BN Ex 8

____ 7. According to the Uniform Determination of Death Act, which bodily function must be lost to declare death? 1) Consciousness 2) Brain stem function 3) Cephalic reflexes 4) Spontaneous respirations

2) Brain stem function According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.

____ 2. According to William Worden, which task in the grieving process takes longest to achieve? 1) Accepting that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy

1) Accepting that the loved one is gone Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.

____ 16. A patient reports experiencing gas, abdominal bloating, and diarrhea after consuming milk or cheese. Lactose intolerance might immediately be suspected if the patient is of which heritage? 1) African American 2) Mexican American 3) European American 4) Arab American

1) African American Lactose intolerance, caused by a deficiency of the enzyme lactase, is more commonly seen in African Americans than in the other cultural groups listed. Of course, one would assume lactose as the cause of the patients symptoms, but it would be important to rule it out.

____ 8. Which special consideration may the nurse need to make when caring for a female Rastafarian patient? 1) Allow the patient to wear her own clothing. 2) Provide a diet that is caffeine-free. 3) Allow the patient to wear jewelry with religious symbols. 4) Provide free-flowing water for bathing.

1) Allow the patient to wear her own clothing. Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible.

____ 6. Which of the following is considered a practice (as opposed to a belief or value)? 1) Always drinking water after exercise 2) Thinking often about cleanliness 3) Emphasis on success 4) Maintaining youth

1) Always drinking water after exercise A practice is a set of behaviors that one follows, such as always drinking water after exercise. Preoccupation with cleanliness, emphasis on success, and maintaining youth are examples of values that are dominant in United States culture.

____ 6. The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patients religion, for which religious rite should she expect to notify the hospital chaplain? 1) Anointing of the Sick 2) Baptism 3) Eucharist 4) Sacrament of Reconciliation

1) Anointing of the Sick In Catholicism, those who are seriously ill might want to receive the sacrament of Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typically administered to someone who is critically ill. Baptism may be offered when infants or children of Christian parents are critically ill.

____ 15. A patient of Scandinavian heritage is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically, without grimacing or vocalizing. The nurses thinking is an example of a/an 1) Archetype 2) Bias 3) Prejudice 4) Stereotype

1) Archetype An archetype is an example of a person or thingsomething that is recurrentand it has its basis in facts. Therefore, it becomes a symbol for remembering some of the culture specifics and is usually not negative. A bias is the tendency to see only one side of an issue, a lack of impartiality. Prejudice refers to negative attitudes toward other people that are based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on. A cultural stereotype is the unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects. Similar to biases, a stereotype may be positive or negative.

____ 13. Which dysrhythmia confirms death? 1) Asystole (absence of heart activity) 2) Pulseless electrical activity 3) Ventricular fibrillation 4) Ventricular tachycardia

1) Asystole (absence of heart activity) Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment.

____ 12. Which type of medicine do those of Hindu faith typically practice? 1) Ayurvedic medicine 2) Western medicine 3) Chiropractic medicine 4) Qigong

1) Ayurvedic medicine Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of hot and cold foods, which have nothing to do with temperature or degree of spiciness. People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is used to achieve healing through focus on the bodys energy centers.

____ 10. A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth

1) Bathing water Muslims may want water to wash the mouth, nostrils, and hands before praying. Roman Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious items.

____ 3. A family assessment should include the following areas. Choose all that apply. 1) Coping patterns 2) Health beliefs 3) Medical history 4) Physical exam

1) Coping patterns 2) Health beliefs Conducting a family assessment includes identifying the following: data; family composition; family history and developmental stage; environmental data; family structure; family function; health beliefs, values, and behaviors; family stressors and coping; and abuse and violence within the family. The medical history and physical exam of individuals are only relevant to the family assessment if it affects other family members.

____ 1. Which statement(s) about culture is/are true? Choose all that apply. 1) Culture exists on both material and nonmaterial levels. 2) Culture mainly influences food choices and special holidays. 3) Cultural customs change over time at different rates. 4) Culture is learned through life experiences shared by other cultural members.

1) Culture exists on both material and nonmaterial levels. 3) Cultural customs change over time at different rates. 4) Culture is learned through life experiences shared by other cultural members. Culture is learned through life experiences that are shared by other members of the culture, such as family members, those sharing similar religious beliefs, and people of similar cultural heritage in the same community. Culture exists at many levels that are both material and nonmaterial. Cultural customs, beliefs, attitudes, and practices are not static but change over time at different rates, depending on current events, other significant people, and social influences. Culture is all encompassing and affects everything its members think and do; it is not limited to food and holidays. Although those are visible manifestations of a culture, dietary practices and cultural calendars are not the essence of true and meaningful culture.

____ 25. An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about whether he should consent to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient? 1) Decisional Conflict 2) Death Anxiety 3) Powerlessness 4) Ineffective Denial

1) Decisional Conflict Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is uncertain about whether he should take the surgical risk. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is suffering from Death Anxiety at this time. Powerlessness is a perceived lack of control over a current situation; this patient is trying to exert some control over his care. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge.

____ 1. Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A life-long journey involving accumulation of experience and understanding 4) Codes of conduct that integrate beliefs and values

1) Discussions and theories related to God and His relation to the world Theology is best described as discussions and theories related to God and His relation to the world. Eschatology includes doctrines about the human soul and its relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values.

____ 27. The nurse caring for a patient admitted with severe depression identifies a nursing diagnosis of Hopelessness on the care plan. Which outcome is appropriate for this diagnosis? 1) Displays stabilization and control of mood 2) Sleeps 6 to 8 hours per night with report of feeling rested 3) Does not engage in risky, self-injurious behavior 4) Eats a well-balanced diet to prevent weight change

1) Displays stabilization and control of mood An outcome for the nursing diagnosis Hopelessness is displays stabilization and control of mood. Sleeps 6 to 8 hours per night and reports feeling rested and eats a well-balanced diet to prevent weight change are example of outcomes for the diagnosis Depressed Mood. Does not engage in risky, self-injurious behavior is an outcome for the nursing diagnosis Risk for Suicide.

____ 17. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing? 1) Environmental loss 2) Internal loss 3) Perceived loss 4) Psychological loss

1) Environmental loss This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them.

____ 15. Which nursing diagnosis is categorized as a psychosocial, rather than a self-concept, diagnosis? 1) Ineffective Individual Coping 2) Situational Low Self-Esteem 3) Disturbed Personal Identity 4) Disturbed Body Image

1) Ineffective Individual Coping Ineffective Individual Coping is considered a psychosocial nursing diagnosis. It implies poor life choices, inability to use available resources, and other interactional and relationship symptoms. The term psychosocial encompasses both psychological and social factors. The other diagnoses represent primarily individual, psychological factors. They are examples of self-concept nursing diagnoses.

____ 1. Which assessment finding(s) might suggest that the patient has low self-esteem and requires more in-depth assessment? Choose all that apply. 1) Infrequent eye contact 2) Straight posture 3) Overly critical of others 4) Careful grooming

1) Infrequent eye contact 3) Overly critical of others Assessment findings that suggest low self-esteem include avoiding eye contact and being overly critical of others. You would not need to follow up if the person displayed straight posture and careful grooming.

____ 2. A 65-year-old patient is admitted to the hospital with heart failure. The patients best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene? 1) Involve the friend and children in the patients care, discharge planning, and home care. 2) Encourage the friend to wait until discharge to provide care for the patient at home. 3) Explain to the friend that for confidentiality reasons she cannot be involved in the patients care. 4) Encourage liberal visiting hours by the friend and the patients children.

1) Involve the friend and children in the patients care, discharge planning, and home care. The nurse can best intervene by involving the friend and the patients children in the patients care, discharge planning, and home care. The friend may or may not be able to care for the patient at home. But if planning to provide home care, the patients friend should be informed of the patients needs while in the hospital and have an opportunity to participate prior to discharge. The nurse can involve the friend with the patients consent without infringing on the patients privacy. Her name needs to be listed on the patient privacy (HIPAA) form. The nurse should also encourage liberal visiting hours by the friend and the patients children if it is beneficial for the patients recovery; however, comprehensive involvement in care is more inclusive than simply liberalizing visiting hours and therefore is the best answer.

____ 4. A patient who came from Central America is admitted with diabetes mellitus. The nurse is collecting biographical information. Which information provided by the patient represents his ethnicity? 1) Latino 2) Catholic 3) White 4) Teacher

1) Latino Ethnicity refers to groups whose members share a common cultural heritage. This patient came from a Spanish-speaking country in Central America; therefore, his ethnicity is considered Latino. Catholic is his religion, white is his race, and teacher is his occupation.

____ 1. Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply. 1) Meeting the emotional needs of family members 2) Reinforcing ethical and moral values 3) Promoting joint decision making among parents and children 4) Being productive members of society

1) Meeting the emotional needs of family members 4) Being productive members of society Family functions outlined in the structural-functional family theory include being productive members of society, caring for elderly members, meeting physical and emotional needs of family members, and socialization of children. This model is more focused on the outcomes of family function than the process by which action occurs. Maintaining support for young adults as they leave the security of the family, reinforcing ethical and moral values, and promoting joint decision making among parents and children are examples of tasks outlined in family development theories.

____ 5. A 13-year-old patient is admitted to the hospital. There is no medical restriction on visitation. To help maintain the patients social identity while hospitalized, it is most important for the nurse to encourage visits by 1) Peers 2) Grandparents 3) Siblings 4) Parents

1) Peers Peers are more important than family in maintaining social identity in this age group.

____ 14. A Hispanic patient is frustrated because the healthcare team does not understand the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for this patient? 1) Powerlessness 2) Impaired Verbal Communication 3) Spiritual Distress 4) Risk for Noncompliance

1) Powerlessness Powerlessness is the best nursing diagnosis for the patient who is unable to make healthcare personnel understand the importance of his cultural beliefs. Impaired Verbal Communication can be used for patients who do not speak or understand the healthcare personnels language. Spiritual Distress might occur because a treatment is not in agreement with the patients religious beliefs. Risk for Noncompliance can be identified when a patient fails to follow a health-promoting or therapeutic plan the healthcare provider believes they agreed to.

____ 2. A homeless patient is admitted with an infected leg wound. According to Maslows hierarchy of needs, which nursing intervention meets one of his basic physiological needs? 1) Providing the patient with a dinner tray 2) Administering antibiotics as prescribed 3) Irrigating a wound with normal saline solution 4) Encouraging the patient to express his feelings

1) Providing the patient with a dinner tray According to Abraham Maslow and his hierarchy of needs, basic physiological needs, such as food, should be addressed first. After the patients basic needs are met, the nurse can provide wound care, administer antibiotics as prescribed (safety needs), and encourage the patient to express his feelings (love and belonging or self-actualization, depending on what feelings he expresses).

____ 30. An elderly patient admitted from a skilled nursing residence to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of dehydration. Which of the following should lead the nurse to suspect that dementia, rather than depression or dehydration, is the source of the symptoms? The history and nursing observations indicate that the patient 1) Rambles, speaks incoherently, and answers questions inappropriately 2) Speaks slowly with delayed response to questions but responds appropriately 3) Awakens early in the day yet sleeps almost constantly during the day 4) Sometimes has difficulty concentrating on details of the present situation

1) Rambles, speaks incoherently, and answers questions inappropriately In dementia, a patients language is disoriented, rambling, and incoherent and the patient responds to questions inappropriately or with near misses. Speaking slowly and being slow to respond to verbal stimuli are signs of depression, and in depression, the patient usually answers questions appropriately. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragmented and the person awakens often during the night. Difficulty concentrating on details is a thinking pattern seen more in depression; in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment.

____ 11. The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? An advance directive is a document 1) Specifying your healthcare intentions should you become unable to make self-directed decisions 2) Identifying the activities considered to be evidence of quality care 3) Verifying your understanding of the risks and benefits associated with a procedure 4) Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice

1) Specifying your healthcare intentions should you become unable to make self-directed decisions An advance directive is a group of instructions stating the patients healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patients understanding of risks and benefits associated with a procedure. An against medical advice form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient.

____ 13. A patient tells the nurse, I feel that God has abandoned me. I am so angry that I cant even pray. The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? 1) Spiritual Distress 2) Risk for Spiritual Distress 3) Impaired Religiosity 4) Moral Distress

1) Spiritual Distress This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action.

____ 12. A 17-year-old patient sustained facial fractures and a 6-inch laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her looking this way. Which statement by the nurse is most appropriate? 1) Tell me what you mean by looking this way. 2) OK, Ill restrict your visitors until your face heals. 3) Your friends and family love you no matter what. 4) Youre young; your face will heal quickly.

1) Tell me what you mean by looking this way. Tell me what you mean . . . encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assume that the patient is talking about her facial wounds. Ill restrict your visitors . . . assumes that the patient is speaking about her facial wounds when she might not be. The other options are examples of false reassurance and do not address the patients concerns.

____ 4. A 13-year-old girl is admitted to the adolescent unit with acute leukemia. The patient has a support system that includes her brother, sister, mother, father, and grandmother as well as members of her local community. Which component of her support system is considered a suprasystem? 1) The community 2) The parents 3) Her mother 4) Her sister

1) The community Her surrounding community is considered a suprasystem because it is larger than the family system. Subsystems within the family include the parents, mother, siblings, sister, brother, father, and grandmother; they are smaller components that fit within the family system.

____ 7. The nurse is caring for a group of patients on the medical-surgical unit. Which patient is most likely to experience the most difficulty in adapting to a change in body image? The patient 1) Who suffered a traumatic amputation of the left leg in an industrial accident 2) With hypothyroidism who has coarse, dry, thinning hair and weight gain 3) Who is obese and who underwent gastric bypass surgery 4) With peripheral vascular disease who required a wound graft

1) Who suffered a traumatic amputation of the left leg in an industrial accident Theoretically, the patient who suffered a traumatic amputation in an industrial accident will most likely have more difficulty adjusting to his change in body image because the change occurred abruptly. The patients described in the other options will naturally have some difficulty adjusting to their body image change, but it should not be as great because the physical changes are more gradual, which allows for adaptation over time.

____ 5. The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking 2) Availability of community resources 3) Adherence to a low-fat diet 4) Importance of physical exercise

2) Availability of community resources When teaching the family of an older adult, the nurse should include information about community resources that are available, especially when caring for chronically ill, disabled, or elderly family members. Middle-age adults typically begin experiencing signs and symptoms associated with long-standing, unhealthy behaviors. Therefore, consuming a low-fat diet and limiting the intake of alcohol and tobacco are likely appropriate topics to include in the teaching plan for a middle-aged adult. Physical exercise and activity promote the quality of life. Careful planning is necessary to ensure safety and well-being for the family member with memory loss, confusion, and disorientation.

____ 3. Which of the following can the nurse assess using Erik Eriksons theory? 1) Moral development 2) Developmental tasks 3) Social identity 4) Self-esteem

2) Developmental tasks Using Eriksons theory, the nurse can assess for successful completion of developmental tasks. The theory does not help the nurse assess social identity or self-esteem. However, these factors are components of developmental tasks that Eriksons theory explores. Moral development was addressed in the Kohlbergs theory.

____ 2. The nurse is caring for a patient of Japanese heritage who refuses pain medication despite the nurses explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. 1) Assess the patients pain levels at less frequent intervals. 2) Document in the patients record that the patient does not want to take opioids. 3) Utilize nonpharmacological measures to help control the patients pain. 4) Notify the primary care provider of the patients noncompliance.

2) Document in the patients record that the patient does not want to take opioids. 3) Utilize nonpharmacological measures to help control the patients pain. Patients of Japanese heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that they improve the healing process. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patients wishes and utilize nonpharmacological measures to control pain. The nurse should document that the patient wishes to avoid opioid use in the nurses notes. The nurse should continue to assess pain levels in this patient at the same frequency as before. She should recognize and respect his cultural beliefs and not label him as noncompliant. Note that the same intervention would be appropriate for any patient in this situation, not just a Japanese patient.

____ 2. Which of the following suggest that a family health problem may exist? Select all that apply. Family members 1) Respect each others need for privacy 2) Enact decisions made by the most powerful member 3) Do not consider a conflict resolved until everyone agrees 4) Set boundaries between family members

2) Enact decisions made by the most powerful member 3) Do not consider a conflict resolved until everyone agrees Respect for privacy and clear boundaries between family members are characteristics of a healthy family. Boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. In healthy families, there is typically egalitarian distribution of power. In healthy families, it is not always necessary for all members to agree; instead, they have the ability to compromise and members feel free to disagree.

____ 21. A 73-year-old patient was admitted with a perforated bowel. Following surgical repair, he developed complications and required an extensive stay in the hospital. How can the medical-surgical nurse best promote self-esteem in this patient? 1) Assist the patient to ambulate in the hallway once daily. 2) Encourage the patient to participate in self-care. 3) Introduce herself to the patient if he does not know her. 4) Listen attentively when the patient speaks.

2) Encourage the patient to participate in self-care. Encouraging the patient to his accomplish own self-care, such as bathing and brushing his teeth, encourages independence and promotes self-esteem. Assisting the patient to ambulate in the hallway prevents complications of immobility. Introducing yourself and listening attentively to the patient prevents depersonalization.

____ 15. North American healthcare culture typically reflects which culture? 1) Asian 2) European American 3) Latino 4) African American

2) European American Although the demographics are changing in this recent decade with increasing Hispanic and Asian inhabitants, North American healthcare culture typically reflects the dominant (European American) culture because most healthcare providers belong to that culture.

____ 4. A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? 1) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2) Explore with the patient her beliefs and determine which might have caused her to make this statement. 3) Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4) Comply with the patients request and assign a female nurse to care for the patient.

2) Explore with the patient her beliefs and determine which might have caused her to make this statement. The charge nurse can best serve the patient and her staff by exploring the patients beliefs that might prevent her from being cared for by a male. There are many reasons the woman may prefer a female nurse: she may be very modest, or she may be prejudiced against male nurses, for example. Hospital policy might state that, to prevent discrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, even if this is so, before explaining this to the patient, the charge nurse should explore the patients beliefs and make special arrangements with hospital administration to uphold the patients beliefs, if possible. Telling the patient that each nurse is capable of providing care is not sensitive to the patient and her beliefs. Simply complying with the patients wishes without further investigation may alienate the nursing staff.

____ 3. The nurse is caring for a 42-year-old Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patients discharge? 1) Ethnic background 2) Family support 3) Employment status 4) Healthcare coverage

2) Family support The nurse should focus on the patients strengths and resources for health restoration and self-care. In this case, that is the patients family. His family can be a great support for him when he is discharged (e.g., preparing healthy meals, helping him manage exercise and treatment regimens). Although the patients ethnic background is very important to his care, discharge planning should revolve around his available resources. Insurance should not be the focus at this time, although at some point the nurse has probably obtained data about these topics.

____ 26. Which nursing intervention specifically helps reduce a patients anxiety? 1) Teaching the importance of adequate nutrition and hydration 2) Giving clear fact pertaining to the patients circumstances 3) Promoting small-group activities to improve self-esteem 4) Monitoring the patient for the risk of suicide

2) Giving clear fact pertaining to the patients circumstances Using clear and factual knowledge that is tailored to the patients circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promoting small-group activities to improve self-esteem, and monitoring the patient for suicide risk are interventions designed to help the patient with depression.

____ 7. Which question helps the nurse to assess family structure? 1) Where does your family live? 2) How are family decisions made? 3) With which religious affiliation is your family associated? 4) What is your ethnic background?

2) How are family decisions made? Asking how family decisions are made helps the nurse to assess family structure. Asking about religious affiliation, ethnic background, and where the family lives provides identifying data but does not reveal lines of authority and relationships among family members.

____ 13. A patient who had surgery 8 hours ago has not voided. The nurse notifies the physician for an order to insert an indwelling urinary catheter. Which of the following statements should the nurse use to describe the procedure to the patient? 1) I need to put a Foley in you because you havent voided since your surgical procedure. 2) I need to insert a tube into your bladder to drain the urine because you havent urinated since surgery. 3) I need to catheterize you because you havent urinated since having your surgery. 4) I need to place a catheter in your bladder because you havent voided since surgery.

2) I need to insert a tube into your bladder to drain the urine because you havent urinated since surgery. I need to insert a tube into your bladder . . . best describes the procedure for the patient because the explanation is in terms most patients will understand. The other options contain medical jargon that could confuse the patient.

____ 13. A patient has recently had a change in a family relationship that is greatly affecting his health. Which nursing diagnosis could you probably make for this patient? 1) Parental Role Conflict 2) Interrupted Family Processes 3) Compromised Family Coping 4) Ineffective Individual Coping

2) Interrupted Family Processes Interrupted Family Processes is defined as a change in a family relationship significantly affecting a patients health. Parental Role Conflict occurs when significant role confusion by a parent results in response to crises. Compromised Family Coping occurs when support from a usual family member is compromised or disabled, causing a significant health challenge. Ineffective Individual Coping occurs when the patient is unable to comprehend and effectively judge stressors.

____ 2. Which of the following is considered a religious denomination within the tradition of Christianity? 1) Buddhism 2) Jehovahs Witnesses 3) Sikhism 4) Islam

2) Jehovahs Witnesses Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, and Islam are all religious traditions outside of Christianity.

____ 1. A patient has a nursing diagnosis of Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications. The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with healthcare therapy? (Choose all that apply.) The patient says 1) I will try to pray more often for stronger faith that God will heal me. 2) Let me think about it until tomorrow; I may see my way to taking those pills then. 3) You know, Ive known some very holy people who were not cured by God. 4) There is no confusion in my mind as to the right thing for me to do.

2) Let me think about it until tomorrow; I may see my way to taking those pills then. 3) You know, Ive known some very holy people who were not cured by God. Agreeing to consider treatment (think about it) and recognizing that sometimes faithful people are not cured both suggest that the patient is at least considering that it is all right for her to question her beliefs. Praying for stronger faith in Gods healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith. Having no confusion about the right thing to do would be evidence of problem resolution, provided the right thing to do is to take the medication. However, you need more information to know if that is what the patient means. It could just as easily mean that she is more sure than ever that she should not take the medication.

____ 2. Which intervention(s) by the nurse might help the patient maintain a sense of personhood during hospitalization? Assume that all are culturally appropriate. Choose all that apply. 1) Addressing the patient by his first name 2) Making eye contact if it is comfortable for the patient 3) Always offering an explanation before beginning a procedure 4) Speaking to others about the patient so that the patient can hear you

2) Making eye contact if it is comfortable for the patient 3) Always offering an explanation before beginning a procedure The nurse can help the patient maintain a sense of personhood by addressing him by his preferred name, which might be his first name or might be his surname with title. Using eye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the room are additional ways for the nurse to offer care that respects patient rights.

____ 7. The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the 1) Practices of the patients ethnic group 2) Patients individual cultural beliefs 3) Values of her own culture 4) Spanish-speaking community

2) Patients individual cultural beliefs The nurse cares for this patient by becoming familiar with the patients individual cultural and ethnic beliefs and values. It is helpful to become familiar with the patients ethnic group and the Spanish-speaking community; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as his ethnic group or community. The nurse should explore her own culture but not assume that the patient holds those same beliefs and practices.

____ 3. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frail elderly 4) Family with teenagers and young adults

2) Postparental family This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their children moving into phases of adulthood. In the stage of family launching young adults, the parents maintain support of young adults as they leave the security of family and the parents rediscover marriage. During the stage of family with teenagers and young adults, open communication is maintained among family members, ethical and moral values are reinforced, and there is a balance established between rules and independence among teens.

____ 17. Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will 1) Request pain medication when needed 2) Report or demonstrate satisfactory pain control 3) Use only nonpharmacological measures to control pain 4) Verbalize understanding that it may not be possible to control his pain

2) Report or demonstrate satisfactory pain control The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an as needed basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain-control medications are available and can be administered by several routes; it should be possible to control the pain.

____ 10. The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patients indigenous healthcare system and should be included in the plan of care? 1) Asking the family to bring in medals and amulets 2) Scheduling a visit from the shaman 3) Providing the patient with her favorite herbal tea 4) Requesting that the physician consult the patients acupuncturist

2) Scheduling a visit from the shaman For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea and medals and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. Asians and Pacific Islanders might benefit from a visit by the acupuncturist.

____ 11. A patient undergoing fertility treatments for the past 9 months learns that despite in vitro fertilization she still is not pregnant. This patient is at risk for experiencing a crisis in which component of self-concept? 1) Body image 2) Self-esteem 3) Personal identity 4) Role performance

2) Self-esteem Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem. The patient is not at risk for experiencing a crisis in body image, personal identity, or role performance.

____ 17. A patient who lost his job last month has now been told that his wife wants a divorce. He says, I know I dont have much to offer a woman. She wants more than what I am, and now Im not even bringing home any money. Which nursing diagnosis is most appropriate? 1) Chronic Low Self-Esteem 2) Situational Low Self-Esteem 3) Disturbed Personal Identity 4) Disturbed Body Image

2) Situational Low Self-Esteem Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of a job and a marriage). There are no data to indicate long-standing (Chronic) Low Self-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself.

____ 5. Which patient is at most risk for experiencing difficult grieving? 1) The middle-aged woman whose grandmother died of advanced Parkinsons disease 2) The young adult with three small children whose wife died suddenly in an accident 3) The middle-aged person whose spouse suffered a slow, painful death 4) The older adult whose spouse died of complications of chronic renal disease

2) The young adult with three small children whose wife died suddenly in an accident Although it is impossible to predict with certainty and the grieving process is highly individual and personal, in general those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g., cancer) have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs.

____ 18. When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? 1) To prevent blood from settling in the head, neck, and shoulders 2) To perform these actions more easily before rigor mortis develops 3) To set the mouth in a natural position for viewing by the family 4) To prevent discoloration caused by blood settling in the facial area

2) To perform these actions more easily before rigor mortis develops Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patients eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patients mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area.

____ 16. Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a death rattle? 1) Perform nasotracheal suctioning of secretions. 2) Turn the patient on his side and raise the head of the bed. 3) Insert a nasopharyngeal airway as needed. 4) Administer morphine sulfate intravenously.

2) Turn the patient on his side and raise the head of the bed. If a death rattle occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a death rattle and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a death rattle. This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest.

____ 14. The nurse is updating a care plan for a patient who has a nursing diagnosis of Anxiety. Which patient behavior might suggest that the problem is resolving? 1) Pacing in the hallway at intervals 2) Using relaxation techniques 3) Speaking rapidly when spoken to 4) Avoiding eye contact

2) Using relaxation techniques Using relaxation techniques might suggest that the patients anxiety is resolving. Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the patient. The patients use of relaxation techniques indicates problem solving by the patient.

____ 12. A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patients condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? 1) Ill call your physician right away so he can discuss this with you. 2) You have the right to change your decision about treatment at any time. 3) Are you sure you want to change your decision? 4) We must follow whatever is written in your living will.

2) You have the right to change your decision about treatment at any time. The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patients decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patients decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.

____ 8. A patients wife tells the nurse that she wants to be with her husband when he dies. The patients respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? 1) Certainly, go ahead; your husband will most likely hold on until you return. 2) Your husband could live for days or a few hours; you should do whatever you are comfortable with. 3) You need to take care of yourself; go home and shower, and Ill stay at his bedside while you are gone. 4) Dont worry. Your husband is in good hands; Ill look out for him.

2) Your husband could live for days or a few hours; you should do whatever you are comfortable with. The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husbands bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wifes return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wifes concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death.

____ 9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur 1) Moments before death 2) Days to hours before death 3) 1 to 2 weeks before death 4) 1 to 3 months before death

3) 1 to 2 weeks before death Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.

____ 5. A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing 1) Assimilation 2) Socialization 3) Acculturation 4) Immigration

3) Acculturation This patient is experiencing acculturation; she has accepted both her own and the new culture and has incorporated elements of both into her life. Socialization is the process of learning to become a member of a society or group. Cultural assimilation occurs when the new member gradually learns and takes on, to a great extent, the dominant cultures values, beliefs, and behaviors. Immigration is the act of moving to a new country.

____ 10. Which intervention takes priority for the patient receiving hospice care? 1) Turning and repositioning the patient every 2 hours 2) Assisting the patient out of bed into a chair twice a day 3) Administering pain medication to keep the patient comfortable 4) Providing the patient with small frequent, nutritious meals

3) Administering pain medication to keep the patient comfortable A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the bodys need for nutrition and hydration is reduced as the body begins the desiccation process.

____ 8. Which individual is most likely to have a positive body image? 1) Child who has been deaf since birth 2) Child who was born with cystic fibrosis 3) Adolescent of average appearance who had an appendectomy 4) Adult born with a spinal defect and associated paralysis of the lower body

3) Adolescent of average appearance who had an appendectomy The adolescent with average appearance who had an appendectomy is likely to have a positive body image because the adolescent suffered an acute, reversible illness. Those born with physical handicaps are less likely to have a positive body image because many times the handicap leaves them socially isolated. This is, of course, not to imply that no one born with a physical handicap has a positive body image; and, of course, a particular adolescents body image might suffer after an appendectomy. However, the question asks which is most likely based on theoretical knowledge of body image.

____ 13. Which of the following is considered a strength of the nursing profession? 1) Biomedical focus 2) Psychosocial focus 3) Biopsychosocial focus 4) Physical focus

3) Biopsychosocial focus A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient.

____ 14. A 12-year-old patients mother recently married a man who has a 13-year-old daughter. The nurse recognizes that the patient belongs to which type of family? 1) Extended 2) Traditional 3) Blended 4) Nuclear

3) Blended The patient belongs to a blended family; in which two single parents marry and raise their children together. An extended family may contain grandparents, aunts, uncles, cousins, and other biological relatives. A traditional, or nuclear, family contains a husband, wife, and their children.

____ 14. A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, I just cant make up my mind about it. Which nursing diagnosis is most appropriate for this patient? 1) Deficient Knowledge 2) Spiritual Distress 3) Decisional Conflict 4) Death Anxiety

3) Decisional Conflict This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict.

____ 2. A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? 1) A belief in taboos against narcotic use to relieve pain 2) Expectation of immediate treatment for relief of pain 3) Endurance of pain longer and report it less frequently than some patients do 4) Use of herbal teas, heat application, and prayers to manage his pain

3) Endurance of pain longer and report it less frequently than some patients do In general, patients of Mexican heritage may endure pain longer and report it less frequently than some. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes and are not necessarily true for all members of a cultural group.

____ 19. How should the nurse respond to a family immediately after a patient dies? 1) Ask the family to leave the patients room so postmortem care can be performed. 2) Leave tubes and IV lines in place until the family has the opportunity to view the body. 3) Express sympathy to the family (e.g., I am sorry for your loss). 4) Tell the family that they will have limited time with their loved one.

3) Express sympathy to the family (e.g., I am sorry for your loss). The nurse should express sympathy to the family immediately after the patients death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready.

____ 22. The nurse is developing a plan of care for a mother of three small children who has been admitted with a serious acute illness, which is likely to continue long term. The nurse writes the following intervention: Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness. The purpose of this intervention is to help 1) Promote self-esteem 2) Promote positive body image 3) Facilitate role enhancement 4) Prevent depersonalization

3) Facilitate role enhancement Facilitating communication between the patient and significant other regarding sharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. The intervention is not designed to promote self-esteem or positive body image or to prevent depersonalization.

____ 8. The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present oriented? 1) I know I need to lose weight; Ill have to begin an exercise program right away. 2) If I change my diet and begin exercising, maybe I can control my blood pressure without medications. 3) I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult. 4) I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke.

3) I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult. Knowing an action is needed but giving reasons for not beginning it just now shows a focus on the present. The patient knows that he should reduce his sodium intake, but his present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future oriented because they indicate that the patient is planning lifestyle changes that will affect his future.

____ 16. Which statement by the nurse is best when communicating with a patient with clinical depression? 1) Its a beautiful day today; youll feel better if you look out the window. 2) Youre having a bad day; Im sure youll feel better soon. 3) Life seems overwhelming at times; would you like to discuss how youre feeling? 4) You are very lucky to have such a supportive family.

3) Life seems overwhelming at times; would you like to discuss how youre feeling? When caring for a patient with depression, the nurse should encourage the patient to discuss his feelings. Its a beautiful day . . . and Youre having a bad day . . . offer false reassurance. It would not be therapeutic to say, You are very lucky . . .; that is offering a judgment.

____ 4. Which statement best describes self-concept? An individuals 1) Understanding of how others perceive him 2) Evaluation of himself 3) Overall view of himself 4) Perspective of his role in society

3) Overall view of himself Self-concept is an individuals overall view of himself. The overall view includes his evaluation of himself and how he thinks others evaluate him.

____ 11. When performing a spiritual assessment, who is the preferred source of information? 1) Durable power of attorney 2) Next of kin 3) Patient 4) Patients clergyman

3) Patient The patient is the preferred source of information. In the event of an emergency admission or when a patient cannot give information, the nurse can consult the next of kin or the durable power of attorney for information about the patients spirituality. Contacting the clergyman without the patients permission is a breach of patient confidentiality.

____ 6. Which factor is related to the increased risk of acquiring polio in the United States after the disease was thought to be eradicated? 1) Lack of health insurance 2) Bioterrorism 3) Reduced compliance with vaccinations 4) Drug resistance

3) Reduced compliance with vaccinations Reduced compliance with community immunization in the United States increases the risk for diseases, such as polio, that were thought to be eradicated. For vaccines to be effective, the population needs to receive them. Bioterrorism involves the introduction of a highly infectious microbe for which there is no protection to the population. Polio is not such a threat because immunization is available. Vaccinations are available through governmental programs for those who do not have health insurance. Drug resistance has led to the reemergence of tuberculosis, which was previously cured with antibiotics.

____ 23. A patient comes to the emergency department complaining of headache, palpitations, nausea, and dizziness. After determining that the patient is anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting? 1) Mild anxiety 2) Moderate anxiety 3) Severe anxiety 4) Panic anxiety

3) Severe anxiety The patient experiencing severe anxiety may experience physical symptoms including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. The patient experiencing moderate anxiety might experience a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. The patient suffering from panic anxiety might believe he has a life-threatening illness. Physical symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements.

____ 12. An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states I dont want a man taking care of me. Which cultural barrier is this patient exhibiting? 1) Ethnocentrism 2) Racism 3) Sexism 4) Chauvinism

3) Sexism This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased toward their own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior.

____ 20. The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child? 1) Take the child to the funeral even if he is frightened. 2) Notify the physician immediately if the child shows signs of regression. 3) Spend as much time as possible with the child. 4) Provide distraction whenever the child begins to express feelings of sadness.

3) Spend as much time as possible with the child. The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears.

____ 14. The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and not important in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement? 1) Spiritual Support 2) Self-Esteem Enhancement 3) Values Clarification 4) Hope Inspiration

3) Values Clarification One of the steps of most values-clarification processes is to list values (what is important and not important in ones life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although it can indirectly contribute to development of spiritual identity.

____ 21. Which intervention should be included in the plan of care for a patient in the end-stage death process? 1) Encourage the patient to accept as much help as possible. 2) Avoid administering laxatives. 3) Wet the lips and mouth frequently. 4) Administer pain medication on an as-needed basis.

3) Wet the lips and mouth frequently. If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.

____ 8. Which family member is most likely to be disabled? 1) 60-year-old African American male 2) 65-year-old Asian male 3) 70-year-old Caucasian female 4) 75-year-old Native American female

4) 75-year-old Native American female Slightly more females (15.6%) than males (14.4%) reported a disability. In 2006, the prevalence of disability was lowest for persons ages 16 to 20 (6.9%) and highest for those 75 years and older (52.6%). Disability differs by ethnic group. Asians reported 6.3%, Caucasians 12.7%, African Americans 17.5%, Native Americans 21.7%, and persons of other ethnic backgrounds reported 11.9% disability. Therefore, the prevalence of disability would be highest in a female Native American who is 75 years or older.

____ 9. A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as 1) A punishment for immoral behavior 2) A part of life 3) Best treated with herbal teas and prayer 4) A virtue and a matter of family honor

4) A virtue and a matter of family honor Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarily apply to all members of a cultural group.

____ 11. A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? 1) Use of herbs and roots 2) Application of oils and poultices 3) Burning of dried plants 4) Acupuncture

4) Acupuncture Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects.

____ 5. A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patients religious affiliation, which of the following actions should the nurse take? 1) Administer the medication as prescribed. 2) Hold the medication until after Yom Kippur. 3) Explain the importance of taking the medication despite the holiday. 4) Ask the physician to change the route of administration.

4) Ask the physician to change the route of administration. Orthodox Jews require an alternative to the oral route of drug administration on Yom Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician to change the route of administration. Administering the medication as prescribed breaks the patients religious tradition on the holiest day of the Jewish calendar. Holding the medication until after Yom Kippur delays treatment and may cause harm to the patient; furthermore, it is not within the scope of nursing practice to hold medications that have been prescribed by a physician. The nurse should explain the importance of the medication in any case; but the nurse should not try to convince the patient to break away from his religious tradition when an alternative route of administration is available.

____ 19. A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis? 1) Decision Making 2) Distorted Thought Content 3) Role Performance 4) Depression Level

4) Depression Level Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis Chronic Low Self-Esteem. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem, Role Performance with Ineffective Role Performance, and Distorted Thought Content with Disturbed Personal Identity. Although the other options might contribute to the patients low self-esteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate resolution of the nursing diagnosis. Decision Making is the only outcome that does that.

____ 9. What is the most effective action by the nurse when delivering spiritual care to a patient of the same religion as the nurse? 1) Understanding that the patient shares the same beliefs 2) Striving to meet the patients spiritual needs independently 3) Explaining her own religious beliefs to the patient 4) Developing a greater awareness of her own spirituality

4) Developing a greater awareness of her own spirituality The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patients spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient.

____ 3. What emotional response is typical during the Randos confrontation phase of the grieving process? 1) Anger and bargaining 2) Shock with disbelief 3) Denial 4) Emotional upset

4) Emotional upset During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities.

____ 15. Which nursing intervention should be included in the plan of care for a patient dying of cancer? 1) Encourage at least one family member to remain at the bedside at all times. 2) Follow-up with other healthcare team members during weekly meetings. 3) Avoid discussing the dying process with family (to reduce sadness). 4) Encourage family members to participate in care of the patient when possible.

4) Encourage family members to participate in care of the patient when possible. The plan of care should include encouraging family members to help with the patients care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns.

____ 18. The nurse is updating the care plan of a patient who must undergo a right mastectomy for breast cancer. Which nursing diagnosis should the nurse anticipate in expectation of the body changes associated with the upcoming surgery? 1) Deficient Knowledge 2) Impaired Adjustment 3) Hopelessness 4) Grieving

4) Grieving Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associated with the expected body changes associated with the upcoming surgery, although they could certainly occur.

____ 10. Which statement best describes self-esteem? 1) View of oneself as a unique human being 2) Ones mental image of ones physical self 3) Ones overall view of oneself 4) How well one likes oneself

4) How well one likes oneself Personal identity is ones view of oneself as a unique human being. Body image is described as ones mental image of ones physical self. Self-concept is defined as ones overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect.

____ 6. Which response by the patient demonstrates an internal locus of control? 1) My blood sugar wouldnt be out of control if my wife prepared better foods. 2) I knew I shouldnt have come to this hospital; Id be better if I hadnt. 3) God must be getting even with me for my past behavior. 4) Im just glad to be alive; the accident couldve been a lot worse.

4) Im just glad to be alive; the accident couldve been a lot worse. People who demonstrate an internal locus of control take responsibility for their life experiences and their responses to them. This allows them to interpret unexpected events in a positive light, as the response the accident couldve been a lot worse illustrates. The other options demonstrate an external locus of control; control of the situation is attributed to external factors.

____ 9. A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following? 1) Role strain 2) Interpersonal role conflict 3) Role performance 4) Inter-role conflict

4) Inter-role conflict The patients wife is most likely experiencing inter-role conflict, in which her role as a mother and worker are making competing demands on her. Role strain is a mismatch between role expectations and role performance. Interpersonal role conflict results when another persons idea about how a role should be performed differs from that of the person who is performing the role. Role performance is defined as the actions a person takes and the behaviors he demonstrates in performing a role.

____ 29. A frail, elderly patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. What is most important for the nurse do? 1) Recognize these symptoms as signs of normal, physiologic aging. 2) Obtain a urine specimen before notifying the primary care provider. 3) Be sure she is placed in a room occupied with another patient. 4) Interview the patient to screen for clinical depression.

4) Interview the patient to screen for clinical depression. Depression is often masked in older adults and expressed as physical and personality changes. Memory loss and confusion are also common symptoms of depression in older adults. Any one of the symptoms might occur as a result of physical illness, but the combination should prompt the nurse to suspect depression and interview and screen for it before exploring physiological causes for the symptom (as with a urine specimen). Placing the patient with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes.

____ 7. Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with 1) Islam 2) Bahai 3) Hinduism 4) Jehovahs Witness

4) Jehovahs Witness Those of Jehovahs Witness faith believe that taking blood into ones body is morally wrong. Therefore, they will not consent to transfusions of whole blood or its components. Those of Islam, Bahai, and Hindu faith will, as a rule, consent to blood transfusion.

____ 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate? 1) Delayed 2) Chronic 3) Disenfranchised 4) Masked

4) Masked Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported.

____ 20. The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which of the following is an example of an individualized goal for that patient? 1) Distorted Thought Control 2) Anxiety Level 3) Self-Mutilation Restraint 4) No Self-Injury, Consistently Demonstrated

4) No Self-Injury, Consistently Demonstrated No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. The other options are examples of NOC outcomes; they are not written as goals.

____ 24. The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells the nurse that he is often short of breath and says, I lie awake nights worrying about everything. He has been unable to work or care for his family for the past 6 months. What is the nurses priority after documenting this information in the nurses notes? 1) Provide emotional support for the patient using reflective listening technique. 2) Do nothing; people with duodenal ulcers typically cannot work. 3) Question the patients family about the information received from the patient. 4) Notify the primary care provider and ask for a referral to a mental health professional.

4) Notify the primary care provider and ask for a referral to a mental health professional. The nurse should involve a mental health professional immediately, because the patient is exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. Doing nothing is neglectful. Questioning the patients family about the information violates the patients right to privacy, unless the nurse obtains the patients permission to do so.

____ 4. An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate? 1) Shock and numbness 2) Yearning and searching 3) Disorganization and despair 4) Reorganization

4) Reorganization According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.

____ 3. Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or gods 3) Rules prohibiting alcohol consumption 4) Sacred writings that reveal the nature of the Supreme Being

4) Sacred writings that reveal the nature of the Supreme Being Many of the world religions have sacred writings that are authoritative and reveal the nature of the Supreme Being. Mormons follow a strict health code, which advises healthful living. Islam means submission; therefore people of Islamic faith submit to Allah. Some religions, such as Mormon, Christian Science, Bahai, and Sikhism, prohibit alcohol consumption, but many other religions permit it.

____ 15. The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the following actions by the nurse is appropriate? 1) Offer a prayer for healing using the nurses usual words and format. 2) Begin the prayer with Jehovah God as she always does while avoiding the name of Jesus. 3) Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer. 4) Say, What name would you like for me to use to address the Supreme Being when I am praying for you?

4) Say, What name would you like for me to use to address the Supreme Being when I am praying for you? Ask how the patient prefers to address the Divine. Some people prefer the use of parental language in their prayers; for example, Father God or Divine Mother. Some use the names Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. The nurse should not assume that using the names Jesus and Jehovah God would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing God by a name, but the most supportive way to do so is to find out the name the patient wishes to use. Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually.

____ 28. The nurse is assessing a patient for depression. Which of the following sets of behavioral symptoms may indicate depression? 1) Preoccupation with loss, self-blame, and ambivalence 2) Anger, helplessness, guilt, and sadness 3) Anorexia, insomnia, headache, and constipation 4) Tearfulness, withdrawal, and present substance abuse

4) Tearfulness, withdrawal, and present substance abuse Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are affective findings associated with depression. Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain, and constipation.

____ 16. Religion provides people with instruction and guidance about what to believe and what values are essential.

T Religion provides instruction and guidance on beliefs, values, and codes of conduct. In contrast, spirituality is a journey that integrates life experiences and understanding.

____ 2. Spirituality occurs over time and involves the accumulation of life experiences and understanding.

T Spirituality is like a journey; it occurs over time and involves the accumulation of experiences and understanding, whereas religion provides general instruction and guidance on beliefs, values, and codes of conduct.