Intro to Nursing Exam 3

32. Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs? 1. "Do you have a religious preference?" 2. "Have you given thought to your spiritual needs?" 3. "Is there a particular clergy you would like to visit with?" 4. "Are there any spiritual needs you have that I may help with?"

"Are there any spiritual needs you have that I may help with?"

23. The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? 1. "What makes the pain worse?" 2. "When did you first notice the pain?" 3. "What do you do to lessen the pain?" 4. "Can you rate your pain using the pain scale that we've discussed?"

"Can you rate your pain using the pain scale that we've discussed?"

14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? 1. "I understand how you must feel." 2. "This medication is used to lower your blood pressure." 3. "You appear anxious. You're wringing your hands constantly." 4. "Could you give me an example of how you handle stressors?"

"Could you give me an example of how you handle stressors?"

21. The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse? 1. "How long have you been dealing with GERD?" 2. "Are you currently taking any medications for your GERD?" 3. "Do you follow a particular diet to help manage your GERD?" 4. "Do you have any other gastrointestinal problems besides GERD?"

"Do you have any other gastrointestinal problems besides GERD?"

20. Which of the following statements best reflects the nurse's correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit? 1. "I'm going to do the client's history before his family leaves so they can help with the admission history questions." 2. "You are scheduled for some x-rays, so I'd like to complete this admission history interview before you have to leave." 3. "I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable." 4. "Please let me know when the blood lab is finished with the new client so I can complete his admission history interview."

"I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable."

27. Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized? 1. "Mom falls asleep fastest with the television on." 2. "Dad starts off the day with hot coffee; it regulates his bowels." 3. "My wife's sister died 4 months ago, and she is still grieving over her loss." 4. "My husband doesn't like to let people know his arthritis is bothering him."

"My husband doesn't like to let people know his arthritis is bothering him."

16. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data? 1. "Client appears sleepy" 2. "No physical distress noted" 3. "Abdomen soft and non-tender" 4. "States feels anxious and tense"

"States feels anxious and tense"

19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression? 1. "Have you ever felt this depressed before?" 2. "What do you believe is the cause of your depression?" 3. "What makes you feel that you are experiencing depression?" 4. "What can we do to make you comfortable while you are here?"

"What do you believe is the cause of your depression?"

6. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? 1. "Is your pain worse or better than it was an hour ago?" 2. "Do you believe that your nausea is from the new antibiotic?" 3. "What do you think has been causing your current depression?" 4. "What have you done to alleviate the side effects from your medications?"

"What do you think has been causing your current depression?"

17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time? 1. "Can you describe your pain?" 2. "Have you had this problem before?" 3. "What have you done to ease the pain?" 4. "When did your abdominal pain begin?"

"When did your abdominal pain begin?"

22. A new graduate nurse missed cues regarding the client's emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is: 1. "That is why we perform assessments at least daily; so we can catch missed cues." 2. "Everyone has missed cues; don't be too hard on yourself and just keep trying." 3. "You will be less likely to miss client cues as you acquire more experience with assessments." 4. "The positive side to making this mistake is that you won't miss those cues again in another client."

"You will be less likely to miss client cues as you acquire more experience with assessments."

The second component of critical thinking in the "critical thinking model" is: 1. Experience 2. Competencies 3. Specific knowledge 4. Diagnostic reasoning

1 Experience is the second component of critical thinking in the "critical thinking model." The third component of the "critical thinking model" is competencies. Specific knowledge base is the first component of the "critical thinking model." Diagnostic reasoning is a specific critical thinking competency in clinical situations.

The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is "not right" with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology

1 Intuition is an inner sensing that something is so, as in this example. Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality.

1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1. "Think about several interventions that you could use with this client." 2."Don't draw subjective inferences about your client—be more objective." 3."Please think harder—there is a single solution for which I am looking." 4."Trust your feelings—don't be concerned about trying to find a rationale to support your decision."

1 The nurse educator is asking the student to synthesize critical thinking skills by encouraging the student to examine alternatives to meet the client's unique needs within the context of the nursing process. Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The educator who tells the student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. The critical thinker will look beyond a single solution to a problem. Intuition develops as one's clinical experience increases. The nursing student should examine

The primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff is: 1.Critical thinking 2.Years of education 3.Professional licensure 4.Complexity of the task

1 Clinical decision making separates professional nurses from technical personnel. While advanced education is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. Although licensure is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. 4. While complexity is a distinction, the primary factor regarding client care is that the professional nurse is responsible for actions that require critical thinking decision making.

Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1.Reporting client difficulties 2.Offering an alternative approach 3.Looking for a different treatment option 4.Sharing ideas about nursing interventions

1 Reporting client difficulties demonstrates the critical thinking attitude of responsibility and authority. Asking for help if uncertain and following standards of practice also demonstrate the critical thinking attitudes of responsibility and authority. Offering an alternative approach would demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions demonstrates the critical thinking attitude of thinking independently.

The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1.Has a documented blood pressure of 90/50 2.Was medicated for back pain 10 minutes ago 3.Has an order to be out of bed and ambulated 4.Requires instructions for wound care before discharge

1 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practice-based criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslow's hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care.

The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1.Humility 2.Risk-taking 3.Accountability 4.Independent thinking

2 This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. Humility is a critical thinking attitude in which a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions. To be accountable means to be answerable for the outcomes of your actions. To think independently, one questions others' ways of interpreting knowledge and looks for rational and logical answers to problems.

A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1."A person with the educational background to solve problems." 2."A person who finds the problem and does what is best to fix it." 3."It's someone who uses the scientific method to solve problems." 4."Someone who uses a system to work through and solve a problem."

2 A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions. Educational background may have an impact on critical thinking but it is not the primary or sole factor to consider. Although the scientific method is often used in critical thinking it is neither the only method nor the sole factor to consider. While an orderly method is used in critical thinking, it is not the only factor to consider.

A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs? 1."That surgery is painful. I'll get her pain medication ready." 2."She was sleeping when I checked 15 minutes ago. I'll go back in right now." 3."I'll be responsible for her PM care so I can spend some uninterrupted time with her." 4."A mastectomy is a blow to a woman's self image. I'll notify her provider that she is depressed."

2 Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this client's tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurse's intention to analyze the client's needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume.

With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1.The veteran nurse has a varied history of client care experiences 2.Critical thinking improves with experience, longevity, and interest 3.Today's short hospital stays minimize the opportunity to develop critical thinking skills 4.New graduates often lack the self-confidence to take the risks often required of critical decision making

2 Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. While experience is a factor in the development of critical thinking skills, it is not the only factor. While having extended periods of time with clients has a positive effect on the development of critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a negative effect on the development of critical thinking skills, it is not the primary or sole factor.

A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1.Curiosity 2.Experience 3.Perseverance 4.Scientific knowledge

2 Having worked for many years and being able to adapt a procedure to meet the client's needs is an example of the second component of the critical thinking model—experience. Curiosity is a critical thinking attitude where the nurse asks why, and continues to learn more about the client to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science. It may be acquired through education, such as coursework, or by reading nursing literature to remain current in nursing science.

Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1."I feel it's good practice to always have alternative interventions in mind." 2."I trust my feelings about a client's needs since I work hard at knowing my client." 3."I always try to keep an open mind about what interventions my client will require." 4."I will wait until my assessment is completed before determining the client's needs."

2 Intuition develops as one's clinical experience increases. The nursing instructor should instruct the student to examine rationales in order to make good decisions regarding client needs. The instructor would encourage the student to examine alternatives to meet the client's unique needs, so this statement would not require follow-up. Basing client care on identified client needs is the appropriate use of critical thinking, and so would not require follow-up. Basing client care on client needs identified by thorough nursing assessments is the appropriate use of critical thinking, and so would not require follow-up.

Which of the following nursing situations best reflects accountability? 1.The nurse takes the oncology nursing certification examination. 2.The nurse files an incident report regarding a medication error. 3.The nurse assesses the client for the possible cause of his pain. 4.The nurse tells the client, "I don't know but I will find out for you."

2 To be accountable means to be answerable for the outcomes of your actions. Answer 2 is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. To think independently, one questions others' ways of interpreting knowledge and looks for rational and logical answers to problems. Humility is a critical thinking attitude where a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions.

Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1.Performing a head-to-toe assessment on a new admission 2.Placing a client experiencing shortness of breath on oxygen 3.Arbitrating a complaint between roommates over the television 4.Notifying a provider of a client's allergy to an ordered medication

2 Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a client's immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. Notifying a provider of a client's allergy is an example of nursing responsibility.

The scope of a client's health problem is a result of which of the following factors? (Select all that apply.) 1.Religious beliefs 2.Life experiences 3.Lifestyle choices 4.Work environment 5.Family relationships 6.Educational background

2,3,4,5 Each client's problems are unique and a product of many factors, including the client's physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences.

Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1.A new admission admitted for swelling in the right ankle and knee 2.A second day postoperative client who received pain medication 30 minutes ago 3.A client who the nursing assistant found crying in the bathroom 4.A client ready for discharge who requires a final assessment and documentation

3 This client has an acute need that requires the nurse's attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority. While a pain assessment is required to evaluate the effectiveness of pain medication, it does not the have the priority of the other presented options. This client has no acute problems and so the assessment does not have the priority of some of the other options.

The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1.Inference 2.Management 3.Problem-solving 4.Diagnostic reasoning

3 This is an example of the critical thinking strategy of problem-solving. The nurse gathers information from the client and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem-solving involves the examination of alternatives. Inference is the process of drawing conclusions. Management is not a critical thinking strategy. Diagnostic reasoning is a process of determining a client's health status after the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the client.

Which of the following statements made by a new graduate nurse regarding a client's care needs requires follow-up by the mentor? 1."No one really enjoys being hospitalized." 2."Every client is offered a back rub at bedtime." 3."All post surgery clients are reluctant to ambulate." 4."I always spend extra time with new clients to help them relax."

3 Because no two clients respond exactly alike to similar health problems, you always have to observe each client closely in order to make critically sound decisions regarding that client's needs. Answer 1 does not require follow-up because even if it is not true, it does not have an impact on the nurse's perception of the client's care needs. Answer 2 does not require follow-up because it is a nursing action that should be offered to all clients at bedtime.

A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1."I'm sure that friction and pressure have caused this problem." 2."Please be sure that her ankles are well padded when you place her in bed." 3."Do you have any suggestions on how we can minimize the pressure to her ankles?" 4."It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour."

3 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion.

he nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1.Defining the problem 2.Making final decisions 3.Testing possible options 4.Considering consequences

3 The nurse who observes the absorbency of different brands of dressing is demonstrating testing of possible options. This is not an example of defining the problem. The nurse has not yet made a final decision. The nurse is not examining pros and cons, and therefore is not considering consequences.

Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1.Determining that the client's ankle edema is worse after he ambulates 2.Asking the client to rate his ankle pain after receiving oral pain medication 3.Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4.Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. Assessment involves the gathering of data. Planning involves establishing goals and expected outcomes of care.

Which of the following nursing actions is the best example of problem solving? 1.Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2.Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3.Trying several difficult wound dressings to determine which one the client can apply the most effectively 4.Calling for another pain medication order when the current drug results in the client experiencing nausea

3 This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the client. Effective problem solving involves the examination of alternatives. While requesting the IV team solves a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances.

The concept of nursing responsibility is best reflected in which of the following nursing actions? 1.Providing accurate and timely documentation regarding an incident resulting in a client fall 2.Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3.Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4.Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

4 Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury. Reporting client difficulties demonstrates the critical thinking attitude of responsibility but is not the best option of those available because it would not result in client injury/harm. Offering an alternative approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about nursing interventions best demonstrates the critical thinking attitude of thinking independently.

There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1.Giving medication at the time ordered 2.Following a procedure for catheterization step-by-step 3.Reviewing all clients' medical records thoroughly 4.Discussing various alternative pain management techniques

4 Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently. Giving medication at the time ordered is an example of the basic level of critical thinking. Following a procedure step-by-step is an example of the basic level of critical thinking. Reviewing the client's medical records thoroughly is an example of gathering data and may be used in evaluation of a client's care.

The nurse is best demonstrating perseverance by: 1.Having a perfect attendance record 2.Completing a lengthy course on current chemotherapies 3.Repeatedly irrigating the nasogastric tube until it is patent 4.Sitting with a client until she is ready to discuss why she is crying

4 Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. While perfect attendance shows a nurse's willingness to complete the work responsibilities regardless of barriers, it is a better representation of responsibility. While completing a course on current chemotherapies shows the nurse's willingness to pursue knowledge, it is more representative of the acquiring of scientific knowledge to remain current in nursing science. While repeatedly irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is appropriate, it is a better representation of possessing knowledge of the procedure.

Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit's nurse manager? 1."Mary and I were comparing foot wound dressing techniques." 2."I've been caring for orthopedic clients for 10 years and I think I've seen it all." 3."I can't believe that my client isn't improving after 2 weeks of physical therapy." 4."I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

4 Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs. Answer 1 needs follow-up because it shows a willingness to explore other's opinions. Answer 2 requires no follow-up because it does not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because it does not reflect an inflexible attitude toward client care needs.

Which of the following is the best example of a nurse's use of reflection? 1.The nurse places a client experiencing respiratory difficulties in a high-Fowler's position. 2.The nurse calls the provider when a client reports feeling "chilled and achy" while having an oral temperature of 100.2° F. 3.While caring for a client with a history of asthma, the nurse assesses the client's pulse oximetry reading when he "doesn't sound right." 4.A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."

4 Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality. Intuition is an inner sensing that something is so, as in this example.

Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process? 1."I believe that this client is getting depressed." 2."The client doesn't look right to me; I think something is wrong." 3."The client's husband told me that she is feeling very uncomfortable." 4."The client reports more pain than yesterday and her blood pressure is elevated."

4 Reporting more pain than yesterday and elevated blood pressure reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the client is depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects information gathering, which may be used in diagnostic reasoning.

The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1.Assessment 2.Nursing diagnosis 3.Planning 4.Implementation

4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and identifies the client's response to a problem. The nurse may then determine priorities. Planning involves establishing goals and expected outcomes of care.

Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1.Being physically present when a client is given the results of a tissue biopsy 2.Witnessing the client sign consent for surgery forms before cardiac surgery 3.The client is informed of the various treatments available for his condition. 4.The nurse explains to the client the risks of leaving the hospital against medical advice.

4 The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being physically present is not an example of defining the problem. Witnessing the client sign consent is an example of a final decision. In Answer 3 the client is being given various options.

Use of the intellectual standard of critical thinking implies that the nurse: 1.Questions the physician's order 2.Recognizes conflicts of interest 3.Listens to both sides of the story 4.Approaches assessment logically

4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. Questioning the physician's order is an example of the critical thinking attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude of fairness.

25. When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information? 1. A 50-year-old in the ED reporting chest pain 2. A 70-year-old admitted with fever of unknown origin 3. A 81-year-old receiving follow-up treatment for a hip replacement 4. A 22-year-old being treated at a clinic for a sexually transmitted disease

A 81-year-old receiving follow-up treatment for a hip replacement

A mother and her child sit in a playroom on the pediatric unit. The boy wants to play with a toy that another child has but the mother says no. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as: A. Displacement B. Compensation C. Conversion D. Denial

A. Displacement Displacement is transferrin emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute.

An adolescent child who is having behavioral problems has had added responsibilities put upon her because the father has just lost his job and is experiencing periods of depression and the mother has a chronic debilitation illness. The nurse is involved in crises intervention and intervenes to specifically focus the family on their feelings by: A. Pointing out the connection between the situation and their responses B. Encouraging the use of the family's usual coping skills C. Working on time management skills D. Discussing past experiences

A. Pointing out the connection between the situation and their responses When using a crisis intervention approach, pointing out the connections between situation and responses, the nurse helps the client make the mental connection between the stressful event and the client's reaction to it. Because an individual's or family's usual coping strategies are ineffective in managing the stress of the precipitating event in a crisis situation, the use of new coping mechanisms are required.

For a lifestyle stress indicator and reduction in the incidence of heart disease a recommended intervention would be: A. Regular physical exercise B. Attendance at a support group C. Self-awareness skill development D. Effective time management techniques

A. Regular physical exercise A regular exercise program reduces tension, promotes relaxation, increases one's resistance to stress, and reduces the risk of cardiovascular disease.

Which of the following client behaviors best reflects Neuman Systems Model of tertiary prevention? The client who: A. Swims daily to strengthen muscles weakened as a result of hip surgery B. Follows a low-fat diet in order to bring her HDLs to under 200 mg/dL C. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mmHg D. Attends a survivor support group after the loss of a spouse in an automobile accident

A. Swims daily to strengthen muscles weakened as a result of hip surgery At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention.

15. When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as: 1. Respiratory 2. Activity and exercise 3. Sleep and rest pattern 4. Self-care deficit: activities of daily living

Activity and exercise

5. For an older adult client, an example of a common behavioral task or critical event is: 1. Selecting a mate 2. Rearing children 3. Finding a congenial social group 4. Adjusting to decreasing physical strength

Adjusting to decreasing physical strength

8. The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for: 1. Coordination with the physician's visit 2. The time when the client's family are visiting 3. Immediately before the client's scheduled MRI testing 4. After the client has become comfortably oriented to the room

After the client has become comfortably oriented to the room

The husband of a client with terminal cancer has expressed a high degree of stress over his role as caregiver. When asked whether he has suicidal or homicidal thought he answered, "Sometimes." Which of the following nursing statements is most therapeutic initially? A. "What is the hardest part about your wife's impending death?" B. "Can you describe your plan for killing yourself and your wife?" C. "What can I do to help make caring for your wife less stressful?" D. "Can you tell me how caring for your wife has affected you personally?"

B. "Can you describe your plan for killing yourself and your wife?" If a client indicates suicidal or homicidal ideations, the nurse should first determine in a caring and concerned manner if the person has a plan and determine how lethal the means are.

Which of the following statements made by the nurse shows the best understanding of the therapeutic value of a support system for a client experiencing stress? A. "They will be there when you need them and make sure you will have your needs met." B. "They will provide you with someone to talk with about your problems and support your decisions." C. "When you are experiencing stress, it is always comforting to have people who care about you nearby." D. "These individuals have experienced what you are going through and can offer you effective suggestions."

B. "They will provide you with someone to talk with about your problems and support your decisions." A support system of family, friends, and colleagues who will listen, offer advice, and provide emotional support benefits a client experiencing stress. The individuals need not have actually experienced the same stressors nor is it necessary or reasonable to expect that they will meet all your needs.

Which of the following clients shows the greatest risk factor for stress coping related to situational stressors? A. An 18 year old high school athlete who breaks his leg just before college football tryouts B. A 74 year old widow whose only son is severely injured in an automobile accident C. A 36 year old who loses his job days after his marriage to his high school sweetheart D. A 60 year old who is diagnosed with prostate cancer after deciding to retire from his job of 26 years

B. A 74 year old widow whose only son is severely injured in an automobile accident The timing of stress-inducing events significantly influences older adults' ability to cope. The fact that older adults have several stressful events occur within a short period of time often results in negative effects on coping ability.

Clients undergoing stress may have periods of regression. The nurse assesses this regressive behavior in the situation where: A. An adult client exercises to the point of fatigue B. An 8 year old child sucks his thumb and wets the bed C. An adult client avoids speaking about health concerns D. An 11 year old child experiences stomach cramps and headaches

B. An 8 year old child sucks his thumb and wets the bed Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period, such as an 8 year child sucking his thumb and wetting the bed.

The response to stress for older adults may be manifested differently than in younger adults. The nurse recognizes that. For the older adult client, the nurse is aware that: A. Losses are more stress-provoking B. Anxiety disorders are most prevalent C. Psychosocial factors are the greatest threats D. Timing of stress-inducing events is not significant

B. Anxiety disorders are more prevalent Anxiety disorders are the most prevalent disorders in later life and are continuations of life-long illnesses. Losses in later life may be less stress provoking than generally assumed, partly because certain life transitions are anticipated and people prepare by coping in advance.

A client who has experienced massive soft tissue trauma is handling both the physical and emotional stressors via the GAS. The major benefit of this defense mechanism is through the: A. Identification of foreign antigens on invading bacteria B. Production of endorphins that decrease awareness of pain C. Increased epinephrine, resulting in improved cardiac output D. Increased norepinephrine directed towards sustaining blood pressure

B. Production of endorphins that decrease awareness of pain Endorphins, hormones that act on the mind like morphine and opiates, produce a sense of well-being and reduce pain. It is the body's immune system that recognizes antigens on the surface of the bacterial cells and thus identifies bacteria as invaders. During the alarm reaction stage of the GAS process, rising epinephrine and norepinephrine levels result in increased heart rate and blood flow.

The son of a client is diagnosed with moderately advanced Alzheimer's disease shows concern over the care his mother will receive after making the decision to institutionalize her. Which of the following statements made by the admitting nurse is most therapeutic in addressing the son's concerns? A. "We care deeply for all our clients and take great pride in the care and attention we give each one of them." B. "Please feel free to talk to our staff and to the other clients about care and attention we give to each of our clients." C. "I hope that you will be able to visit your mother often and offer us suggestions on how best to meed her physical and emotional needs." D. "I know is has been a difficult decision, and you must have concerns about leaving her, but rest assured we have her best interest at heart."

C. "I hope that you will be able to visit your mother often and offer us suggestions on how best to meet her physical and emotional needs." The decision to institutionalize a family member and the aftermath of that decision cause emotional distress and are a threat to family members' psychological well-being. When their role shifted from primary caregiver to advocate for the patient, the family members felt empowered. Previous studies showed that institutionalized residents have a better quality of life when family members are involved.

A 72 year old client is in a long term care facility after having had a cerebrovascular accident. The client is non-communicative, enteral feedings are not being absorbed, and respirations are becoming labored. Which of the stages of the GAS is the client experiencing? A. Alarm reaction B. Resistance stage C. Exhaustion stage D. Reflex pain response

C. Exhaustion stage The exhaustion stage occurs when the body can no longer resist the effects of the stressor and when the energy necessary to maintain adaptation is depleted. During the alarm reaction, rising hormone levels result in increased blood volume, NE and E amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. During the resistance stage, the body stabilizes. Reflex pain response is not a stages of GAS.

It appears to the nurse the client is experiencing a crisis. The nurse plans to: A. Allow the client to work through independent problem-solving B. Complete an in-depth evaluation of stressors and responses C. Focus on immediate stress reduction D. Recommend ongoing therapy

C. Focus on immediate stress reduction The nurse's focus for a client experiencing a crisis is immediate stress reduction. A person who has experienced a crises has changed, and the effects may last for years or for the rest of the person's life. If a person has successfully coped with a crises and its consequences, he or she becomes a more mature and healthy person, and ongoing therapy may not be necessary.

Clients experiencing PTSD following the World Trade Tower bombing work with nurses in the medical center. An approach that is appropriate and should be incorporated into the plan of care is: A. Suppression of anxiety-producing memories B. Reinforcement that the PTSD is short term C. Promotion of relaxation strategies D. Focus on physical needs

C. Promotion of relaxation strategies Teaching the client relaxation strategies can help reduce the stress of anxiety-provoking thoughts and events, as seen in PTSD, and reinforces an adaptive coping strategy.

The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the resulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.) A. Rectal temperature of 102.2F B. Pulse ox of 97% on room air C. Respirations of 30 breaths/minute D. Heart rate greater than 100 beats/minute E. Fasting glucose level of 118 mg/dL F. Systolic blood pressure 26 mmHg above baseline

C. Respirations of 30 breaths/minute D. Heart rate greater than 100 beats/minute E. Fasting glucose level of 118 mg/dL F. Systolic blood pressure 26 mmHg above baseline This reaction prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar levels. Body temperature and oxygen saturation are not typically affected by fight or flight.

A 23 year old man who recently had a head injury from a motor vehicle accident is in a state of unconsciousness. Which of the following physiological adaptations is primarily responsible for his level of consciousness? A. Pituitary gland B. Medulla oblongata C. Reticular formation D. External stress response

C. Reticular formation The reticular formation is primarily responsible for an individual's level of consciousness. The pituitary gland supplies hormones that control vital functions. The medulla oblongata controls vital functions such as heart rate, blood pressure, and respiration. The external stress response is not primarily responsible for a person's level of consciousness.

Which of the following client behaviors best reflect Neuman Systems Model of primary prevention? The client who: A. Swims daily to strengthen muscles weakened as a result of shoulder surgery B. Follows a low-fat diet in order to bring her HDLs to under 200 mg/dL C. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mmHg D. Attends a survivor support group after the loss of a spouse in an automobile accident

C. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mmHg According to Neuman's theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention.

18. Which subjective assessment data are most supportive of a client's diagnosis of anxiety? 1. Diaphoretic and cool skin 2. An apical pulse rate of 120 beats per minute 3. Reports "needing to leave now" 4. Claims "something is terribly wrong"

Claims "something is terribly wrong"

11. The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the: 1. Client 2. Physician 3. Family member 4. Experienced unit nurse

Client

12. The process of data collection should begin with the nurse performing a: 1. Physical exam 2. Client interview 3. Review of medical records 4. Discussion with other health team members

Client interview

13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the client's health problem. To obtain these data most efficiently, the nurse should use: 1. Channeling 2. Open-ended questions 3. Closed-ended questions 4. Problem-seeking responses

Closed-ended questions

4. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: 1. Clustering data 2. Validating data 3. Peer reviewing 4. Problem statement

Clustering data

10. A child's understanding of the concept of ice becoming water, Piaget's stage of cognitive development, is seen in: 1. Sensorimotor 2. Preoperational 3. Formal operations 4. Concrete operations

Concrete operations

12. In applying Gould's developmental theory, the nurse anticipates that a client will have a greater concern for one's health within the following theme and age-group: 1. First theme (20s) 2. Second theme (early 30s) 3. Fourth theme (40s) 4. Fifth theme (50s)

Fifth theme (50s)

The nurse is caring for a client who was admitted with various physical traumas resulting from an assault by a stranger attempting to steal her purse. Which of the following statements made by the nurse is most therapeutic in assessing the degree of stress the event has caused the client? A. "Would you like to talk about the attack?" B. "What may I do to help you emotionally?" C. "Has being attacked been traumatic for you?" D. "How has this experience affected your life?"

D. "How has this experience affected your life?" The vital question for a person in crisis is, "What does this mean to you; how is it going to affect your life?" What causes extreme stress for one person is not always stressful to another. The perception of the event, the situational supports, and the coping mechanisms all influence return equilibrium or homeostasis.

Which of the following statements reflects the correct interpretation of the effect of age on coping strategies? A. "The young adult client generally handles stress more effectively than does the elder adult." B. "Life provides the older adult with more opportunities to effectively manage their stressful events." C. "Children appear to be less aware of stressors in their lives and so are less negatively affected by it." D. "Stress is evident in everyone's life and we all learn to cope with it regardless of our age or life experiences."

D. "Stress is evident in everyone's life and we all learn to cope with it regardless of our age or life experiences." There are very few age-related differences in coping strategies, and older adults are just as effective at coping as younger adults.

During the end of shift report the nurse notes that a client has been very nervous and preoccupied during the evening and that no family visited. To determine the amount of anxiety that the client is experiencing, the nurse should respond: A. "Would you like for me to call a family member to come support you?" B. "Would you like to talk with another client who had the same surgery?" C. "How serious do you think the illness you are experiencing really is?" D. "You seem worried about something. Would it help to talk about it?"

D. "You seem worried about something. Would it help to talk about it?" The nurse learned from the client both by asking questions and by making observations of nonverbal behavior and the client's environment. To determine the amount of anxiety the client is experiencing, the nurse gathers information from the client's perspective. Noting that he seems worried and offering to discuss it is the correct response.

What priority assessment area has been noticed by a nurse while working with clients who are experiencing a significant degree of stress? A. The client's primary physical needs B. What else is happening in the client's life C. How the stress has influenced the client's activities of daily living D. Determining whether the client is thinking about harming self or others

D. Determining whether the client is thinking about harming self or others A priority assessment is to determine if the person is suicidal or homicidal by asking directly. The priority assessment for the client who is experiencing a significant degree of stress is not the client's physical needs. The nurse should first determine if the client is a danger to self or others.

A corporate executive works 60 to 80 hours/week. The client is experiencing some physical signs of stress. The practitioner teaches the client to "include 15 minutes of biofeedback." This is an example of which of the following health promotion intervention? A. Guided imagery B. Regular exercise C. Time management D. Relaxation technique

D. Relaxation technique Biofeedback is a training program designed to develop one's ability to control the autonomic nervous system. Clients learn to monitor their functioning such as heart rate, blood pressure, skin temperature, or muscle tension, and learn to relax in response in order to create desired changes.

A client is experiencing job-related stress. The nurse is working with the client in an outpatient health care setting. The nurse believes this client is dissociated as a result of observing the client: A. Avoid discussion of job problems B. Act like another colleague on the job C. Experience chronic headaches and stomach aches D. Sit quietly and not interact with any of the staff

D. Sit quietly and not interact with any of the staff Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one's surrounding. The client who is sitting quietly and not interacting with any of the staff may be displaying dissociation.

A client recently lost a child in a severe case of poisoning. The client tells the nurse, "I don't want to make any new friends right now." This is an example of which of the following indicators of stress? A. Spiritual indicator B. Emotional indicator C. Intellectual indicator D. Sociocultural indicator

D. Sociocultural indicator The client who recently experienced a loss and does not want to meet new people is an example of a sociocultural indicator of stress.

7. The nurse recognizes that which one of the following statements about growth and development is correct? 1. Development ends with adolescence. 2. Growth refers to qualitative events. 3. Developmental tasks are age-related achievements. 4. Cognitive theories focus on emotional development.

Developmental tasks are age-related achievements.

10. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? 1. Pain in the left leg 2. Elevated blood pressure 3. Fear of impending surgery 4. Discomfort upon breathing

Elevated blood pressure

2. The nurse using Erikson's theory to assess a 20-year-old client's developmental status expects to find which of the following behaviors? 1. Coping with physical and social losses 2. Enjoys participating in the community 3. Applying self to learning skills 4. Overcoming a sense of guilt or frustration

Enjoys participating in the community

30. The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to: 1. Facilitate the exchange of information between appropriate parties 2. Minimize the opportunity for this information to be assessed inappropriately 3. Ensure the client's right to have his medical information regarded as personal and confidential 4. Guarantee that the information will be shared with only those requiring it for client care purposes

Ensure the client's right to have his medical information regarded as personal and confidential

26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor? 1. Conducting the interview with the client's boyfriend present 2. Stopping the interview to answer a page from the nursing station 3. Frequently checking the time while waiting for the client to answer 4. Heard asking the client, "Am I correct; you've rated your pain a 9 out of 10?"

Frequently checking the time while waiting for the client to answer

9. The nurse has completed an assessment and found that the client has "an activity and exercise abnormality." This type of wording indicates that which of the following organizing formats has been used? 1. Review of systems 2. Nursing health history 3. Gordon's functional health patterns 4. Biographical information database

Gordon's functional health patterns

6. The nurse working in an adult medical clinic wishes to learn more about a developmental theory that focuses on the adult years. The nurse investigates different possibilities and selects the theory proposed by: 1. Gould 2. Piaget 3. Freud 4. Chess and Thomas

Gould

28. What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift? 1. Document the request in the nursing notes. 2. Include the client's request in the shift report. 3. Place instructions regarding the client's wishes above the client's bed. 4. Verbally inform the unit clerk of the client's request.

Include the client's request in the shift report.

1. A nurse who wants to apply a theory that relates to moral development should read more from the work of: 1. Gould 2. Freud 3. Erikson 4. Kohlberg

Kohlberg

11. The nurse in a pediatric health care setting is using Kohlberg's developmental theory. A child is evaluated as having reached level I, the preconventional level, if the child: 1. Makes sure that he or she is not late for school 2. Cleans the blackboards after school for the teacher 3. Runs for school council in order to change policies 4. Stays away from peer groups that harass other children

Makes sure that he or she is not late for school

13. The nurse is working with a new mother who will require surgery. The follow-up treatment will interfere with bonding. In applying Freud's theory, the nurse recognizes that the stage of development that may be affected is the: 1. Oral stage 2. Anal stage 3. Phallic stage 4. Latent stage

Oral stage

1. A client interview consists of three phases. The nurse recognizes that those phases are: 1. Orientation, working, termination 2. Introduction, controlling, selection 3. Introduction, assessment, conclusion 4. Orientation, documentation, database

Orientation, documentation, database

8. In Kohlberg's Moral Development theory, an individual who reaches level II (conventional thought) is expected to exhibit: 1. Absolute obedience to authority 2. Reasoning based on personal gain 3. Personal internalization of other's expectations 4. Self-chosen ethical principles, universality, and impartiality

Personal internalization of other's expectations

3.The nurse recognizes that Freud's theory approaches development by looking at: 1. Moral reasoning. 2. Logical maturity 3. Psychosexual aspects 4. Cognitive development

Psychosexual aspects

7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories? 1. Family history 2. Psychosocial history 3. Biographical history 4. Environmental history

Psychosocial history

29. While discussing a client's medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation? 1. Note the allergy on the client's Kardex. 2. Inform the provider of the client's possible allergy. 3. Review the client's medical record for confirmation of the allergy. 4. Tell the client to have all medications identified before taking them.

Review the client's medical record for confirmation of the allergy.

9. According to Piaget, the infant is in the first period of development, which is characterized by: 1. Concrete operations 2. Preoperational thought 3. Sensorimotor intelligence 4. Identity versus role confusion

Sensorimotor intelligence

24. When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be: 1. The client tearing when being ambulated to the chair 2. A report from the ancillary staff that the client is reporting pain 3. The client observed grimacing when positioning self in the bed 4. Overhearing the client discuss hip pain with family on the phone

The client observed grimacing when positioning self in the bed

2. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: 1. The onset and duration of his present breathing problem 2. His personal smoking, alcohol use, and exercise practices 3. Any extended family members who have diagnosed heart disease 4. Changes in other body systems that the client perceives as problematic

The onset and duration of his present breathing problem

3. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: 1. A family history of heart problems 2. Medications currently being taken at home 3. Questions or concerns about hospitalization 4. The onset, severity, and duration of the chest pain

The onset, severity, and duration of the chest pain

5. The client recently became febrile and stated he "felt hot." The nurse takes the client's temperature and finds it to be 38.2° C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? 1. Pulse rate of 88 beats per minute 2. Blood pressure of 168/80 mm Hg 3. The statement regarding his feeling hot 4. The supported fact that he became febrile

The statement regarding his feeling hot

4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected by the nurse to exhibit which of the following behaviors? 1. Far-reaching problem-solving 2. Exploration of the environment 3. Cooperation and sharing with others 4. Thinking with the use of symbols and images

Thinking with the use of symbols and images

31. The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle? 1. Speaking slowly, clearly, and in a normal tone 2. Using various forms of nonverbal communication 3. Relying heavily on touch to convey caring and interest 4. Involving family in discussions concerning meeting client's needs

Using various forms of nonverbal communication