Concepts exam 3 Troy U

22 year old has a cholesterol level done at a screening clinic sponsored by a local health club. Which of the following statements would be accurate and appropriate teaching by the volunteer nurse?

"Your low HDL reading puts you at higher risk for heart disease."

A client is to undergo a CT scan of the abdomen with IV and PO contrast in the morning. As the nurse you should assess for which of the following in pretest preparation? (Select all that apply.)

-Allergies to iodine and shellfish - BUN and creatinine -NPO status

What will the nurse do during the post-test phase of diagnostic testing for a client? (Select all that apply).

-Compare the previous and current test results - Modify nursing interventions as necessary - Report the results to the appropriate health team members

A verbally abusive partner has told his significant other many negative comments over the years. In the crisis center, the nurse would anticipate that the patient may have which of the following self-concept deficits? a. Body image b. Role conflict c. Rigidity d. Yearning

A Consistent negative comments can cause devaluation of an individual's self-concept. The impact of negative self-esteem can invade all areas of a person's life, including body image. Role confusion is part of a developmental task (identity versus role confusion). Rigidity and yearning are not components of self-concept.

Based on the following data, which person is likely to have the highest self-esteem? a. Latino adolescent female who has strong ethnic pride b. Caucasian boy who lives below federal poverty level c. African American adolescent male who has sever acne d. Adolescent who was suspended twice from high school

A Ethnic and cultural differences in self-concept and self-esteem have been noted across the life span. Ethnic pride and self-esteem often are positively correlated. Environmental stressors such as low-income, body image stressors such as acne, and role performance failure often influence self-esteem negatively.

The nurse in an addictions clinic is working with a patient on priority setting before the patient's discharge from residential treatment. An appropriate priority for a patient at this clinic would be a. Identifying local self-help groups before being discharged from the program. b. Staying away from all triggers that cause substance abuse. c. Stating a plan to never be tempted by illicit substances after discharge. d. Identifying personal areas of weakness to grow stronger.

A Providing the patient with resources such as local self-help groups can help to turn limitations into strengths. It is not realistic to avoid ALL triggers that can result in addictive behaviors. It is unrealistic to believe that the patient will never be tempted because temptation can arise from multiple sources. On the other hand, an appropriate priority would be to recognize that triggers will arise, and that the patient should learn how to handle being confronted in the postdischarge setting. Having a person talk about his or her weaknesses without recognizing a person's strengths could be a trigger to return to an addictive lifestyle, so this would not be the most appropriate priority

A newly hired nurse is struggling with night shift work and caring for multiple family members at home. The nurse manager calls the new nurse in to talk about how the nurse is negatively affecting patient self-concept by ignoring patients' concerns. The nurse manager should focus on the new nurse's a. Role overload b. Self-esteem c. Ego integrity d. Ethics and morals

A Role overload involves having more roles or responsibilities than are manageable. Self-esteem is the overall feeling of self-worth. The nurse is not involved in an ethical or moral dilemma. Ego integrity is part of a developmental task associated with older adults.

"I'm such a loser. I only had that job for a month." Identify appropriate nursing outcome criteria for this individual. a. The patient will verbalize two life areas in which he or she functions well. b. The patient will find new employment before the next clinic visit. c. The patient will confront his or her former boss about work problems. d. The patient will identify why he or she is considered a bad employee.

A Verbalizing two life areas in which a person functions well is an individualized measurable outcome that is realistic. Confronting a former boss could have physical and emotional repercussions for the patient. If the person is voicing that he or she has problems obtaining employment, then putting extra pressure to obtain employment would be detrimental to the patient and does not reflect a supportive and caring nursing outcome.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

A, B, D, E

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

A. Checking the amount of oxygen in the cylinder before using it

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter. B. Notify the primary care provider. C. Check that the airway is the appropriate size for the patient. D. Place the patient on his or her back.

A. Remove the catheter

A nurse is explaining lab work to a client and reports to the client that his liver function tests are abnormal. The nurse is aware that which of the following tests indicate liver function?

ALT

7. A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

4. The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

ANS: A The health belief model addresses the relationship between a person's beliefs and behaviors. The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behavior- specific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Maslow's' hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health.

1. A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate healthy life in America.

ANS: A The nurse should include eliminating health disparities in America. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages.

8. The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures.

ANS: B A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. External variables can have a major impact on compliance. Employment status is an external variable, not an internal variable. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices; noncompliance does not occur from thriving on disapproval of authority figures.

5. A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members

ANS: B According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs.

3. A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Making sure the patients are disease free b. Making sure to involve the whole person c. Making sure care is strictly personal in nature d. Making sure to focus only on the pathological state

ANS: B The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Therefore, nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not necessarily healthy. Strictly personal and a focus only on pathological states do not correlate to WHO's definition.

6. The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

ANS: B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person's beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

2. A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d. Focus on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The goals do not include continuing current behaviors to reduce stress, focusing only on health changes for communities, or focusing on fast recuperation.

9. The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

While gathering an adolescent's health history, the nurse recognizes that the patient began to act out behaviorally and engage in risky behavior when her parents divorced. In considering an altered self-concept nursing diagnosis, the nurse would gather what information? a. How long the parents were married b. How the patient views her behaviors c. Why the parents are divorcing d. Why she is acting out of control

B A nurse can identify situational life stressors that can impact a person's self-concept. By openly exploring a patient's thoughts and feelings, the nurse will be able to use communication skills in a therapeutic manner. This will facilitate the patient's insight into behaviors and will enable the nurse to make referrals or provide needed health teaching. The length of time married and the reason for the parents' divorce do not explain the patient's behaviors. Why the patient is out of control is not as important as how the patient views her actions when out of control.

Identify the assessments suggestive of an altered self-concept. a. Limping gait and large smile b. Slumped posture and poor personal hygiene c. Verbally responds when asked a question d. Appropriately dressed with clean clothes

B A self-concept is created by an individual's identity, body image, and role performance. Poor personal hygiene and slumping posture best describe a person with an impaired self-concept. Smiling, appropriate responses, and appropriate appearance are all signs of normal self-concept.

The nurse can assist the patient in becoming more self-aware by using which technique? a. Setting up an appointment to allow the patient to vent b. Allowing the patient to openly explore thoughts and feelings c. Assisting the patient to physically punch a pillow when upset d. Providing materials for the patient to write complaint letters

B By allowing open communication about thoughts and feelings, the nurse creates an environment for therapeutic communications. Punching pillows does not create self-awareness. Writing complaint letters and venting can create more internal turmoil in a person and do not promote self-awareness.

Which of the following individuals is most likely to need the nurse's assistance because of the presence of identity confusion? a. 49-year-old male with stable employment b. 35-year-old recently divorced mother of twins c. 22-year-old in third year of college d. 50-year-old self-employed woman

B Identity confusion can occur when people do not maintain a clear, consistent, and continuous consciousness of personal identity. A newly divorced woman would be trying to adapt to a new lifestyle of being single while handling parenting of twins as a single parent. This situation could lead to identity confusion. A college sophomore would have had at least 2 years to adjust to the new life setting, and a self-employed woman would likely be content with creating her own employment opportunity. There is no indication that the middle-aged man with stable employment should have identity confusion.

A 9-year-old is proudly telling everyone about mastering the yellow belt in her martial arts class. Identify the appropriate developmental task. a. Initiative versus guilt b. Industry versus inferiority c. Identity versus role confusion d. Autonomy versus shame and doubt

B Industry versus inferiority occurs between the ages of 6 and 12 years. It is during this developmental task that a person gains self-esteem through new skill mastery. The other self-concept development tasks occur at other stages of life and would not apply to this situation.

The nurse can best assess the patient's self-concept by evaluating the patient's a. Drug abuse history b. Nonverbal behavior c. Personal journal d. Social networking site

B Nonverbal behaviors are key indicators of a patient's self-concept. A history of drug abuse does not necessarily indicate current self-concept, and people who do not have a drug abuse history may have a low self-concept. It would be an invasion of privacy and trust for a nurse to read a patient's personal journal or social networking site.

The nursing student can help geriatric patients' self-concept by using which technique? a. Discussing current weather b. Reviewing old photos with patients c. Encouraging patients to sing d. Allowing patients extra computer time

B Nurses can improve self-image by reviewing old photographs when working with elderly patients. This form of life review is helpful to older adults in remembering positive life events and people. Discussing weather does not involve personal reflection. Singing improves global cognition, not self-concept. Giving patients extra computer time is not applicable to improving self-concept.

The developmental self-concept task known as initiative versus guilt would occur in which person? a. 3-week-old neonate b. 5-year-old kindergarten student c. 11-year-old student d. 15-year-old high school student

B The initiative versus guilt developmental stage occurs between the ages of 3 and 6 years. If a child shows initiative, the outcome of this developmental task is to develop purpose. A neonate developmental task is to develop trust. An 11-year-old is into new skill mastery, and a 15-year-old is struggling with identity versus role confusion.

A priority nursing intervention for a postoperative mastectomy patient is which of the following? a. Using therapeutic silence to encourage the patient to talk b. Using communication skills to clarify family and patient expectations c. Telling her that you know she will do fine because many other women have d. Rotating nursing personnel in the patient's care, so the patient can talk to many people

B The nurse recognizes the need to use therapeutic communication skills, allowing the opportunity to talk openly about issues that are important to a person who has undergone body-altering surgery. When a nurse does not allow for the development of a patient-nurse therapeutic relationship, open and honest conversation is impossible. Silence can be useful, but building rapport and opening the conversation are necessary first. Reassurance that a person will do fine dismisses any potential concerns the patient may have. Rotating nursing personnel does not allow time for the patient to build rapport with any one nurse.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient

B. Hold the mask tightly over the patient's nose and mouth.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure

B. Pulse oximetry

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Refrain from exercise. B. Reduce anxiety. C. Eat meals 1 to 2 hours prior to breathing treatments. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. F. Drink 2 to 3 pints of clear fluids daily.

B. Reduce anxiety. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? A.The age of the patient B. The size of the endotracheal tube C. The type of secretions to be suctioned D. The height and weight of the patient

B. The size of the endotracheal tube

Which of the following blood tests is indicative of heart failure?

BNP

Children learn to live an authentic lifestyle through culturally accepted behaviors, values, and role modeling. A child who does this is attempting to create his or her own a. Body image b. Self-esteem c. Identity d. Role performance

C Identify versus role confusion occurs between the ages of 12 and 20 years. Body image and self-esteem are attitudes related to personal reflection and attitudes. Role performance is the result of creating an identity.

Two 50-year-old men are discussing their Saturday activities. The first man describes how he tutors children as a volunteer at a community center. The other man says that he would never work with children, and that he prefers to work out at the gym to meet young women to date. The second man's statement reflects which developmental stage? a. Inferiority b. Role confusion c. Self-absorption d. Mistrust

C In the generativity versus self-absorption developmental task, a self-absorbed person is concerned about his or her own personal wants and desires in a self-centered manner. Mistrust versus trust occurs in the first year of life. Industry versus inferiority commonly occurs in school children. Identity versus role confusion commonly occurs at the start of adolescence into young adulthood.

A nurse who grimaces when seeing a patient's colostomy opening while changing the colostomy bag is most likely to have what effect on the patient? a. Assist recovery by using honest communication b. Motivate the patient to increase physical activity c. Promote development of a negative body image d. Develop a kind nickname for the colostomy opening

C Negative nonverbal reactions by a nurse to a patient's scar or surgical alterations contribute to the patient's developing a negative body image. Expressions of distaste by the nurse will not facilitate recovery or ongoing communication; encourage physical activity; or promote acceptance of the colostomy opening by adopting a positive nickname.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia

C. A teenager with cystic fibrosis

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A. Instruct the assistant to notify the primary care provider. B. Assess the patient's vital signs. C. Remove the tape, adjust the depth to ordered depth and reapply the tape. D. No action is required as depth will adjust automatically.

C. Remove the tape, adjust the depth to ordered depth and reapply the tape.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more

C. The nurse encourages the patient to breathe through the nose with the mouth closed.

The nurse is to collect a urine specimen from the client's indwelling urinary catheter. Which method is the correct procedure for obtaining a urine specimen from an indwelling urinary catheter?

Clean the sampling port on the catheter with an alcohol pad and insert a sterile needle with a syringe into the port

Which of the following roles would the nurse perform in the intratest phase?

Collect the specimen

Based on current evidence, the nurse who plans smoking cessation interventions for adolescent girls should focus on interventions directed toward a. Obeying parents and reducing television viewing. b. Fostering generativity over self-absorption c. Role overload, addiction counseling, and depression d. Weight management, self-esteem, and stress management

D Current research indicates that smoking cessation efforts should include stress management and improvement of self-esteem and body image. Weight concerns, especially in females, promote continued smoking. Obeying parents and reducing television viewing are not effective smoking cessation strategies. The developmental task of generativity versus self-absorption occurs in adulthood. Role overload is not a usual contributor to smoking in adolescents, although it could be; addiction counseling is not a smoking cessation intervention; depression is associated with decreased self-esteem but is not a primary smoking cessation target for adolescent girls in general.

Potential predictors for suicidal thoughts and behaviors in adolescents are a. Stressful life events and a scholarship b. Very high self-esteem and work failure c. Health problems and developmental milestones d. Negative body image and low self-esteem

D Low self-esteem and negative body image can be predictors for suicidal thoughts and behaviors. High self-esteem would help a person cope with work failure. Stressful life events when balanced with positive issues, such as receipt of a scholarship, are less likely to induce depression. Suicidal tendencies are based more on the individual's frame of mind than on individual events such as health problems and developmental milestones.

An adult is adjusting to the idea of his chronically ill parent moving into the family home. The community health nurse would assess the adult son for which potential stressor secondary to the new family living arrangement? a. Role confusion b. Role ambiguity c. Role performance d. Role overload

D Role overload involves having more roles or responsibilities within a role than are manageable. Role overload is common in individuals who unsuccessfully attempt to meet the demands of work and family while trying to find some personal time. Role confusion is an aspect of the developmental task of adolescence and young adulthood (identity versus role confusion). Role ambiguity involves unclear role expectations. Role performance itself is not a stressor unless it is judged ineffective.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I will be careful not to shake up the canister before using it." B. "I will hold the canister upside down when using it." C. "I will inhale the medication through my nose." D. "I will continue to inhale when the cold propellant is in my throat." E. "I will only inhale one spray with one breath." F. "I will activate the device while continuing to inhale."

D, E, F

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning.

D. A nosebleed is noted with continued suctioning.

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C. Teach the patient to take short shallow breaths when performing hygiene measures. D. Group personal care activities into smaller steps, allowing rest periods between activities.

D. Group personal care activities into smaller steps, allowing rest periods between activities.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline.

D. Put on gloves and insert the chest tube in a bottle of sterile saline.

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate

Dyspnea

Which of the following lab values should the physician be notified of immediately?

Hematocrit 24%

A client has been experiencing frequent black, tarry stools on your shift. Which of the following diagnostic tests would the physician most likely order for your patient?

Hemoccult

A client with diabetes needs to have a blood test drawn to determine how well the diabetes has been controlled over the last three months. Which blood test will provide this information?

Hemoglobin A1C

A client with atrial fibrillation, who is receiving maintenance therapy of warfarin sodium (Coumadin), has a prothrombin time of 35 seconds and an INR of 4.3. Based on the prothrombin time and INR, the nurse anticipates which of the following orders?

Holding the next dose of Coumadin and decreasing the dose

A patient with a WBC count of 13,000 would have the diagnosis of:

Leukocytosis

Which of the following components are included on the differential portion of a WBC count? (Select all that apply)

Neutrophils Lymphocytes Monocytes

Which of the following steps should the nurse perform when obtaining a sputum specimen?

Offer mouth care

A client is presently taking an antibiotic that has a narrow therapeutic range. In order for the client to get optimal results from the medication without toxicity, the nurse expects which of the following labs to be drawn?

Peak and trough levels

Which of the following should the nurse assess the patient for prior to an MRI? (Select all that apply)

Piercings Pacemakers Tattoos

A patient has recently been diagnosed with anemia. Which of the following test provide more information regarding the size and hemoglobin content of the red blood cells so the type anemia can be properly diagnosed?

Red blood cell indices

Which returned demonstration by the client indicates an accurate understanding of performing a blood glucose monitoring test?

The client washes her hands prior to the procedure

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? a. The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain. b. The nurse prepares the patient's health care provider-approved herbal tea and uses meditation to relax the patient prior to bed. c. The nurse administers naproxen and performs prescribed range-of-motion exercises. d The nurse arranges for acupuncture for the patient and designs a menu high in omega-3 fatty acids.

a

A nurse manager who works in a hospital setting is researching the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CHA? a. A patient who is anxious about residual pain from cervical spinal surgery b. A patient who is experiencing abdominal discomfort c. A patient who has chronic pain from diabetes d. A patient who has frequent cluster headaches

a (energy healing for lingering pain post injury)

A nurse mentor is teaching a new nurse about the underlying beliefs of CHAs versus allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. a. "CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." b. "CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." c. "Allopathy proponents believe that the main cause of illness is an imbalance or disharmony in the body systems." d. "Curing according to CHA proponents seeks to destroy the invading organism or repair the affected part." e. "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." f. "According to CHA proponents, health is the absence of disease."

a, b, e

A nurse working in a hospital setting cares for patients with acute and chronic conditions. Which disease states are chronic illnesses? Select all that apply. a. Diabetes mellitus b. Bronchial pneumonia c. Rheumatoid arthritis d. Cystic fibrosis e. Fractured hip f. Otitis media

a, c ,d Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time.

nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. a. Applying heat or ice to an extremity b. Explaining the use of electrical stimulation c. Teaching a patient relaxation techniques d. Teaching a patient about a prescription e. Explaining an invasive procedure to a patient f. Teaching about dietary supplements

a,b,c,f

A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility? a. By being a role model for healthy behaviors b. By not requiring sick days from work c. By never exposing others to any type of illness d. By budgeting time and resources efficiently

a. Good personal health enables the nurse to serve as a role model for patients and families.

The nurse uses the agent-host-environment model of health and illness to assess diseases in patients. This model is based on what concept? a. Risk factors b. Demographic variables c. Behaviors to promote health d. Stages of illness

a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease.

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) b. A young clergyperson whose vocal cords are paralyzed after a motorbike accident c. A 32-year-old accountant who survives a massive heart attack d. A 23-year-old model who just learned that she has breast cancer

a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach, the 32 year old's massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

a. Personal Identity Disturbance An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? a. Realistic and positively motivating his development b. Unrealistic and negatively motivating his development c. Unrealistic but positively motivating his development d. Realistic but negatively motivating his development

a. Realistic and positively motivating his development The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. a. Teach the parents to reinforce their child's positive qualities. b. Teach the parents to overlook occasional negative behavior. c. Teach parents to ignore neutral behavior that is a matter of personal preference. d. Teach parents to listen and "fix things" for their children. e. Teach parents to describe the child's behavior and judge it. f. Teach parents to let their children practice skills and make it safe to fail.

a. Teach the parents to reinforce their child's positive qualities. c. Teach parents to ignore neutral behavior that is a matter of personal preference. f. Teach parents to let their children practice skills and make it safe to fail. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. a. The nurse makes a point to address the patient by name upon entering the room. b. The nurse avoids fatiguing the patient by performing all procedures in silence. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. e. The nurse ignores negative feelings from the patient since they are part of the grieving process. f. The nurse avoids conversing with the patient about her life, family, and occupation.

a. The nurse makes a point to address the patient by name upon entering the room. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences.

A female patient with a RBC count of 3.9 would have a diagnosis of:

anemia

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? a. A patient who has insomnia b. A patient who has nausea c. A patient who has dementia d. A patient who has migraine headaches

b

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply. a. A White male diagnosed with HIV b. An African American teenager who is 6 months pregnant c. A Hispanic male who has type II diabetes d. A low-income family living in rural America e. A middle-class teacher living in a large city f. A White baby who was born with cerebral palsy

b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs.

Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students. f. A nurse teaches new parents how to choose and use an infant car seat.

b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity.

A nurse working in a primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply. a. Health and illness are the same for all people. b. Health and illness are individually defined by each person. c. People with acute illnesses are actually healthy. d. People with chronic illnesses have poor health beliefs. e. Health is more than the absence of illness. f. Illness is the response of a person to a disease.

b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential. An illness is the response of the person to a disease.

A nurse works for a health care provider who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. a. Treating the symptoms of the disease b. Providing patient education c. Focusing on treating individual body systems d. Making appropriate interventions to prevent illness e. Believing in the healing power of nature f. Encouraging patients to take responsibility for their own health

b,d,e,f

A patient in a community health clinic tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the patient exhibiting? a. Stage 1: Experiencing symptoms b. Stage 2: Assuming the sick role c. Stage 3: Assuming a dependent role d. Stage 4: Achieving recovery and rehabilitation

b. Stage 2: Assuming the sick role. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: Experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities.

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? a. "Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worrying about doing yoga." b. "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into." c. "Ashtanga yoga is a gentle paced yoga that would help with your breathing and blood pressure." d. "Yoga is contraindicated for patients who have had a heart attack."

b. "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into."

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

b. Body Image Disturbance This patient's concern is with body image. The information provided does not suggest a nursing diagnosis of Personal Identity Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? a. Lack of self-esteem b. Deficient self-knowledge c. Unrealistic self-expectation d. Inability to evaluate himself

b. Deficient self-knowledge The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? a. The patient will make above-B grades in all tests at school. b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. c. The patient reports that she feels more self-confident in her music and art, which she enjoys. d. The patient expresses that she is very smart in school.

b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. All of these patient goals may be appropriate for the patient, but the only goal that directly addresses her body image disturbance is "the patient will demonstrate by diet control and skin care, increased interest in control of acne."

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psychological balance? a. Teach the patient to always lie down in a comfortable position during meditation. b. Teach the patient to focus on multiple problems that the patient feels demand attention. c. Teach the patient to let distractions come and go naturally without judging them. d. Teach the patient to suppress distracting or wandering thoughts to maintain focus

c

A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? a. Tertiary b. Secondary c. Primary d. Promotive (Taylor 63)

c. Giving influenza injections is an example of primary health promotion and illness prevention.

Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms? a. Jane, whose best friend had a benign breast lump removed b. Sarah, who lives in a low-income neighborhood c. Tricia, who has a family history of breast cancer d. Nancy, whose family encourages regular physical examinations

c. The physical dimension includes genetic inheritance, age, developmental level, race, and biological sex. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor.

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? a. "I love my child so much I 'hug him to death' every day." b. "I think children need challenges, don't you?" c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." d. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? a. Recommend that she discipline her daughter more strictly and consistently. b. Make a list of things her husband can do to give her more time and help her improve her parenting skills. c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. d. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

A nurse is providing a lecture on CHAs to a group of patients in a rehabilitation facility. Which teaching point should the nurse include?a. CHAs are safe interventions used to supplement traditional care. b. Many patients use CHA as outpatients but do not wish to continue as inpatients. c. Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients. d. Most complementary and alternative therapies are relatively new and their efficacy has not been established.

c. Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients.

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? a. Negative self-concept and low self-esteem b. Negative self-concept and high self-esteem c. Positive self-concept and fairly high self-esteem d. Positive self-concept and low self-esteem

c. Positive self-concept and fairly high self-esteem The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

c. Self-Esteem Disturbance This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

A nurse is caring for a postoperative patient who is experiencing pain. Which CHA might the nurse use to ensure active participation by the patient to achieve effective pre- or postoperative pain control? a. Acupuncture b. TT c. Botanical supplements d. Guided imagery

d

A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health-illness continuum and the high-level wellness models? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Both these models view health as a dynamic (constantly changing state).

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

d. Altered Role Performance Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? a. There is no disturbance in self-concept. b. This patient has ego strength and high self-esteem but may have a disturbance of body image. c. The area of self-esteem has very low priority at this time and should be ignored until much later. d. It is probable that there are disturbances in self-esteem and body image.

d. It is probable that there are disturbances in self-esteem and body image. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? a. Negative self-concept b. Modesty (lack of conceit) c. Body image disturbance d. Low self-esteem

d. Low self-esteem The nurse can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (what we think we really are) and the "ideal self" (what we think we would like to be). The nurse would have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.

A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do?

start the test over

A client's platelet count is 70,000/ mm cubed. The nurse instructs the client to:

use an electric razor