exam 4
Which diagnoses would be written for stress as the cause of the problem? A) Anxiety related to conflicts about values and goals in life B) Caregiver Role Strain related to long-term stress of care for a parent with Alzheimer's disease C) Spiritual Distress related to inability to accept diagnosis of terminal illness D) Hopelessness related to presence of disabling physical injuries
A) Anxiety related to conflicts about values and goals in life
To obtain subjective data about a burn client's self-concept, the nurse should do what? A) Ask the client how she would describe herself. B) Observe the client's interactions with others. C) Document the client's lack of eye contact. D) Note how the client conceals her wound.
A) Ask the client how she would describe herself.
Which of the following body systems are the primary controllers of homeostatic mechanisms? Select all that apply. A) Autonomic nervous system B) Endocrine system C) Respiratory system D) Cardiovascular system E) Gastrointestinal system
A) Autonomic nervous system B) Endocrine system
The nurse walks into the client's room and finds her sobbing uncontrollably. When the nurse asks what the problem is, the client responds I am so scared. I have never known anyone who goes into a hospital and comes out alive. On this client's care plan the nurse notes a nursing diagnosis of Ineffective coping related to stress. What is the best outcome you can expect for this client? A) Client will adapt relaxation techniques to reduce stress. B) Client will be stress free. C) Client will avoid stressful situations. D) Client will start anti-anxiety agent
A) Client will adapt relaxation techniques to reduce stress
For which persons are death certificates necessary? Select all that apply. A) Death from an infectious disease B) Death in an institutional setting C) Unexpected death D) Murder victims E) Death before age 65 years
A) Death from an infectious disease B) Death in an institutional setting C) Unexpected death D) Murder victims E) Death before age 65 years
What term is used to describe painful intercourse? A) Dyspareunia B) Dysmenorrhea C) Impotence D) Vulvodynia
A) Dyspareunia
As decisions related to health care become increasingly complex, nurses need to be familiar with concepts related to advance directives. Which statement regarding advance directives is correct? A) Hospitals are legally required to inform clients about advance directives. B) The status of advance directives remains consistent from state to state. C) Advance directives should be developed with the assistance of a physician or nurse. D) Nurses can be appointed a surrogate decision maker by the client.
A) Hospitals are legally required to inform clients about advance directives.
The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care? A) Improve the client's and family's quality of life. B) Support aggressive treatment for cure. C) Provide physical support for the client. D) The client may develop a separate plan with each discipline of the health care team.
A) Improve the client's and family's quality of life.
A boy age 13 years visits the school nurse's office and asks to speak privately with her. He looks very upset and embarrassed and struggles to make eye contact with the nurse. After some stuttered stops and starts, he finally asks about masturbating and if the things he has heard about it are true. The nurse provides correct education and information for the young man about masturbation by telling him which of the following? Choose all that apply. A) It is a technique of self-stimulation B) People do it regardless of age or gender C) Masturbation can lead to blindness D) Masturbation is not dirty or wrong E) Masturbation can decrease intelligence
A) It is a technique of self-stimulation B) People do it regardless of age or gender D) Masturbation is not dirty or wrong
A client with an inflamed appendix is feeling pain in the stomach area. What is the term for this body response to stress? A) Local adaptation syndrome B) General adaptation syndrome C) Physiological homeostasis D) Fight-or-flight response
A) Local adaptation syndrome
The clinic nurse sees the client today and asks about his chief complaint. The client describes to the nurse his inability to attain an erection. Which of the following would be a priority for the nurse to assess? Choose all that apply. A) Medication history B) Specifics about sexual problem C) Sleep history D) Physical activity history E) History of diabetes
A) Medication history B) Specifics about sexual problem E) History of diabetes
After instructing the male client on the performance of a testicular examination, the nurse instructs the client to perform the examination how often? A) Monthly B) Weekly C) Bi-monthly D) Bi-yearly
A) Monthly
Which of the following persons is responsible for handling and filing a death certificate with proper authorities? A) Mortician B) Physician C) Nurse D) Hospital administrator
A) Mortician
The wife of a client on hospice at home is diagnosed with "caregiver burden." Which of the following best describes this syndrome? A) Prolonged stress from caring for a family member at home B) Inability to provide competent care for a family member C) Insufficient funds to pay for medical care of a family member D) Effect of the illness causing stress in siblings
A) Prolonged stress from caring for a family member at home
A dying client is crying. She states, Why me, Lord?" and "I can't pray." What would be an appropriate nursing diagnosis based on this data? A) Psycho-spiritual distress B) Low self esteem C) Ineffective coping D) Knowledge deficit related to praying
A) Psycho-spiritual distress
A client who is being seen at a physician's office states that he has "bad headaches all the time." Diagnostic tests are normal. What is this type of response to stress called? A) Psychosomatic disorder B) Acute illness C) Chronic illness D) Pretend disorder
A) Psychosomatic disorder
The nurse is caring for a female age 45 years who discloses during the admission nursing history that she is no longer able to enjoy sex with her husband because it causes too much pain in her vagina. The nurse includes which of the following nursing diagnoses in the client's care plan related to this information? A) Sexual Dysfunction: Dyspareunia B) Altered Sexuality Patterns: Change in sexual expression C) Altered Sexuality Patterns: Loss of desire D) Altered Sexuality Patterns: Change in positioning
A) Sexual Dysfunction: Dyspareunia
A client has been brought to the health care facility with accident-related injuries. During the initial interview, the client becomes agitated, upset and is unable to answer any more of the nurse's questions. What does the nurse conclude about the condition of the client? A) The client's mind is preparing for a fight-or-flight response as he relates the incident. B) The client's mind is numb, and he is not able to react to further questions from the nurse. C) The brain is receiving less oxygen with each passing minute, which does not allow him to speak. D) The brain is sending chemicals to the bloodstream that make the client afraid of the questions.
A) The client's mind is preparing for a fight-or-flight response as he relates the incident.
A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations. Based on these findings, the nurse recognizes which of the following? A) These are signs of impending death. B) These signs do not indicate any abnormality. C) The client requires immediate resuscitation. D) The client's family should be asked to leave.
A) These are signs of impending death.
The nurse promotes the self-concept of the parents of an infant age 6 months admitted to the hospital with a fever and dehydration by doing what? A) Telling the parents that the infant's condition was not their fault B) Allowing the parents to participate in the infant's care C) Encouraging the parents to visit the infant every other day D) Educating the parents on health-maintenance behaviors
B) Allowing the parents to participate in the infant's care
A middle-age woman is mentally preparing for the death of her mother. What is the term for this mental preparation? A) Grieving B) Anticipatory grieving C) Bereavement D) Loss
B) Anticipatory grieving
Which of the following illnesses has been associated with long-term stress? A) Bacterial infections B) Cardiovascular disease C) Renal disease D) Fractures
B) Cardiovascular disease
A young woman has been in an automobile crash and sustained a laceration across the left side of her face, resulting in a large scar. What nursing diagnosis would be appropriate for this disfigurement? A) Anxiety B) Disturbed Body Image C) Deficient Knowledge D) Impaired Memory
B) Disturbed Body Image
A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis. A) Altered self-esteem related to colostomy and poor self-image B) Disturbed body image related to colostomy as evidenced by avoidance of colostomy C) Fear of rejection by others related to colostomy and altered self-image D) Altered role performance related to inability to cope with visitors
B) Disturbed body image related to colostomy as evidenced by avoidance of colostomy
Which strategy can be used to help clients overcome powerlessness? A) Encourage clients to identify their weaknesses. B) Encourage clients to identify their strengths. C) Provide advice on how to handle problems. D) Set goals and make decisions for the client
B) Encourage clients to identify their strengths.
A terminally ill client states to the nurse, "My situation is hopeless; I have no control over anything." The nurse implements which of the following interventions to enable hope for the client? A) State to the client, "We have explored all treatment options." B) Encourage the client to discuss his feelings. C) Sit in a chair next to the client. D) Hold the client's hand. E) Withhold information about disease progression.
B) Encourage the client to discuss his feelings. C) Sit in a chair next to the client. D) Hold the client's hand.
The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system? A) Blood sugar of 65 mg/dL B) Heart rate of 102 beats/minute C) Increased bowel sounds D) Cool, clammy skin
B) Heart rate of 102 beats/minute
Various physiologic mechanisms within the body respond to internal changes to maintain relative constancy in the internal environment. The state that results is called what? A) Nirvana B) Homeostasis C) Fight-or-flight response D) Anxiety
B) Homeostasis
A young woman client admits to a nurse that she cannot control her jealousy when she and her partner are out together and states, "It's like we're back in high school again." This is an example of which identity disorder? A) Self-actualization B) Identity diffusion C) Depersonalization D) Lack of self-esteem
B) Identity diffusion
The nurse conducting a class on human sexuality includes which of the following about gender identity? A) It is opposite of biologic gender. B) It may be the same as or different from biologic gender. C) It is determined by male (XY) or female (XX) chromosomes. D) It is determined by physical characteristics.
B) It may be the same as or different from biologic gender.
A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies? A) Follow his or her own conscience and perform CPR. B) Make no attempt to resuscitate the client. C) Follow a verbal physician's order for a slow code. D) If the client is at home, call 911 and begin CPR.
B) Make no attempt to resuscitate the client.
What is the most significant difficulty regarding sexuality faced by people taking medications for hypertension? A) Medications result in increased desire for sex. B) Medications change sexual functioning. C) Clients experience a growth of body hair. D) Clients experience increased body odors.
B) Medications change sexual functioning.
A student is preparing for her first client care assignment. She wakes up at 4 AM with a pounding pulse and diarrhea. What type of adaptive response to stress is she experiencing? A) General adaptation syndrome B) Mind-body interaction C) Local adaptation syndrome D) Coping or defense mechanism
B) Mind-body interaction
In which of the phases of the sexual response cycle may secretions from Cowper's glands appear at the glans of the penis? A) Excitement B) Plateau C) Orgasm D) Resolution
B) Plateau
An individual steps into a tub of very hot water and immediately jumps out again. What mechanism caused this response? A) Inflammatory response B) Reflex pain response C) General adaptation syndrome D) Fight-or-flight response
B) Reflex pain response
A nurse teaches a client deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique? A) Meditation B) Relaxation C) Anticipatory guidance D) Guided imagery
B) Relaxation
While interviewing a compulsive gambler 45 years of age, the woman blames her loss of job, estrangement from spouse, and lack of friends on destiny. The nurse interprets this information as indicative of which aspect of altered self-concept? A) Self-care deficit B) Self-destructive behavior C) Behavioral changes D) Anxiety and depression
B) Self-destructive behavior
A client states, "I am not smart enough to learn how to take care of my mother, and I just don't think I can do it." This is an example of ... A) Self-perception B) Self-knowledge C) Self-expectation D) Social self
B) Self-knowledge
Which statement is an example of the effect of aging, illness, or trauma on self-concept? A) Society values the wisdom of aging B) Society devalues aging and chronic illness C) Few people take a healthy body for granted D) Most people accept the inevitability of illness
B) Society devalues aging and chronic illness
A new client has come to the clinic wanting a method of birth control. The client asks about a diaphragm. What would the nurse teach this client about a diaphragm? A) One size fits all females. B) The diaphragm must be used during each episode of sexual activity. C) A diaphragm's effectiveness does not require spermicidal jelly. D) The diaphragm may be removed an hour following intercourse.
B) The diaphragm must be used during each episode of sexual activity.
Palliative care is a structured system for care delivery that has what as its aim? A) To give traditional medical care B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope
B) To prevent and relieve suffering
The nurse is caring for a female client 64 years of age who is admitted for knee replacement. As the nurse performs the shift assessment, the client comments, I wouldn't mind getting old if it were not for the physical losses, like the wrinkles, all the drooping, and the wearing out of everything. People like to be around youthful, beautiful men and women; I feel so unattractive. Is the client correct about how society views older people? In general, which of the following does society emphasize and reward? Choose all that apply. A) Wisdom for sharing B) Youthfulness C) Mentoring the inexperienced D) Health and fitness E) Physical attractiveness
B) Youthfulness D) Health and fitness E) Physical attractiveness
Which of the following questions or statements would be most useful for the nurse to make when eliciting information about a client's sexual history? A) "We need to talk about this." B) Why did you have unprotected sex? C) "How would you describe the problem? D) I need to know sex partners' numbers."
C) "How would you describe the problem?
While caring for a client near end of life, a student talks to her. Another student asks why she is talking to someone who is dying. Which response would be accurate? A) "It makes me feel better to talk to my clients." B) "I do this so I won't be so afraid the client will die." C) "I believe the client can hear me as long as she is alive." D) "I don't know; the nurse in charge of the client told me to."
C) "I believe the client can hear me as long as she is alive."
Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the bargaining stage? A) "The doctors must have made a mistake." B) "Why did this happen to me? I always exercised." C) "Just let me live to see my grandson born." D) "I've had a good life and I can die in peace."
C) "Just let me live to see my grandson born."
Family members of a dying client are in the room with their loved one. As the client nears death, what should the nurse tell the family? A) "Please leave the room now. It is time to let go." B) "Only one family member at a time can stay in the room." C) "Please stay with your loved one and talk to him." D) "I will have to get an order for you to stay now."
C) "Please stay with your loved one and talk to him."
A woman age 70 years tells the nurse that she is still sexually active. How would the nurse respond? A) "You are too old for that kind of behavior." B) "Tell me what you enjoy the most." C) "You can be sexually active as long as you want to be." D) "There comes a time in life when this is no longer important."
C) "You can be sexually active as long as you want to be."
Which of the following is an example of a perceived loss? A) A client mourns the loss of his amputated leg. B) A client grieves for the loss of his wife to cancer. C) An older client grieves for the loss of his independence. D) A client grieves for the loss of his job.
C) An older client grieves for the loss of his independence.
A child learns to feel secure within the bonds of his immediate family by interacting with his caretakers. What is the term for this process? A) Self-reflection B) Adaptation C) Attachment D) Globalization
C) Attachment
The client suffered a myocardial infarction (MI) and has shared with the nurse that he is reluctant to resume sexual activity. He is worried about having another MI. The nurse discusses various methods of sexual expression and points out that the most important body area for sexual arousal and stimulation is which of the following? A) Breasts B) Skin C) Brain D) Genitalia
C) Brain
A nurse caring for critically ill clients uses interventions to help clients maintain a sense of self. Which of the following are recommended interventions? A) Disregard the client's status. B) Do not use touch out of respect for the client's privacy. C) Converse with the client about his or her life experience. D) Do not acknowledge or allow expression of negative feelings.
C) Converse with the client about his or her life experience.
A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor? A) Adaptation B) Homeostasis C) Coping mechanism D) Defense mechanism
C) Coping mechanism
The children of immigrants may have different values and practices than do their parents, causing them to abandon their parents' cultural beliefs. What is this called? A) Cultural expectations B) Cultural competence C) Cultural dissonance D) Cultural modernization
C) Cultural dissonance
When conducting a class on sexuality with teenagers, the nurse includes that sexuality is which of the following? A) External appearance of one's genitalia as male or female B) Male or female internal organ structure and function C) How one experiences maleness or femaleness physically, emotionally, and mentally D) The pleasure experienced during sexual activity
C) How one experiences maleness or femaleness physically, emotionally, and mentally
A nurse is caring for a young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members? A) Inform the family that the client may soon be out of danger B) Request the family members not to talk about death to the client C) Inform the family members that it is time to bid farewell to the client D) Provide respite care to the client's family members
C) Inform the family members that it is time to bid farewell to the client
A woman is using Depo-Provera as a method of birth control. What common side effect should the nurse explain to the client? A) Constipation B) Nausea C) Irregular bleeding D) Pregnancy
C) Irregular bleeding
A client asks a nurse to explain a living will. What is the nurse's best answer? A) It specifies who will inherit the client's estate. B) It determines an individual's quality of life. C) It lists specific instructions for health care provisions. D) It identifies a trusted person to make health care decisions.
C) It lists specific instructions for health care provisions.
A nurse is educating a student nurse on how STIs affect the health of their clients. Which of the following statements accurately describes an effect of an STI? A) STIs are most common in young to middle adulthood populations. B) The incidence of STIs is decreasing due to health promotion efforts. C) Most of the time STIs cause no symptoms, especially in women. D) Health problems caused by STIs are more severe and frequent in men.
C) Most of the time STIs cause no symptoms, especially in women.
Which area of nursing experiences the highest levels of stress in the work setting? A) Obstetric nurses B) Pediatric nurses C) New graduates D) Aging nurses
C) New graduates
While answering questions posed by a nurse during a health history, a young woman says, "Before my period I get headaches, am moody, and my breasts hurt." What is the client experiencing? A) Perimenopause B) Menarche C) PMS D) Menses
C) PMS
A nurse visits a diabetic client age 60 years in his home after the client's above-the-knee amputation of his left leg. The client appears disheveled and with poor hygiene. He also avoids making eye contact with the nurse. Which of the following is likely to occur as a result of the client's reduced self-esteem? A) Lethargy B) Withdrawal C) Self-care deficit D) Lack of interest
C) Self-care deficit
A nurse is responding to sexual harassment from a client at work. Which of the following is a recommended guideline for dealing with this behavior? A) If confronted by management, deny any feelings about being harassed. B) Do not confront the person harassing you in person. C) Set and enforce limits to the behavior and maintain boundaries. D) Document the incident but do not report it to the supervisor unless harassment continues.
C) Set and enforce limits to the behavior and maintain boundaries.
A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crisis is she experiencing? A) Adventitious B) Maturational C) Situational D) Emotional
C) Situational
A hospice nurse is providing emotional care and support for a family who lost a son. The care will be provided based on what knowledge? A) All members of the family will react to loss in the same way. B) Grief is an abnormal physical reaction to a loss. C) Stages of grief reactions may overlap and are individualized. D) Bereavement is a normal process, requiring little intervention.
C) Stages of grief reactions may overlap and are individualized.
When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem? A) Change jobs. B) Avoid people who dump tasks on him. C) Take control of the situation. D) Avoid doing petty jobs.
C) Take control of the situation.
Cold temperatures and loud noises are stressors to one person but not another. Why does this occur? A) Although the perception is the same, the response is individualized. B) Both individuals will respond the same, depending on the situation. C) The perception and effects of stressors are highly individualized. D) The internal environment of one person is more selective.
C) The perception and effects of stressors are highly individualized.
A client age 35 years is stressed because he is having problems with his superiors at work. The client says that he had an argument with his superiors about his salary. He has become very anxious and has started consuming large amounts of caffeine very frequently. He also suffers from insomnia and gets angry quickly. Which of the following techniques should the nurse suggest to help the client? A) Non-therapeutic coping strategy B) Negative coping strategy C) Therapeutic coping strategy D) Sensory manipulation strategy
C) Therapeutic coping strategy
A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is what? A) To aggressively treat the disease. B) To provide care for the dying in the home. C) To aggressively treat the symptoms of the disease. D) To support the family of the dying client.
C) To aggressively treat the symptoms of the disease.
During a class for 5th- and 6th-grade girls about menstruation, one student comments that she has heard that girls smell bad during their menses. Other students chime in saying they have heard the same thing and ask how to prevent odors. The nurse correctly answers with which of the following solutions? A) Stay at home during heaviest flow B) Use deodorizing pads and tampons C) Utilize good hygiene and regular bathing D) Change pads or tampons at least daily
C) Utilize good hygiene and regular bathing
A woman tells a nurse, "My husband wants to have sex when I have my period. Is that safe?" What is an appropriate answer? A) "No, the flow of blood could be slowed down." B) "No, it will tend to make your cramps worse." C) "Yes, but be sure to douche after sex." D) "Yes, there is no reason not to have sex then."
D) "Yes, there is no reason not to have sex then."
Which of the following is an example of developmental stress? A) A newborn who needs to be fed by bottle B) A school-age child learning to read C) A teenager learning to drive a car D) A middle adult accepting signs of aging
D) A middle adult accepting signs of aging
Which of the following statements, made by a senior citizen who has taken a class on stress reduction, would indicate to the nurse the need for further instruction? A) Adults draw on coping skills learned throughout life. B) Family members can be supportive during stress. C) Stress may be positive or negative. D) As one grows older, their stress decreases
D) As one grows older, their stress decreases.
According to the Harvard University Medical School committee, what function must be irreversibly lost to define death? A) Respiratory functions B) Reflexes C) Consciousness D) Brain function
D) Brain function
A young woman has been diagnosed with human papilloma virus (HPV). As a result, she will be at increased risk for which of the following? A) Infertility B) Genital warts C) Vaginal bleeding D) Cervical cancer
D) Cervical cancer
A nurse who works on the pediatric unit wants to help a child cope with the loss of a leg in a hunting accident. What would the nurse implement to help the child express feelings? A) Support from other family members B) Television cartoons C) Story books D) Dolls or animals
D) Dolls or animals
A school nurse is teaching parents how to build self-esteem in their children. Which is a recommended strategy? A) Use praise and compliments judiciously B) Wait for your child to initiate conversation C) Focus on remedying the child's negative qualities D) Give your child many opportunities to display abilities
D) Give your child many opportunities to display abilities
If a nurse assessed the vital signs of a person who was in the initial alarm reaction stage (shock phase) of the GAS, what would be the expected findings? A) Slow, deep breathing B) Fatigue and lethargy C) Hypotension D) Hypertension
D) Hypertension
A nurse is explaining the use of an IUD to a female client interested in obtaining contraception. Which of the following statements regarding the IUD is correct? A) The intrauterine device (IUD) is an object that is placed by the client within the uterus to prevent implantation of a fertilized ovum. B) IUDs are small devices made of flexible plastic that provide irreversible birth control. C) IUDs do not prevent fertilization of the egg. D) IUDs seem to affect the way the sperm or egg moves.
D) IUDs seem to affect the way the sperm or egg moves.
In which age group do interpersonal losses play a role in disturbances in self-concept? A) Child B) Teenager C) Adult D) Older adult
D) Older adult
A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility? A) Placing the body in normal anatomic position B) Removing tubes and soiled dressings C) Washing the body to remove blood and excretions D) Placing ID tags on the shroud and ankle
D) Placing ID tags on the shroud and ankle
An adolescent male tells the nurse that he is afraid his penis will be damaged because he masturbates every day. The nurse's response is based on what knowledge? A) Masturbation is not a normal activity. B) Only adult men masturbate. C) Masturbation may delay puberty. D) Self-stimulation is a normal activity.
D) Self-stimulation is a normal activity.
What phase of the general adaptation syndrome is a client in when he uses all of his adaptive mechanisms for dealing with stress, leaving no defense against the distress? A) Alarm reaction stage B) Fight-or-flight stage C) Stage of resistance D) Stage of exhaustion
D) Stage of exhaustion
The client is a child age 5 years hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of ... A) compensation. B) displacement. C) reaction formation. D) regression.
D) regression.
The nurse is assessing his client's self-concept. The client is status post-myocardial infarction and is due to be discharged tomorrow. Which of the following focuses will give the nurse the most information about the client's self-concept? Choose all that apply. A) Body image B) Gender identity C) Self-esteem D) Role performance E) Sexual orientation
A) Body image C) Self-esteem D) Role performance
Of the following physiologic stressors, which one is a physical agent? A) Heat B) Drugs C) Bacteria D) Hypoxia
A) Heat
The nurse is caring for a girl 13 years of age, who is admitted after taking some of her mother's sleeping pills. She is withdrawn and declines to eat or engage in conversation, except to say she doesn't like herself. The nurse is aware that potential causes of poor self-concept at this age can be related to which of the following? Choose all that apply. A) Inability to accept bodily changes B) Identify confusion C) Failure to accept role responsibility D) Failure to develop meaningful goals E) Inability to resolve child versus adult roles
A) Inability to accept bodily changes B) Identify confusion E) Inability to resolve child versus adult roles
The nurse is conducting a class on human sexual response. The participants have understood the education when they identify that, during the excitement phase of the sexual response, the man may experience what? A) Nipple erection B) Hypotension C) Bradycardia D) Decreased blood flow to genitals
A) Nipple erection
A nurse is developing a plan of care for a dying client. Which of the following physiologic basic human needs should be addressed? A) Personal hygiene B) Rsk for infection C) Family support D) Spirituality
A) Personal hygiene
A nurse working with clients in a health care facility influences them to make healthy lifestyle choices. According to Coopersmith, which base of self-esteem for the nurse does this example represent? A) Power B) Significance C) Competence D) Virtue
A) Power
An infant learns that the physical self is different from the environment. What term is used to describe this stage of self-concept? A) Self-awareness B) Self-recognition C) Self-definition D) Self-concept
A) Self-awareness
Parents of an infant express concern because the infant is touching his genitals. What should the nurse teach the parents? A) Self-manipulation of genitals is normal behavior in an infant. B) Have the child wear clothes that prohibit touching. C) If this bad behavior continues, seek counseling. D) Make him have time out every time it happens.
A) Self-manipulation of genitals is normal behavior in an infant.
A young client died following a cardiac arrest. The nurse caring for the client and the family notes that some members of the family refuse to accept that the client has died. What stage of grief is the family experiencing? A) Shock and disbelief B) Developing awareness C) Restitution period D) Idealization
A) Shock and disbelief
The nurse is providing sexual education to a group of teenagers. One of the class members reports feeling sexually aroused when her boyfriend strokes her arms. The nurse points out that the human body has many erogenous zones, the largest being which of the following? A) Skin B) Brain C) Genitalia D) Breasts
A) Skin
The client is a single parent being seen at an employee wellness clinic. The client tells the nurse he has three school-age children who participate in various activities. He states, "Every night, I am taking them to soccer practice, football practice, Girl Scouts. I have to fix dinner and then go over homework. I have no time for myself. I am so tired." The client exhibits tremors of his hands. Blood pressure is 140/88 mm Hg, heart rate is 98 beats/minute, and respirations are 30 breaths/minute. Data best supports which of the following nursing diagnoses? A) Stress Overload related to single parenting B) Defensive Coping related to inability to appraise stressors C) Hopelessness related to multiple responsibilities D) Disturbed Sleep Pattern related to anxiety
A) Stress Overload related to single parenting
What do most nursing interventions pertaining to sexuality involve? A) Teaching to promote sexual health B) Examinations to identify sexually transmitted infections C) Advocacy for those with sexual dysfunctions D) Maintaining confidentiality and privacy
A) Teaching to promote sexual health
A nurse is counseling a female victim of sexual assault. Which of the following statements accurately describes the increased risks for this client? A) The client is three times more likely to suffer from depression. B) The client is 10 times more likely to suffer from post-traumatic stress disorder. C) The client is 20 times more likely to abuse alcohol and 26 times more likely to abuse drugs. D) The client is 20 times more likely to contemplate suicide.
A) The client is three times more likely to suffer from depression.
The husband of a client who died of breast cancer is still grieving for his wife two years later. What type of grief is he experiencing? A) Unresolved B) Situational C) Inhibited D) Maturationa
A) Unresolved
A male client tells the nurse that he does not understand why he feels the way he does when he is sexually excited. What would the nurse teach the client? A) "I don't know, but I will ask my boyfriend if he can describe his feelings to me." B) "The sexual response cycle includes excitement, plateau, orgasm, and resolution." C) "That is something that just happens and nobody knows why." D) "Isn't sex wonderful? I think it has different parts to the experience."
B) "The sexual response cycle includes excitement, plateau, orgasm, and resolution."
What is the term for the change that takes place in response to a stressor? A) Rehabilitation B) Adaptation C) Positive movement D) Negative movement
B) Adaptation
A dying client states in writing ahead of time what her choices would be for health care should certain circumstances develop. What is the term for this document? A) Living will B) Advance directives C) Durable power of attorney D) Comfort measures only
B) Advance directives
A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing? A) Maturational loss B) Anticipatory loss C) Dysfunctional grieving D) Bereavement
B) Anticipatory loss
Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief? A) Socioeconomic factors B) Cultural influences C) Religious influences D) Cause of death
B) Cultural influences
The wife of an older adult man has recently died. The couple was married for 32 years. What part of the man's self-concept may be influenced by this loss? A) Ideal self B) Global self C) Body image D) False self
B) Global self
Who or what plays the most influential role in the internalization of self-concept in children? A) Peers B) Parents C) School D) Church
B) Parents
What are the primary nursing considerations when assisting with, or conducting, a physical assessment of the genitalia? A) Ensuring sterility of all equipment and supplies B) Respecting the client's privacy and modesty C) Providing a means for cleansing the area D) Leaving the room during the assessment
B) Respecting the client's privacy and modesty
A heterosexual couple enjoys both anal and vaginal intercourse. What may result from these sexual activities? A) Feelings of guilt and shame B) Vaginal infections C) Damage to the vagina D) Penile infections
B) Vaginal infections
During a self-esteem assessment of a young woman undergoing a complicated divorce, a nurse states: "Tell me something about the moral-ethical principles that govern your life." What aspect of self-esteem is the nurse assessing? A) Significance B) Virtue C) Power D) Competence
B) Virtue
During an assessment of a client's self-esteem, a man age 45 years tells the nurse that he lost his job due to downsizing and has been unemployed for six months. What would be the appropriate response from the nurse? A) "You shouldn't feel bad about losing a job; it happens to everyone." B) "Do you need your job to support a family?" C) "How has losing your job affected your life and the lives of your significant others?" D) "There are more important things in life to worry about other than losing a job."
C) "How has losing your job affected your life and the lives of your significant others?"
A nurse is educating a client about the benefits of exercise in reducing stress. How often would the nurse recommend the client exercise? A) Two hours every day B) One hour once a week C) 30 to 45 minutes, most days of the week D) 60 to 75 minutes, four to five times a week
C) 30 to 45 minutes, most days of the week
A man has noticed bright red blood in his bowel movements for over a month. He says to himself, "Oh, it's just my hemorrhoids." What defense mechanism is the man using? A) Rationalization B) Repression C) Denial D) Compensation
C) Denial
What is the name given to the evaluative and affective component of the self-concept? A) Ideal self B) Body image C) Self-esteem D) Self-knowledge
C) Self-esteem
A teenager describes herself as "tall, attractive, female, student, intelligent." What part of her self-concept is she describing? A) Self-expectations B) Self-esteem C) Self-knowledge D) Self-evaluation
C) Self-knowledge
Which of the following questions would be helpful in eliciting data about the effects of stress during a health history? A) "Why are you having so much difficulty breathing at night?" B) "Why do you think smoking and drinking will calm you?" C) "Do you often drink too much and have hangovers?" D) "How does your body feel when you are upset?"
D) "How does your body feel when you are upset?"
What might a nurse ask during a health history to assess personal identity? A) "Tell me how your illness has affected you in your job." B) "Tell me what you do for fun and what you do for work." C) "How do you believe others see you? Why do you believe that?" D) "How would you describe yourself to others?"
D) "How would you describe yourself to others?"
The nurse is caring for a female 29 years of age who is admitted with chronic pain secondary to rheumatoid arthritis. She confides in the nurse that she would like to be able to have sex with her husband but it just hurts too much. The nurse's best response is which of the following? A) After a time that sort of thing doesn't matter. B) Is your husband willing to forgo sex? C) It may be time to put that behind you. D) Modified positions may be possible.
D) Modified positions may be possible.
A male client age 15 years is experiencing nocturnal emissions. What nursing intervention would be appropriate for this client? A) Ask the parents to consult with a specialist. B) Tell the client to limit physical activity in the evening. C) Ask the primary care provider to perform a physical examination. D) No intervention is necessary as this is a normal phenomenon.
D) No intervention is necessary as this is a normal phenomenon.
A woman who was assaulted in the street is brought to the emergency room for observation. A nurse documents that the woman has difficulty communicating verbally, is agitated, and complains of chest pain and a sense of impending doom. What type of anxiety is this client experiencing? A) Mild anxiety B) Moderate anxiety C) Severe anxiety D) Panic
D) Panic
A client is diagnosed with a terminal illness. Who is usually responsible for deciding what, when, and how the client should be told? A) Family B) Clergy C) Nurse D) Physician
D) Physician
A nurse is preparing to educate a client about care at home. On entering the room, she finds the client pacing around the room, hyperventilating, and complaining of nausea. Based on these manifestations of severe anxiety, what would the nurse do? A) Provide both verbal and written information to the client. B) Ignore the client and teach the family the information. C) Modify the education plan to the client's anxiety level. D) Postpone implementation of the education plan.
D) Postpone implementation of the education plan.
A nurse is caring for a young client with acute renal failure who is dying. What care should the nurse take when helping dying clients to cope? A) Avoid discussing death with the client. B) Ask the client's family not to disturb the client. C) Avoid informing the client of his or her actual health status. D) Provide opportunities for the client to express his or her feelings freely.
D) Provide opportunities for the client to express his or her feelings freely.
Which one of the following statements accurately describes the process known as grief reaction? A) Reactions to grief and dying are different. B) Reactions to grief are similar for all people. C) Reactions to grief follow all stages of the grieving process. D) Reactions to grief may differ from client to family.
D) Reactions to grief may differ from client to family.
As a child grows, he unconsciously develops a component of self-concept based on the image of role models. What part of the self-concept does this describe? A) False self B) Evolving self C) Self-knowledge D) Self-expectations E) `
D) Self-expectations
Which term best describes an individual's self-concept? A) Self-esteem B) Self-actualization C) Self-realization D) Self-image
D) Self-image
Which of the following occurs in the male during the resolution phase of the sexual response cycle? A) The penis becomes erect due to increased pelvic congestion of blood. B) Involuntary spasmodic contractions occur in the penis. C) The male orgasm occurs usually with ejaculation of semen from the penis. D) The male experiences a period during which he is incapable of sexual response.
D) The male experiences a period during which he is incapable of sexual response.
A dying client is undergoing terminal weaning. What is the purpose of this intervention? A) To manage the symptoms of the illness B) To prepare for resuscitation of the client C) To initiate life-sustaining measures for the client D) To gradually withdraw mechanical ventilation
D) To gradually withdraw mechanical ventilation
An adolescent rapidly develops secondary sex characteristics and body changes. What should the nurse assess to determine how these changes might affect the adolescent's self-concept? A) Expectations of the parents B) Developmental environment C) Meaningful use of time D) Understanding of changes
D) Understanding of changes
Which of the following group of terms best describes anxiety? A) Cognitive, known threat, depression B) Cognitive, visible threat, anger C) Known source, prolonged, solely physical D) Unknown cause, emotional, apprehensive
D) Unknown cause, emotional, apprehensive
The nurse is caring for a man client, age 47 years, who suffers from myasthenia gravis. He has periods of great weakness and is unable to do the things for his family that he would like to. He tells the nurse that he is not worth much these days. Knowing that sometimes clients focus on things they cannot do, which of the following statements by the nurse might be helpful? A) I'm sure that things will be better soon. B) Some days are like that. C) Does your family pitch in and help you? D) What are some of the things you do well?
D) What are some of the things you do well?
The nurse is attending a nursing conference about enhancing self-concept in relation to professional nursing practice. As the nurse is waiting for the first speaker to begin, she tries to recall what she knows and has read about this subject. Which of the following would be good for the nurse to keep in mind to enhance her self-concept as a professional nurse? A) Don't worry about team esteem until your own is good. B) Avoid your weaknesses until they become strengths. C) Remember past errors so you do not repeat them. D) You don't have to know everything to be a good nurse.
D) You don't have to know everything to be a good nurse.
A terminally ill client, in severe pain, asks a nurse to help her die. What must the nurse consider morally, ethically, and professionally before answering the client? A) ANA Code for Nurses, ethical and professional standards B) Own personal moral and ethical values and standards C) Hospital or agency procedures and protocols D) Medical Code of Ethics, belief in active euthanasia
a) ANA Code for Nurses, ethical and professional standards
Which of the following statements is typical of the first stage of grieving described by Engel? A) "No, not me." B) "Why me?" C) "My husband was the best man in the world." D) "The funeral service helped me survive."
A) "No, not me."
Which of the following responses to stressors results from the activation of the local adaptation syndrome? A) A girl quickly withdraws her hand from a stream of hot tap water. B) A woman's impending job interview has prompted the activation of her fight-or-flight response. C) A man is experiencing moderate anxiety before meeting with an important client. D) A man has a sudden urge for a bowel movement before undergoing thoracentesis.
A) A girl quickly withdraws her hand from a stream of hot tap water.
Which of the following best describes stress? A) A response to changes in the normal balanced state B) A perception that something is threatening C) A response to internal environment for homeostasis D) A localized response of a tissue or organ to a stressor
A) A response to changes in the normal balanced state
A nurse always addresses clients by the preferred name when entering a client's home or room. What is the nurse facilitating by this action? A) A sense of self and worth B) Reorientation to who they are C) Personal strengths D) Negative self-concept
A) A sense of self and worth
A woman has had a breast removed to treat cancer. What type of loss will she most likely experience? A) Actual loss B) Perceived loss C) Maturational loss D) Anticipatory loss
A) Actual loss
The nursing instructor is talking with the junior nursing class about male reproductive issues. The instructor tells the students that the causes of erectile dysfunction include which of the following? Select all that apply. A) Alcoholism B) Spinal cord trauma C) Tadalafil D) Phosphodiesterase-5 inhibitors E) Diabetes
A) Alcoholism B) Spinal cord trauma E) Diabetes
The nurse cares for a successful chemical engineer, age 29 years, who is admitted with a respiratory infection. The client reports feeling more stress than ever since a job promotion six months ago and asks, Why would something so positive and wonderful cause so much stress for me? Which is an appropriate response by the nurse? Select all that apply. A) All major life events can cause stress for us. B) People vary greatly in their perception of what constitutes a crisis or stressor. C) Your job promotion probably has nothing to do with the stress you feel. D) Positive life events do not cause stress or illness. E) Even positive life events can affect us in negative ways.
A) All major life events can cause stress for us. B) People vary greatly in their perception of what E) Even positive life events can affect us in negative ways.
An appropriate nursing diagnosis for the family of a client dying of cancer, whose members have expressed sorrow over the forthcoming loss, would be ... A) Anticipatory grieving related to loss of family member, as evidenced by sorrow B) Dysfunctional grieving related to the loss of family member, as manifested by behaviors indicating anxiety C) Potential for grieving related to loss of family member and sorrow D) Dysfunctional grieving related to future loss of family member, manifested by family's developmental regression
A) Anticipatory grieving related to loss of family member, as evidenced by sorrow
A woman complains of pain with intercourse. What client medications should the nurse check for that contribute to dyspareunia? A) Antihistamines B) Calcium supplements C) Antibiotics D) Antihypertensives
A) Antihistamines
