chapter 5 thru 10 fa Davis

Which individual is most likely to have a positive body image?

Adolescent of average appearance who had an appendectomy

An 86-year-old patient had prostate surgery 2 days ago. Which nursing action best meets his developmental needs?

Encourage the patient to perform self-care as much as possible.

.After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?

Resistance

Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?

Restful sleep

A couple is planning to move to a housing development that has been built to provide elder-friendly dwellings and environments for independent living. The houses are smaller and on a single level. Their purchase includes home maintenance and repair, snow and trash removal, a pool, and a walking track. Only people 60 years and older qualify to buy a house in this community. Medical and nursing care are not a part of the purchase. How would their living situation be described?

Retirement community

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?

Self-esteem

2. A client lives alone. He is very weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. His personal hygiene is poor. He moves very slowly when doing even small tasks, such as eating a meal. Which of the following are appropriate interventions for this patient? Choose all that apply; assume all are possible.

-Arrange for a home aide to assist with activities of daily living -Assess the patient for symptoms of depression and memory loss -Arrange for nutritious meals to be delivered to the patients home.

Which of the following suggest that a family health problem may exist? Select all that apply. Family members

-Enact decisions made by the most powerful member -Do not consider a conflict resolved until everyone agrees

Many health providers define illness as pathology; however, people experience, rather than define, illness. Which of the following is how most people experience illness?

A change in the way they feel or a disruption in their typical life

Which nursing diagnosis is categorized as a psychosocial, rather than a self- concept, diagnosis?

Ineffective Individual Coping

Which assessment finding(s) might suggest that the patient has low self esteem and requires more in-depth assessment? Choose all that apply.

Infrequent eye contact Overly critical of others

A client tells the nurse, I cant see well enough to read anymore. I have new glasses, but its still hard. What should the nurse advise her to do first

Install a bright but glare-free light near where you read.

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?

Inter-role conflic

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?

Interrupted Family Processes

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?

Interview the patient to screen for clinical depression.

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?

Involve the friend and children in the patients care, discharge planning, and home care.

A mother has brought her 8-month-old daughter to the healthcare clinic for a well-child appointment and any needed immunizations. To assess the childs physical development with age-appropriate norms, which of the following questions should the nurse ask?

Is your child able to sit up without support?

age than men do. My husband and I are the same age, so I am afraid I will have to spend some years without him. That really worries me. Which response is based on correct information?

It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65.

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?

The community

.A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?

Adaptive

.After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?

Displacement

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?

Displays stabilization and control of mood

The client is a 76-year-old man who is experiencing chronic illness. He has a genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him?

Eating habits

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

Encourage the patient to participate in self-care.

.A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?

Encourage the patient to verbalize about stressors and anxiety

.When released in response to alarm, which of the following substances promotes a sense of well-being?

Endorphins

.A patient is in crisis. After assessing the situation, what should the nurse do first

Ensure the safety of both the nurse and patient.

.You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?

Epinephrine

.Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Choose all that apply. 1) The wound is most likely infected.

Exudate formation is occurring. This is a vascular response to inflammation

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

Facilitate role enhancement

Which of the following reflects an understanding of the characteristics of older adults?

Fewer than 5% of all older adults live in nursing homes.

In an effort to promote health, the home health nurse opens the clients bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people?

Florence Nightingale

When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do?

Fold the top bed linens back to open the bed.

Which nursing intervention specifically helps reduce a patients anxiety?

Giving clear fact pertaining to the patients circumstances

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

Grieving

Which of the following is considered a strength of the nursing profession?

Biopsychosocial focus

A family assessment should include the following areas. Choose all that

Health beliefs

4. How can the nurse facilitate communication with an older adult?

Speak slowly, allowing time for the patient to word his answers. Pay special attention to cues from body language Assess for hearing deficit at the beginning of the interaction

Which family member is most likely to be disabled?

female Native American who is 75 years or older

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?

severe anxiety

.The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess?

unresolved anger and may result from stress

Incontinence is not a normal part of aging and should be explored further. The thinning of the layers of the skin causes older adults to feel colda normal part of aging. With aging, the brown fat layer, which contributes to generating and maintaining body temperature, becomes thinner as well. This is not the same type of fat as adipose, which is a white fat layer. Additionally, older adults who are sedentary often feel cooler. The elderly normally experience a decrease in saliva production, so although this is also a symptom of dehydration, dry mouth is a normal change of aging. Visual acuity decreases with age, but this, too, is a normal part of aging.

-My mother seems to get cold very easily. -My mother complains of her mouth being dry. -Mother goes around the house turning on all the lights

5. Which older adult is experiencing normal aging changes of the urinary system?

A man who has difficulty getting a hard erection A woman who wakes up to void once during the night

.During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply.

Amino acids and fats are more available for energy. Liver converts more glycogen to glucose.

.A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?

Anxiety

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?

Availability of community resources

Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply.

Being productive members of society Meeting the emotional needs of family members

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?

Blended

A 76-year-old patient is admitted with an acute myocardial infarction (heart

Dependence on others

A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis?

Depression Level

Which of the following is the most common major challenge for older adults?

Cancer screening with the annual health examinations

Which of the following would be the most important health assessment focus for older adulthood?

Cancer screening with the annual health examinations

.Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope

Could be used by the patient to hurt her

A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization?

Designating a corner of the patients room to display personal mementos

Which of the following can the nurse assess using Erik Eriksons theory?

Developmental tasks

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?

Decisional Conflict

.At the end of a guided imagery session, which physical assessment findin would suggest that the relaxation technique was successful?

Decreased blood pressure

What type of loss is most common among patients who are hospitalized for complex health conditions?

Dignity

Which statement best describes the health/illness continuum?

Health and illness are along a continuum that cannot be divided.

A mother comes to the healthcare clinic for a regular health examination for her 5-year-old son prior to kindergarten admission. Which comment by the mother would indicate the need for follow-up questions to the mother?

Hes not a good boy like my other son.

Which question helps the nurse to assess family structure?

How are family decisions made?

Which statement best describes self esteem?

How well one likes oneself

The nurse teaches a mother of a preschool-age child about expected development. Which comment by the parent indicates that she understands the information?

I am saving to buy her the roller skates shes been asking for.

A 38-year-old client comes into the clinic for a health examination. Knowing the psychosocial development tasks and common health problems for this age group, it would be most important for the nurse to ask

If the client has episodes of feeling depressed

Which response by the patient demonstrates an internal locus of control?

Im just glad to be alive; the accident couldve been a lot worse.

When developing goals, which guideline should the nurse keep in mind? Goals should be

Realistic so that progress is recognized by the patient

Which statement by the nurse is best when communicating with a patient with clinical depression?

Life seems overwhelming at times; would you like to discuss how youre feeling?

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.

Making eye contact if it is comfortable for the patient Always offering an explanation before beginning a procedure

.You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?

Malingering

3. When interpreting a population pyramid, which of the following do you need to know?

Men are on the left side of the pyramid and women on the right.

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?

No Self-Injury, Consistently Demonstrated

When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patients planning and emotional adjustment?

Notify the patient and family as much in advance of the transfer as possible.

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?

Notify the primary care provider and ask for a referral to a mental health professional.

To which age group do most hospitalized patients belong?

Older adults

Which statement best describes self-concept? An individuals

Overall view of himself

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

Peers

Which of the following is known to be a healthy strategy for coping with stress?

Performing meaningful work

Dunn believes that an individuals state of health should be evaluated in the context of the persons environment. This approach illustrates that

Physical environment, family, and social support may help or hinder the health status of an individual

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?

Postparental family

.What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?

Promotes fluid retention by increasing the reabsorption of water by kidney tubules

Which behavior by the mother is most likely to help the infant to develop trust?

Promptly responding to the infants crying

Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended?

Providing a healing presence by listening and being attentive

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?

Providing the patient with a dinner tray

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

Rambles, speaks incoherently, and answers questions inappropriately

Which factor is related to the increased risk of acquiring polio in the United States after the disease was thought to be eradicated?

Reduced compliance with vaccinations

A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply.

Sick-role behavior

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?

Situational Low Self-Esteem

Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self?

Spirituality

A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?

Stigma associated with mental illness

Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who

Teaches negotiation skills and independence

The nurse is assessing a patient for depression. Which of the following sets of behavioral symptoms may indicate depression?

Tearfulness, withdrawal, and present substance abuse

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?

Tell me what you mean by looking this way.

.When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?

The patient will limit his intake of sugar and salt, as well as sweet and salty foods.

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

Who suffered a traumatic amputation of the left leg in an industrial accident

The nurse is talking to a class of children, ages 9 to 11 years. For this age group, it would be most important for the nurse to discuss

Use of seat belts and safety equipment

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?

Using relaxation techniques

.A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first

Vascular response

A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?

What is the greatest concern you are dealing with today?

Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a persons level of hardiness. How can you apply this knowledge to your nursing care?

You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable

.A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, I hate this place; nobody knows how to take care of me or Id be home by now. Which response by the nurse is best in this situation?

You seem angry; whats going on that makes you hate this place?