dependent on the staff may indicate feelings of inadequacy or insecurity after a death has occurred.

A hospitalized older client is recovering from an acute illness. As the client nears the end of his hospitalization, he questions the nurse about medications and care after discharge. The gerontological nurse should 1. inform the physician that the client needs to go to a nursing home. 2. assess the clients independence and ability to function in his own home before discharge. 3. tell the client not to worry about going home. 4. invite the clients family to come to the hospital so the nurse can explain the clients care to them.

Correct Answer: 2 Rationale 1: Informing the physician that the client needs long-term care is inappropriate at this point. Rationale 2: Older adults often perceive that being in the hospital could change their ability to be autonomous and independent. As a result, the nurse needs to assess the older adults stage or perception of need for control and autonomy during his hospitalization and his fears and hopes about being discharged from the hospital setting. Rationale 3: Telling the client not to worry is not therapeutic and does not address his concerns. Rationale 4: The client is a capable adult and should be included in all decision-making situations, not have them deferred to the family.

The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse? 1. Most clients make quicker progress. 2. Self-esteem work takes time and is not easily evaluated. 3. What have you done to help the client with this work? 4. Do you think that the client is really trying?

Correct Answer: 2 Rationale 1: It is not appropriate to reinforce the spouses feelings by comparing the client to other clients. Rationale 2: It would be appropriate to respond that self-esteem work takes time and that improvement is sometimes not easy to evaluate. Rationale 3: It is not appropriate to blame the spouse for the slowness by asking what has been done to help the client. Rationale 4: It is not appropriate to instill doubt by asking if the client is really trying.

A client has had Alzheimers dementia for a period of time and continues to live at home with his spouse. What would be one of the gerontological nurses responsibilities? 1. Make sure the client is being prescribed appropriate medication. 2. Provide support for the spouse. 3. Assess the client early to ensure proper care. 4. Find a suitable long-term care facility for the client.

Correct Answer: 2 Rationale 1: Medication prescription is not a nursing responsibility. Rationale 2: The nurses responsibility is to provide supportive nursing care, accurate information, and referral assistance, if necessary, to the caregiver. Caregivers may experience physical and emotional exhaustion while they render continuous care. Rationale 3: It is important for the nurse to do an ongoing assessment of both the client and the caregiver as the clients condition deteriorates. Rationale 4: The nurses responsibility is to provide supportive nursing care, accurate information, and referral assistance, if necessary, but finding a suitable longterm facility is not a nursing responsibility.

Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client? 1. Low motivation to improve 2. A focus on problems 3. Expressed disinterest in working on improvement 4. Not satisfied with personal situation

Correct Answer: 2 Rationale 1: Motivation is not a characteristic of self-esteem. Rationale 2: Clients with low self-esteem often have difficulty identifying strengths and focus more on their limitations and problems. Rationale 3: Disinterest in working on improvement is not a characteristic of self-esteem. Rationale 4: Not being satisfied with a personal situation is not a characteristic of self-esteem.

A nurse is working with the residents of an assisted living complex. When planning care for the old-old stage, the nurse realizes that what action will be important? 1. Provide as much care to the residents as possible. 2. Allow as much independence for the residents as possible. 3. Make sure to provide safety measures as needed. 4. Make sure the residents maintain peer interactions and social groups.

Correct Answer: 2 Rationale 1: Providing as much care as possible does not meet the independence need required in this age group. Rationale 2: The old-old stage, age 85 and older, is characterized by increasing physical problems. The nursing implication for this age group is to assist with self-care as required, but maintain as much independence as possible. Rationale 3: Safety measures should be applied in the middle-old age group, age 75 to 84 years. Rationale 4: Peer interactions become important in the young-old stage, age 65 to 74 years.

The nurse notes that a 20-month-old child is lagging in stage 6 of Piagets phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage? 1. The child wants the same toy to sleep with during naptime and bedtime. 2. The child merely watches as the other children pretend-play. 3. The child cries when the parents leave the unit. 4. The child does not cooperate with some of the treatments.

Correct Answer: 2 Rationale 1: Ritual is important for the child of the tertiary circular reaction stage, age 12 to 18 months. Rationale 2: In this stage of development, inventions of new means, children interpret the environment by mental images. They use make-believe and pretend-play. A child who is unable to do this would not be demonstrating the behavior that is significant at this stage. Rationale 3: Crying when parents leave the unit and not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development. Rationale 4: Not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development.

A parent reports to the nurse that his child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? 1. Intuitive thought phase 2. Preconceptual phase 3. Concrete operations phase 4. Formal operations phase

Correct Answer: 2 Rationale 1: The intuitive thought phase is from age 4 to 7 years and is where egocentric thinking diminishes. The child thinks of one idea at a time and includes others in the environment. Rationale 2: Ages 2 to 4 years, according to Piaget, is the preconceptual phase where the child uses an egocentric approach to accommodate the demands of an environment. Language development is rapid and the child associates words with objects. Rationale 3: The concrete operations phase, ages 7 to 11, is where the child solves concrete problems. The child also begins to understand relationships such as size and right and left, and is cognizant of viewpoints. Rationale 4: During the formal operations phase (ages 11 to 15), the child uses rational thinking, and reasoning is deductive and futuristic.

During an educational session regarding physical changes of the middle-aged adult, a participant asks about typical weight changes. How should the nurse respond? 1. Weight loss is no different during this time than at any other time of your life. 2. Metabolism slows during middle age, which may result in weight gain. 3. As long as you exercise appropriately, weight loss will be ensured. 4. Weight loss is always a good idea, regardless of your age.

Correct Answer: 2 Rationale 1: The nurse should educate clients regarding physical changes occurring in their bodies. Statements that generalize weight loss with all other age groups are neither accurate nor helpful to the person asking the question. Rationale 2: The nurse should educate clients regarding physical changes occurring in their bodies. Age does make a difference in how the body responds to diet and exercise, and it is important for nurses to be well informed and educated regarding age-related changes. Rationale 3: There are other factors in addition to exercise that can affect weight in this age group. Rationale 4: Statements that generalize weight loss with all other age groups are neither accurate nor helpful to the person asking the question.

Some nursing students are doing their first clinical rotation in a long-term care facility. What should the nurse educator remind the students to do to meet the needs of this particular client group? 1. Do all care for the clients, as theyre unable to do it independently. 2. Always remember that the clients self-respect must be maintained in all interactions of the students. 3. Make sure the clients care is done in a timely manner, and sometimes that means doing things for the client. 4. Treat this group of clients with a greater level of respect than younger clients.

Correct Answer: 2 Rationale 1: There is much diversity among older clients, and nurses should be wary of stereotyping this group. Rationale 2: Older people appreciate the same thoughtfulness, consideration, and acceptance of their abilities as younger people do. Rationale 3: The aging client may be slower and less meticulous in many activities, and many young people err in thinking they are helpful to older people when they take over for them and do the job much faster and more efficiently. This is an unprofessional belief and disregards the clients right to autonomy and independence. Rationale 4: This is not a practice that a nurse educator would encourage because all clients, regardless of age, are treated respectfully.

A community health nurse is doing a screening for cervical cancer at a womens health fair. Which client should the nurse identify as having the highest risk factor for cervical cancer? 1. The client who had a difficult vaginal delivery 2 years ago 2. The client who has a history of genital herpes 3. The client who was married at age 27 4. The client who has a sister with breast cancer

Correct Answer: 2 Rationale 1: There is not current evidence to support this option. Rationale 2: High risk factors for cervical cancer include sexual activity at an early age, multiple sexual partners, and a history of syphilis, herpes genitalis, or trichomonas vaginitis. Rationale 3: There is not current evidence to support this option. Rationale 4: There is not current evidence to support this option.

The nurse is observing a group of young adults engaged in a discussion regarding work schedules over the holidays. What should the nurse realize that these adults will use to balance the emotional as well as logical side of the discussion? 1. Formal operational stage 2. Postformal thought process 3. Kohlbergs theory of moral development 4. Fowlers spiritual development theory

Correct Answer: 2 Rationale 1: Young adults are able to use formal operations, characterized by the ability to think abstractly. Rationale 2: Postformal thought, sometimes called the problemfinding stage, is characterized by creative thought, realistic thinking, problem forming, and problem solving. Postformal thinkers are able to comprehend and balance arguments created by both logic and emotion. Rationale 3: Young adults enter the postconventional level of Kohlbergs moral theory. Rationale 4: This would not be considered a spiritual dilemma, so Fowlers theory would not be utilized.

The nurse is identifying health promotion needs for an older adult client. What should the nurse consider for this client? Standard Text: Select all that apply. 1. Offering to arrange a pneumococcal vaccine for a client turning 60 years old 2. Assessing the 62-year-old client for situational depression. 3. Discussing smoking cessation classes with a 64-year-old 4. Asking a 78-year-old client whether he had his cholesterol tested within the last 3 years 5. Measuring the 79-year-old clients height and weight

Correct Answer: 2, 3, 5 Rationale 1: Appropriate health promotion practices would encourage such a vaccine for the client 65 years of age or older. Rationale 2: Appropriate health promotion practices would encourage depression screenings for older adult clients. Rationale 3: Appropriate health promotion practices would encourage smoking cessation classes for older adult clients. Rationale 4: Appropriate health promotion practices would encourage such screening for older adult clients only until the age of 75. Rationale 5: Appropriate health promotion practices would include regular measuring of both height and weight for older adult clients.

A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care. When considering these supplies, what should the nurse recall? 1. Medicare will cover supplies, but only with a physicians written order. 2. Between insurance supplements and Medicare, the older client shouldnt have any difficulty with coverage. 3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible. 4. Clients have to be responsible for their own supplies.

Correct Answer: 3 Rationale 1: Assuming that all supplies are covered by Medicare when ordered by a physician is erroneous. Rationale 2: Assuming that all supplies are covered by Medicare and/or supplemental insurance is erroneous. Rationale 3: The financial needs of this age group vary considerably, and problems with income are related to low retirement benefits, lack of pension plans, and increasing length of retirement years. Nurses should be aware of the costs of health care and use supplies that are as economical as possible. Rationale 4: The nurse should assist the client to apply for whatever assistance programs are available.

A nurse is presenting a health education program to a group of older adults at a senior citizens center. Considering the physiological changes of this age group, how should the nurse set the temperature of the room? 1. It should be set at a temperature that is comfortable for the nurse. 2. It should be set cooler than what is comfortable for the nurse. 3. It should be set warmer than the nurses preference. 4. The temperature of the room is not one of the nurses concerns.

Correct Answer: 3 Rationale 1: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they would not be comfortable in a temperature suited to a younger individual. Rationale 2: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they typically do not enjoy cooler temperatures. Rationale 3: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they typically enjoy warmer temperatures. Rationale 4: If the environment is not comfortable to the audience, they will be distracted and not be able to focus or concentrate on the presentation and any information the nurse shares.

The nurse is explaining the difference between dementia and delirium to the spouse of a client with Alzheimers disease. What should the nurse say to make this distinction? 1. Delirium is easily distinguished from dementia. 2. Dementia is reversible and treatable. 3. Delirium is an acute and reversible syndrome. 4. Dementia is the only condition that is characterized by changes in memory, judgment, language, mathematic calculation, abstract reasoning, and problem-solving ability.

Correct Answer: 3 Rationale 1: Both dementia and delirium have many of the same characteristics. Rationale 2: Delirium is an acute, reversible syndrome; dementia is not. Rationale 3: Once the underlying pathology is treated, the delirium disappears. Rationale 4: Both dementia and delirium have many of the same characteristics.

The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving.

Correct Answer: 3 Rationale 1: Cognitive and intellectual abilities change very little during this time. Rationale 2: Transition into middle life can be as critical as during adolescence. Some refer to the midlife crisis and call the decade between 35 and 45 years the deadline decade. Rationale 3: Physical capabilities and functions do decrease with age, but mental and social capacities actually increase in the latter part of life. Rationale 4: Cognitive and intellectual abilities change very little during this time.

Chapter 20 Question 1 The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the childrens health is the nurse assessing? 1. Development 2. Health 3. Growth 4. Bone size

Correct Answer: 3 Rationale 1: Development is an increase in the complexity of function and skill progression. It is the capacity and skill of a person to adapt to the environment. Rationale 2: Health is a dynamic process with varying definitions, all of which point to well-being. Rationale 3: Growth refers to physical change and increase in size. Indicators include height, weight, bone size, and dentition. Rationale 4: Bone size is one of the indicators of growth.

A young female client comes into the emergency department with vague physical symptoms and does not make eye contact with the nurse during the interview. In order to best assess the client, what should the nurse ask the client? 1. Can you tell me whats been going on in your life lately? 2. What kind of problems are you having? 3. Is someone hurting you? 4. Can you explain what your family life is like?

Correct Answer: 3 Rationale 1: Generalized questions about life do not adequately address the clients needs during this assessment. Rationale 2: Generalized questions about life problems do not adequately address the clients needs during this assessment. Rationale 3: A nurse who works with women should explicitly ask if the young adult is frightened or hurt by someone she knows. It is essential that nurses make assessment for domestic violence part of their routine. Rationale 4: Generalized questions about family life do not adequately address the clients needs during this assessment.

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included? 1. If the baby awakens at night, let him cry for a few minutes before responding. 2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him. 3. Respond to the babys needs promptly and consistently. 4. Use firm, loving discipline with the baby from the beginning.

Correct Answer: 3 Rationale 1: In order to develop self-esteem in their baby, parents should be taught to respond to the babys needs promptly and consistently. The baby should not be allowed to cry for extended periods of time at this age. Rationale 2: A 3-hour feeding schedule might work for some babies, but it should not be presented as the goal to a group of new parents because every baby is different. Rationale 3: In order to develop self-esteem in their baby, parents should be taught to respond to the babys needs promptly and consistently. Rationale 4: Babies do not need or respond to discipline.

The elderly client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. The nurse initially recognizes that these symptoms 1. indicate a concern and could be caused by cancer. 2. indicate the need for an upper and lower GI x-ray series. 3. could be related to normal changes in muscle tone and activity. 4. are probably indicative of a gastric ulcer or colitis.

Correct Answer: 3 Rationale 1: It would be premature, as well as outside the scope of nursing practice, for the nurse to consider any other pathology. Rationale 2: With the normal aging process, there is a decrease in muscle tone, digestive juices, and intestinal activity. These together may lead to indigestion and constipation in the older adult. It would be premature, as well as outside the scope of nursing practice, for the nurse to tell the client that there is a need for invasive testing. Rationale 3: With the normal aging process, there is a decrease in muscle tone, digestive juices, and intestinal activity. These together may lead to indigestion and constipation in the older adult. Rationale 4: It would be premature, as well as outside the scope of nursing practice, for the nurse to consider any other pathology.

A nurse is teaching a wellness class for older adults. In order to address the sensory loss that accompanies the aging process, the nurse should recommend that these clients take which action? 1. Use hearing aids and glasses. 2. Wear shaded glasses indoors to reduce glare. 3. Switch to brighter lighting in their home. 4. Exercise more and increase calcium intake.

Correct Answer: 3 Rationale 1: Not all elderly people need glasses or hearing aids. Rationale 2: Changes in vision associated with aging include loss of visual acuity, less power of adaptation to darkness and dim light, decrease in accommodation to near and far objects, loss of peripheral vision, and difficulty in discriminating similar colors. Wearing darker glasses will not increase the brightness of the home. Rationale 3: Changes in vision associated with aging include loss of visual acuity, less power of adaptation to darkness and dim light, decrease in accommodation to near and far objects, loss of peripheral vision, and difficulty in discriminating similar colors. Having brighter lighting in their home may help with some of these vision changes. Rationale 4: Exercise and nutrition do not address sensory problems.

A 30-year-old client who plans to travel extensively within the United States asks the nurse about appropriate immunizations. What should the nurse recommend to this client? 1. The client should have a tetanus booster if the client has not had one within the last 5 years. 2. The client should have the hepatitis B immunization series. 3. The client should receive a meningococcal vaccine if the client did not receive one as a teen. 4. The client should not worry about immunizations, as they are not recommended for this age group.

Correct Answer: 3 Rationale 1: Recommended immunizations for this age group include tetanus-diphtheria booster every 10 years. Rationale 2: The hepatitis B series would not be recommended for travel within the United States. Rationale 3: Recommended immunizations for this age group include the meningococcal vaccine if not given in early adolescence. Rationale 4: There are recommended immunizations for this age group.

A nurse educator believes that teaching students without caring about them is an exercise in futility. This educator also believes that in meeting the students needs, educators must also work to take care of themselves and care for their own needs. From which stage of Gilligans theory is the educator approaching the teaching of students? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

Correct Answer: 3 Rationale 1: Stage 1 is caring for oneself. Rationale 2: Stage 2 is caring for others. Rationale 3: Gilligans stage 3caring for self and othersis the last stage of development, where a person sees the need for a balance between caring for others and caring for the self. Rationale 4: Gilligan does not describe more than three stages in her theory.

A client recovering from a lumpectomy for breast cancer tells the nurse that she feels ugly. For which nursing diagnosis should the nurse plan interventions? 1. Powerlessness 2. Social Isolation 3. Grieving 4. Hopelessness

Correct Answer: 3 Rationale 1: The clients feelings of being ugly do not support the diagnosis of Powerlessness. Rationale 2: The clients feelings of being ugly do not support the diagnosis of Social Isolation. Rationale 3: The diagnosis Grieving is appropriate, because the client is expressing a feeling related to a change in physical appearance. Rationale 4: The clients feelings of being ugly do not support the diagnosis of Hopelessness.

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses self-concept along with information to use with clients. Why is the information for nurses important? 1. The nurses self-concept is more important than the clients. 2. Poor self-concept is the number-one reason for nursing burnout. 3. Nurses with positive self-concept are better able to help clients. 4. Nurses with poor self-concept are more likely to make errors.

Correct Answer: 3 Rationale 1: The nurses self-concept is not more important than the clients, but it is of equal importance in the nurseclient relationship. Rationale 2: There is no evidence that nurses with poor self-concept burn out earlier than nurses with good self-concept. Rationale 3: Nurses who have positive self-concept are better prepared to assist clients with their own understanding of needs, desires, feelings, and conflicts. Rationale 4: There is no evidence that nurses with poor self-concept make more errors than nurses with good self-concept.

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freuds theory of development, the nurse should suspect that this person would be fixated at which stage of development? 1. Phallic 2. Latency 3. Genital 4. Anal

Correct Answer: 3 Rationale 1: The phallic stage is from 4 to 6 years of age, and fixation would be related to the individuals genital organs and the pleasure sensations they create. Rationale 2: The latency stage is 6 years to puberty. Energy is directed to physical and intellectual activities. Sexual impulses tend to be repressed. Rationale 3: Freuds genital stage is characterized by energy that is directed toward full sexual maturity and function and development of skills needed to cope with the environment. It occurs during puberty and extends beyond. Implications of this stage include separation from parents, achievement of independence, and decision making. Fixation occurs at any stage and is the immobilization or the inability of the personality to proceed to the next stage because of anxiety. Rationale 4: The anal stage is from 11/2 to 3 years. The anus and bladder are the sources of pleasure (sensual satisfaction, self-control).

A client has been diagnosed with dementia. The family wants to know how to plan for the future. What is the best response by the nurse? 1. Your family members symptoms will get worse, but there are medications to stop the progress. 2. You should plan right now on which long-term care facility you will want to utilize when the time comes. 3. Dementia is a progressive deterioration. Its important for you to clearly understand what to look for in symptoms. 4. Dementia can be treated once the cause is known.

Correct Answer: 3 Rationale 1: There are no cures, but some medications may help to slow the progression. Rationale 2: Family members must be educated on the course of dementia and be encouraged to learn as much about coping skills as possible. Rationale 3: Dementia is a progressive loss of cognitive function. The most common type is Alzheimers disease. The cause is unknown. The most prominent symptoms are cognitive dysfunctions, including decline in memory, learning, attention, judgment, orientation, and language skills. Family members must be educated on the course of dementia and be encouraged to learn as much about coping skills as possible. Rationale 4: There are no cures, but some medications may help to slow the progression.

A client comes to the clinic with a history of pain in his testicle. During the interview assessment, what information should be of concern to the nurse? 1. The client works as an auto-detailer. 2. He smokes half a pack of cigarettes per week. 3. He has not had a yearly exam for 5 years. 4. He does not perform testicular self-exams.

Correct Answer: 3 Rationale 1: There is no current evidence to support such work as a risk factor for such symptoms. Rationale 2: There is no current evidence to support smoking as a risk factor for such symptoms. Rationale 3: Testicular cancer is the most common neoplasm in men between the ages of 20 and 34. Monthly testicular self-examination, a means of early identification of malignancy, used to be recommended for all men. More recent recommendations from the American Cancer Society (ACS) are that men should have a testicular exam as part of a yearly physical exam. Rationale 4: Men who have risk factors for testicular cancer should discuss monthly testicular self-examination with their primary care provider.

The adolescent male client who weighs 100 is considering taking some herbal stuff to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has 1. a strong need for admiration. 2. serious problems with logical thinking. 3. incongruence between reality and ideal self. 4. the need for referral to a psychologist.

Correct Answer: 3 Rationale 1: This cannot be determined by the information provided. Rationale 2: This cannot be determined by the information provided. Rationale 3: The nurse can determine that there is incongruence between reality and this clients ideal self. Rationale 4: This cannot be determined by the information provided.

Kozier & Erbs Fundamentals of Nursing, 10/E Chapter 39 Question 1 Which statement, made by the client, would indicate a me-centered self-concept? 1. I couldnt stand to disappoint my parents. 2. My sister is so much smarter than I am. 3. My future is based on the decisions I make today. 4. The world has always been against people like me.

Correct Answer: 3 Rationale 1: This statement reflects a high need for approval of others, which is not me-centered. Rationale 2: This statement reflects a comparison with others. Rationale 3: Individuals with a positive self-concept are me-centered and value how they perceive themselves over the opinions of others and have learned to depend on themselves. This is reflected in the statement, My future is based on the decisions I make today. Rationale 4: Other-centered persons compare themselves with others and often believe the world is against them. This outward focus results in a poorer self-concept.

A toddler shows fear and begins to cry when her parent leaves her at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? 1. Building wholesome attitudes toward oneself 2. Learning to get along with age-mates 3. Learning to relate emotionally 4. Achieving personal independence

Correct Answer: 3 Rationale 1: This task is part of the middle childhood age period and would not be appropriate for this child. Rationale 2: This task is part of the middle childhood age period and would not be appropriate for this child. Rationale 3: A toddler would be in the infancy and early childhood age period, in which learning to relate emotionally to parents, siblings, and other people is a developmental task. Rationale 4: This task is part of the middle childhood age period and would not be appropriate for this child.

When consulting Eriksons developmental theory, the nurse determines that which older adult will have the least difficulty being successful with the task of this stage? 1. A client who felt success through her childrens accomplishments 2. A client who held his job and work status as the defining feature of his life 3. A client who maintained a balance between work and home 4. A client who planned to really enjoy life once she retired

Correct Answer: 3 Rationale 1: Those who have been concerned only with the accomplishments of their children can be left with a feeling of emptiness when the children leave. Rationale 2: People who have been concerned only with the paycheck and their job status can be left with a feeling of emptiness when the job no longer exists. Rationale 3: People who learned early in life to live well-balanced and fulfilling lives are generally more successful in retirement. Rationale 4: People who attempt suddenly to refocus and enrich their lives at retirement usually have difficulty.

The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? 1. Vygotsky 2. Skinner 3. Kohlberg 4. Piaget

Correct Answer: 3 Rationale 1: Vygotsky explored the concept of cognitive development within a social, historical, and cultural context, arguing that adults guide children to learn and that development depends on the use of language, play, and extensive social interaction. Rationale 2: Skinners research led to the term operant conditioning, and most of his work was with laboratory animals. Rationale 3: Lawrence Kohlbergs theory specifically addresses the moral development of children and adults. Rationale 4: Piaget developed the cognitive theory of development.

A parent is concerned that her 5-year-old is beginning to masturbate. How should the nurse, familiar with Freuds stages of development, respond? 1. All children are curious, but make sure the child knows that this behavior might be offensive to others. 2. You should probably consult a child psychologist if youre this concerned. 3. Lets make sure to ask your physician at the next appointment. 4. This behavior is a normal part of your childs development.

Correct Answer: 4 Rationale 1: Assuring the parent that this is a normal part of development is the best response. Rationale 2: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the childs behavior is abnormal. Rationale 3: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the childs behavior is abnormal. Rationale 4: In the phallic stage, as described by Freud, which occurs from age 4 to 6 years, the childs genitals are the center of pleasure. Masturbation offers pleasure, and questions about sexual topics from parents are normal. Assuring the parent that this is a normal part of development is the best response.

The parents of an adolescent report that their child has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. They ask for the nurses professional opinion about the suitability of the punishment. Which answer best supports self-esteem development in this adolescent? 1. I think the punishment may be excessive. Have you talked with the school officials about the incident? 2. Because my expertise is in health, I really cant respond to your question. 3. Honesty and respect for authorities is important. I am surprised that the punishment is not more extensive. 4. Living with the consequences of your actions is a way to help the adolescent develop good self-esteem.

Correct Answer: 4 Rationale 1: Because the nurse does not have all the information, it would be a mistake to agree that the punishment is excessive. Rationale 2: The nurse does need to respond to these parents, even though the nurse may not have enough information to form an opinion about the situation. Rationale 3: Because the nurse does not have all the information, it would be a mistake to agree that the punishment should be more extensive. Rationale 4: One of the most important tasks of adolescence and a prime way to develop self-esteem is to take responsibility and to live with the consequences of actions.

The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40. According to recommendations from the American Cancer Society, the nurse should explain that it is important for these women to 1. do monthly breast self-exams. 2. have a yearly mammogram. 3. see a physician if there is a strong family history of breast cancer. 4. have an annual breast exam performed by a health care provider.

Correct Answer: 4 Rationale 1: Breast self-exam is no longer recommended for all women. Rationale 2: Yearly mammography for all women over the age of 40 is encouraged, as it decreases mortality from breast cancer. Rationale 3: Although a family history of breast cancer is a risk factor, it is not the sole reason to monitor for breast cancer. Rationale 4: The American Cancer Society recommends that a health care practitioner perform a breast examination at a yearly physical exam.

The nurse is preparing information for a community health education seminar. Which statement should the nurse include regarding disease for the middle-aged adult? 1. Cancer is the leading cause of death in the age group from 25 to 64 years. 2. Coronary heart disease is the leading cause of death. 3. Leading causes of death include suicide and motor vehicle crashes. 4. Injuries and chronic disease are the leading causes of death in this age group.

Correct Answer: 4 Rationale 1: Cancer is the second leading cause of death among people between the ages of 25 and 64 years. Rationale 2: Coronary heart disease is the leading cause of death among all age groups in the United States. Rationale 3: There is no evidence to support this statement regarding suicide. Rationale 4: Motor vehicle crashes as well as occupational injuries along with chronic disease such as cancer and cardiovascular disease combined make up the leading causes of death in the middle-aged adult group.

A parent is concerned that her child is unable to sit alone. The nurse explains that development is based on in-born timetables and the child will be most likely able to meet this milestone at a specific time. Upon which theory did the nurse base the response to the client? 1. Havighursts theory 2. Task theory 3. Psychosocial theory 4. Maturational theory

Correct Answer: 4 Rationale 1: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned. Rationale 2: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned. Rationale 3: Psychosocial theory is focused on the development of personality, not physical development. Rationale 4: The maturational theory (Arnold Gesell) postulates that child development is a maturational process based on an in-born timetable. Although children benefit from experience, they will achieve maturational milestones such as rolling over, sitting, and walking at specific times.

A client is being seen in the mental health clinic for antisocial behavior. According to Eriksons stages of development, the nurse realizes that this client is dealing with which task of development? 1. Initiative versus guilt 2. Industry versus inferiority 3. Intimacy versus isolation 4. Identity versus role confusion

Correct Answer: 4 Rationale 1: Initiative versus guilt is the late childhood stage and occurs from age 3 to 5 years. Industry versus inferiority occurs from 6 to 12 years, during the school-age stage. Rationale 2: Industry versus inferiority occurs from 6 to 12 years, during the school-age stage. Rationale 3: Intimacy versus isolation is the task during young adulthood and occurs from 18 to 25 years. Rationale 4: According to Erik Erikson, the adolescent stage is from 12 to 20 years and the central task is identity versus role confusion. Positive resolution indicates sense of self with plans to actualize ones abilities. Negative resolution indicates feelings of confusion, indecisiveness, and possible antisocial behavior.

An older male client comes to the clinic and states to the nurse that he hasnt been interested in sexual intercourse lately. He states: I guess this is part of getting old, too. What should the nurse explain about decreased sexual interest in older clients? 1. It does decrease and gradually disappears. 2. It should not be taken as seriously as it would be if the client were a younger person. 3. It is caused by decreased hormone activity and there is little that can be done about it. 4. It decreases but does not disappear.

Correct Answer: 4 Rationale 1: Libido may decrease but not disappear. Rationale 2: If an older man reports a loss in sexual interest, the nurse should be as concerned as when a younger man reports a loss of interest in sexual activity. Rationale 3: Decrease in hormone secretion and activity is a normal aging process, but there may be treatment measures that can help if this is the case. Rationale 4: The major age-related change in sexual response is timing. It takes longer to become sexually aroused, longer to complete intercourse, and longer before sexual arousal can occur again.

A nurse educator is working with students and assisting them in addressing their clients spiritual needs. The educator understands that most traditional, second-year college students are aware of their own spiritual development or working to develop their own system of spirituality. The educator realizes that the students are in which stage of Fowlers developmental theory? 1. Mythic-lyrical 2. Intuitive-projective 3. Universalizing 4. Individuating-reflexive

Correct Answer: 4 Rationale 1: Mythical-lyrical describes the person between ages 7 and 12, in a private world of fantasy and wonder. Rationale 2: The intuitive-projective stage, ages 4 to 6 years, is a combination of images and beliefs given by trusted others, mixed with the childs own experience and imagination. Rationale 3: Universalizing, which may never be reached by an individual, is a stage of becoming incarnate of the principles of love and justice. Rationale 4: Fowler describes this as a stage in which the person is constructing his or her own explicit system with a high degree of self-consciousness.

In the review of an elderly clients chart, the nurse reads that the client has sarcopenia. What should the nurse expect the client to report? 1. Weight loss and nausea 2. Hair loss and thin skin 3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily

Correct Answer: 4 Rationale 1: Sarcopenia is not generally related to weight loss or nausea. Rationale 2: Alopecia is loss of hair. Rationale 3: Thrombocytopenia may cause bleeding and bruising. Rationale 4: Sarcopenia is defined as a steady decrease in muscle fibers, a normal physiological change of aging. The age-related mechanism appears to be related to denervation of the muscle and causes elders to often complain about their lack of strength and how quickly they tire.

The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment? 1. Take detailed notes to record client responses. 2. Ask as many questions as possible to explore all areas of concern. 3. Start the interview by asking a series of yes/no questions. 4. Investigate the clients culture prior to the interview.

Correct Answer: 4 Rationale 1: Taking detailed notes to record client responses would not support an accurate assessment. Rationale 2: Asking many questions to explore all areas of concern does not support an accurate assessment. Rationale 3: Asking yes/no questions does not support an accurate assessment. Rationale 4: The nurse should consider how the clients behaviors are influenced by culture. In order to understand what is being said or seen, the nurse should investigate the clients culture prior to the interview.

A middle-aged client is struggling with life changes, including menopause. What is the best response by the nurse to this client? 1. Dont worrymenopause cant last forever. 2. There are some very good antidepressants you can take. 3. What did your mother do to get through menopause? 4. There is a menopause support group that meets every 2 weeks.

Correct Answer: 4 Rationale 1: Telling a client who is struggling not to worry is not therapeutic and does not address the problem. Rationale 2: Advice about medications is not within nurses scope of practice, as they do not prescribe. Rationale 3: Comparing this clients situation to her mothers is neither relevant nor therapeutic. Her mothers age group was going through experiences in a different time and culture. Rationale 4: Clients experiencing developmental stressors like menopause, the climacteric, aging, impending retirement, or any other situational stressors may experience anxiety and depression. These clients may benefit from support groups or individual therapy to help them cope with specific crises.

The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, I learn something new about nursing every day. What does this indicate about the mentors self-awareness? 1. This nurse is not very self-aware. 2. The mentors self-awareness is behind normal development. 3. Because this mentor has been a nurse for so long, self-awareness is no longer an important issue. 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

Correct Answer: 4 Rationale 1: The mentors comment about learning something new about nursing everyday demonstrates self-awareness. Rationale 2: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness. Rationale 3: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness. Rationale 4: Self-awareness takes time and energy and is never completed. This nurse is demonstrating desirable behavior in that there is still intellectual humility and a desire to learn.

A colleague is telling the community health nurse that his adult child has just moved back in with him and his wife. They are finding this situation somewhat difficult to adjust to. The nurse offers support and listens, while understanding that which factor is least likely contributing to this particular trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease

Correct Answer: 4 Rationale 1: These young adults, known as Boomerang Kids, have moved back into their parents homes after an initial period of independent living. A factor that has contributed to this trend is maladaptive behavior. Rationale 2: These young adults, known as Boomerang Kids, have moved back into their parents homes after an initial period of independent living. A factor that has contributed to this trend is high unemployment rates. Rationale 3: These young adults, known as Boomerang Kids, have moved back into their parents homes after an initial period of independent living. A factor that has contributed to this trend is high housing costs. Rationale 4: These young adults, known as Boomerang Kids, have moved back into their parents homes after an initial period of independent living. Chronic disease is not a factor that has contributed to this trend.

An older adult client comes to the clinic with reports of not being able to hold her urine, stating: I feel so terrible. This shouldnt happen at my age. How should the nurse respond? 1. You shouldnt feel badly. Lots of people have this trouble. 2. Youll probably have to start wearing incontinence briefs. Then you wont be worried about accidents. 3. Getting old isnt much fun, is it? 4. There could be a number of causes for this. I need to ask you some more questions about it.

Correct Answer: 4 Rationale 1: This option inappropriately attempts to minimize the clients concerns. Rationale 2: Incontinence briefs are useful products for people who have urinary incontinence (UI), but the cause for all cases must be investigated. Rationale 3: The client already feels badlythe nurse only makes this feeling worse by adding to it. Rationale 4: Elders may be susceptible to urinary incontinence (UI) because of changes in the kidneys and bladder. UI is never normal and the nurse must promptly investigate the cause, onset, and any other symptoms.