HAP Final Practice Book Questions
A baby can sit alone before he or she is able to crawl. This is true because development of gross motor skills: 1.occurs in a cephalocaudal direction. 2.occurs in a distal to proximal direction. 3.is generally the result of a baby's chronological age. 4.is simply the result of the baby's increased desire to move.
ANS: 1 A baby's development of gross motor skills is predictable because it follows the direction of myelinization (laying down of myelin) in the nervous system, cephalo- caudal (head to foot direction), and proximodistal (central to peripheral direction, or midline before extremities).
A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: 1.collect a follow-up database and then check her blood pressure. 2.ask her to read her health record and indicate any changes since her last visit. 3.check only her blood pressure because her complete health history was document- ed 2 months ago. 4.obtain a complete health history before checking her blood pressure because much of her history information may have changed.
ANS: 1 A follow-up database is used in all settings to follow up short-term or chronic health problems.
Being able to think about history and philosophy and analyze and use scientific reasoning corresponds to which of Piaget's stages? 1. Formal operations 2.Sensorimotor skills 3.Concrete operations 4.Preoperational skills
ANS: 1 Adolescence corresponds to Piaget's fourth stage, in which the person focuses on formal operations and the ability to develop abstract thinking, deal with hypothetical situations, and make logical conclusions from reviewing evidence. The adolescent is no longer limited to the present but can ponder the lessons of the past and the possibilities of the future. The adolescent now can analyze and use scientific reasoning.
A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college degree. She now dresses like her peers and says that her family "back home" would hardly recognize her. This illustrates: 1.assimilation. 2.heritage consistency. 3.biculturalism. 4.acculturation.
ANS: 1 Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture.
An 18-month-old who makes the statement, "All done," is using what form of speech? 1.Telegraphic speech 2.Holophrastic speech 3.Preoperational speech 4.Complex-interactive speech
ANS: 1 At 1 year, sentences begin with the one-word holophrase, in which one word represents a complete thought (e.g., "out" for "I want to go out."). A 2-year-old uses simple two-word phrases— "all gone," "me up,""baby crying." This is called telegraphic speech, which is usually a combination of a noun and a verb and includes only words that have concrete meaning.
At the well-child clinic, a nurse is advising the mother of an 8-month-old child about health and safety. Which of the following is appropriate for this age? 1.Stair guards or gates are important to use at this age. 2.A car seat is not necessary if a lap shoulder belt is used. 3.The home's hot water heater should be set at 135° F. 4.They are prime candidates for toilet training because they are so receptive to new ideas.
ANS: 1 By 8 months, a child is crawling and may be able to pull to a standing position and stand while holding an object for support. Stair guards are necessary to prevent injury. A car seat is necessary for children under age 5 years, and the hot water heater should be set below 120° to 130° F.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? 1.Breathing, pain, sleep 2.Breathing, sleep, pain 3.Sleep, breathing, pain 4.Sleep, pain, breathing
ANS: 1 First-level priority problems are immediate priorities (remember the ABCs), followed by second-level problems and then third-level problems.
The largest and fasting growing population in the United States is: 1.Hispanics 2.Blacks 3.Asians 4.American Indians
ANS: 1 Hispanics are the largest and fastest growing population in the United States, followed by blacks, Asians, American Indians, and other groups.
Why can working with children with a different cultural perspective be especially difficult? 1. Children have spiritual needs that are influenced by their stage of development. 2. Children have spiritual needs that are a direct reflection of what is occurring in the home. 3. Religious beliefs rarely affect the parents' perception of the illness. 4. Parents are often the decision makers and have no knowledge of their children's spiritual needs.
ANS: 1 Illness during childhood may be an especially difficult clinical situation. Children as well as adults have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family.
Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as:
ANS: 1 Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it.
Which critical thinking skill helps the nurse to see relationships among the data? 1.Validation 2.Clustering related cues 3.Identifying gaps in data 4.Distinguishing relevant from irrelevant
ANS: 2 Clustering related cues helps the nurse to see relationships among the data.
Which statement is correct regarding the development of one's culture? 1.Culture is genetically determined on the basis of racial background. 2.Culture is learned through language acquisition and socialization. 3.Culture is a nonspecific phenomenon and is adaptive but unnecessary. 4.Culture is biologically determined on the basis of physical characteristics.
ANS: 2 Culture is learned from birth through language acquisition and socialization.
During which age is belonging to a peer group considered a key socializing agent? 1.The preschool years 2.The school-age years 3.Early adulthood 4.Middle adulthood
ANS: 2 During middle childhood, the peer group is a key socializing agent. The child begins to prefer peer group activities to activities with the parents.
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be: 1.objective. 2.reflective. 3.subjective. 4.introspective.
ANS: 3 Subjective data are what the person says about himself or herself during history taking.
The stage of early adulthood (20 to 40 years) is concerned with emancipation from parents and building an independent lifestyle. Tasks of this era include: 1.pursuing activities enjoyed during childhood. 2.assisting younger siblings with gaining their identity. 3.Forming an intimate bond with another and choosing a mate. 4.becoming more involved with activities in their family of origin.
ANS: 3 Tasks of early adulthood include such things as growing independent from the parents' home, establishing a career, forming an intimate bond with another and choosing a mate, managing one's own household, and forming a meaningful philosophy of life.
The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II: 1.tests three areas of development: cognitive, physical, and psychologic. 2.will indicate whether the child has a speech disorder so that treatment can begin. 3.is a screening instrument designed to detect children who are slow in development. 4.is a test to determine intellectual ability and may indicate whether there will be problems later in school.
ANS: 3 The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor- adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of database is most appropriate to collect in this setting? 1.A follow-up database to evaluate changes at appropriate intervals 2.An episodic database because of the continuing, complex medical problems of this patient 3.A complete health database because of the nurse's primary responsibility for monitoring the patient's health 4.An emergency database because of the need to rapidly collect information and make accurate diagnoses
ANS: 3 The complete database is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. In these settings the nurse is the first health professional to see the patient and has primary responsibility for monitoring the person's health care.
The specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society are known as: 1.mores. 2.norms. 3.culture. 4.social learning.
ANS: 3 The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society.
Which of the following is an appropriate developmental task for a toddler (age 1 to 3 years)? 1.Taking a place in a peer group 2.Identifying sex roles and their function 3.Tolerating separation from the mother or parent 4.Building self-esteem and a positive self-concept
ANS: 3 Tolerating separation from the mother or parent is a developmental task for the toddler. The others listed are for the preschool child (response 2) and the school-age child (responses 1 and 4).
The nurse is testing a 10-year-old child's ability to understand conservation of matter. Which test would be appropriate? 1.Ask her to sort blocks by color and by shape. 2.Ask her to order the blocks from smallest to biggest. 3.Ask her to determine which glass of water has more water in it, the tall skinny glass or the short fat glass. 4.Ask her to make a code using the alphabet and then write a message in the code she has made up.
ANS: 3 Understanding conservation of matter is the ability to tell the difference between how things seem and how they really are. It is the ability to see that mass or quantity stays constant even though shape or position is transformed.
When listening to a patient's breath sounds, the nurse is unsure about a sound that is heard. The nurse should: 1. notify the patient's physician immediately. 2.document the sound exactly as it was heard. 3.validate the data by asking a coworker to listen to the breath sounds. 4.assess again in 20 minutes to note whether the sound is still present.
ANS: 3 Validate any data that you need to make sure are accurate. If you have less experience in an area, ask an expert to listen.
If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: 1.will comply with the treatment prescribed. 2.has obviously given up her beliefs in naturalistic causes of disease. 3.may also be seeking the assistance of a shaman or medicine man. 4.will need extra help in dealing with her illness and may be experiencing a crisis of faith.
ANS: 3 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical/scientific health care provider, patients may also seek help from folk or religious healers.
Levinson describes the period of middle adulthood as beginning with a mid-life transition. Which statement best describes this mid-life transition? 1. This is a time of major reassessment—"What have I done with my life?" 2. Most people experience a need to change careers around the age of 40 years. 3. This is a time when people feel a desire to pursue more youthful activities. 4. Most people find that they have basically met all of their goals and experience rejuvenation.
ANS: 1 Levinson (1986) describes the era of middle adulthood as beginning with a mid-life transition. Roughly between 40 and 45 years, the person starts a major reassess- ment, "What have I done with my life?"
Finding a partner or committing one's life to a cause indicates successful resolution of which of Erikson's stages? 1.Intimacy versus isolation 2.Identity versus role confusion 3.Generativity versus stagnation 4.Autonomy versus shame and doubt
ANS: 1 Once self-identity is established after adolescence, it can be merged with another's in an intimate relationship. During the early 20s the adult seeks the love, commitment, and intimacy of a lasting relationship.
The public's concept of health has changed since the 1950s. Which of the following statements most accurately describes this change? 1.Lifestyle, personal habits, exercise, and nutrition are essential to health. 2.Assessment of health is critical to identifying disease-causing pathogens. 3.Accurate diagnosis and treatment by a physician are essential for all health care. 4.An individual is considered healthy when signs and symptoms of disease have been eliminated.
ANS: 1 The accurate diagnosis and treatment of illness are important parts of health care, but the public's concept of health has expanded since the 1950s. We have an increasing interest in lifestyle, personal habits, exercise and nutrition, and the social and natural environment.
Which statement illustrates the biomedical model of Western traditional views? 1.Health is viewed as the absence of disease. 2.Optimal health is viewed as high-level wellness. 3.Health and disease are considered a cyclical process. 4.The treatment of disease is nursing's primary focus.
ANS: 1 The biomedical model of Western tradition views health as the absence of disease.
Critical thinking in the expert nurse is greatly enhanced by opportunities to: 1.apply theory in real situations. 2.work with physicians to provide patient care. 3.follow physician orders in providing patient care. 4.develop nursing diagnoses for commonly occurring illnesses.
ANS: 1 The depth and breadth of expert knowledge, largely gained from opportunities to apply theory in real situations, greatly enhances a nurse's critical thinking ability.
Physical growth is most rapid during which period? 1.Birth to 1 year of age 2.3 to 5 years of age 3.6 to 10 years of age 4.16 to 18 years of age
ANS: 1 The first year is the most dramatic period of growth and development. Height, weight, and head circumference reflect physical growth and are sensitive indicators of an infant's general health.
One aspect of society's value orientation concerns the dimension of time. An example of a person with "present" time value orientation would be: 1.a patient with a total hip replacement who has not been able to plan for discharge. 2.a patient with leukemia who continually seeks the latest medication and treatments. 3.a patient who feels loss after an amputation but is looking forward to finding out about prosthetic limbs. 4.a newly diagnosed diabetic who seeks a consultation with a medicine man who can contact ancestral spirits for guidance.
ANS: 1 The focus may be on the present, with little attention being paid to the past or the future. These individuals are concerned with "now" and the future is perceived as vague or unpredictable. The nurse may have difficulty encouraging these individuals to prepare for the future.
Illness is seen as a part of life's rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the: 1. naturalistic theory. 2. biomedical theory. 3. reductionist theory. 4. magicoreligious theory.
ANS: 1 The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From the perspective of the Chinese, for example, illness is not seen as an introducing agent but as a part of life's rhythmic course and as an outward sign of disharmony within.
An 18-month-old child comes to the well-child clinic for a visit. The nurse notes the following on observation: a rounded "pot belly" abdomen, marked lordosis "sway back," short slightly bowed legs, and a large head. The nurse concludes that the child: 1.is built like a normal toddler. 2.should be worked up for possible hydrocephalus. 3.may have a vitamin deficiency or some form of malnutrition. 4.probably has delayed physical maturation, especially of the long bones.
ANS: 1 Toddler lordosis describes the normal upright posture of the toddler, with the potbelly, sway back, and short, slightly bowed legs.
The patient's record, laboratory studies, objective data, and subjective data combine to form the: 1.database. 2.admitting data. 3.financial statement. 4.discharge summary.
ANS: 1 Together with the patient's record and laboratory studies, the objective and subjective data from the database.
If an Asian-American woman is experiencing a symptom, such as diarrhea (which is felt to be "yin"), she is likely to try to treat it with: 1.foods that are "hot" or "yang." 2.readings and Eastern medicine meditations. 3.high doses of medicines thought to be "cold." 4.no treatment at all because diarrhea is an expected part of life.
ANS: 1 Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness.
A nursing diagnosis made by a critical thinker using a dynamic nursing process would diagnose the actual problem and would also: 1.continue to reassess. 2.predict potential problems. 3.check the appropriateness of goals. 4.modify the diagnosis if necessary.
ANS: 2 A dynamic nursing process, as used by a critical thinker, would include under diagnoses, diagnoses of actual problems, prediction of potential problems, and identification of strengths.
The germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? 1.Holistic 2.Biomedical 3.Naturalistic 4.Magicoreligious
ANS: 2 Among the biomedical explanations for disease is the germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions.
The developmental crisis of generativity versus stagnation could be resolved by: 1.traveling around the world. 2.having and raising a family. 3.buying a large house and filling it with loved belongings. 4.changing jobs frequently to get a feel for what was "missed in youth."
ANS: 2 Erikson believed that during the middle years adults have the urge to contribute to the next generation. This need can be fulfilled either by producing the next genera- tion or by producing something to pass on to the next generation.
An infant weighs 7 pounds at birth. At the well-child visit 6 months later, the nurse would expect the infant to weigh at least: 1.12 pounds. 2.14 pounds. 3.17 pounds. 4.21 pounds.
ANS: 2 Growth spurts double the birth weight by 4 to 6 months and triple the birth weight by 1 year.
Which of the following statements is true regarding pain? 1. All patients will behave the same way when in pain. 2. Just as patients vary in their perception of pain, so will they vary in their expres- sion of it. 3. Cultural norms have very little to do with pain tolerance—it is always biologically determined. 4. A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.
ANS: 2 In addition to expecting variations in pain perception and tolerance, the nurse should also expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison.
Symptoms, such as pain, are often influenced by a person's cultural heritage. Which of the following is a true statement in regard to pain? 1. Nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain. 2. The ethnic background of a patient is important in a nurse's assessment of that patient's pain. 3. A nurse's area of clinical practice is most likely to determine his or her assessment of a patient's pain. 4. A nurse's years of clinical experience and current position are a strong indicator of his or her response to patient pain.
ANS: 2 In research studies of nurses' attitudes toward pain, it was discovered that the ethnic background of patients is important in the nurses' assessment of both physical and psychologic pain.
Novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using: 1.intuition. 2.a set of rules. 3.articles in journals. 4.advice from supervisors.
ANS: 2 Novice nurses operate from a set of rules (such as the nursing process).
The nurse is teaching a class to day care providers. Which of the following statements about growth, development, and preschoolers should be included? 1.Preschoolers are highly egocentric. 2.They are capable of delayed imitation. 3.They are still very unaware of gender and sex. 4.Preschoolers "pretend" to reduce anxiety about their sex roles.
ANS: 2 Piaget's preoperational stage covers age 2 to 7 years, a longer span than the preschool years. It is characterized by symbolic function because the child now uses symbols to represent people, objects, and events. The symbolic function is revealed in child's play, as in delayed imitation.
An example of a person who is heritage consistent would be: 1.a woman who has adapted the clothing style of her new country. 2.a woman who follows the traditions regarding meals that her mother followed. 3.a man who is not sure of the country of origin of his ancestors. 4.a child who is not able to speak his parents' native language.
ANS: 2 Someone who is heritage consistent is traditional, living within the norms of the traditional culture.
A 12-month-old infant is screened with the Denver II and is found to have some delays in gross motor skills. The screening is important because it: 1.can help diagnose a child with problems. 2.provides for early detection, leading to earlier intervention. 3.can be used by a physical therapist to determine the appropriate treatment. 4.can be used in conjunction with other tests to determine a child's overall intellectu- al level.
ANS: 2 The Denver II is a screening instrument designed to detect developmental delays. What the Denver II does do is screen: it helps identify children who may be slow in development. This is important because early detection increases the opportunities for effective treatment.
Jean Piaget proposed four stages of cognitive development. Which of the following statements is true in regard to these stages? 1.The child's current stage is determined by the child's age. 2.Each stage builds on the foundations of the previous stages. 3.Each stage is distinct and clearly separate from the other stages. 4.A child who is "gifted" may actually skip a stage and move on to a higher stage.
ANS: 2 The child's cognitive development proceeds through four definite and sequential stages. Although the ages of reaching the stages are approximate, the sequence of stages never varies. All children move through the same stages in the same order. No stage is skipped.
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with the data collection? 1.Collect history information first, then perform the physical examination and institute life-saving measures. 2.Simultaneously ask history questions while performing the examination and initiating life-saving measures. 3.Collect all information on the history form, including social support patterns, strengths, and coping patterns. 4.Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit.
ANS: 2 The emergency database calls for a rapid collection of the database, often compiled concurrently with life-saving measures.
In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. This is probably because Mexican-Americans: 1.have less efficient immune systems and are often ill. 2.consider these symptoms a part of normal living, not symptoms of ill health. 3.come from Mexico and coughing is normal and healthy there. 4.are usually in a lower socioeconomic group and are more likely to be sick.
ANS: 2 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.
The nurse is advising a father about his 2-year-old daughter's eating habits. He is concerned because she seems "not to eat anything anymore." The nurse tells him that this is normal because: 1.of a decrease in activity. 2.of a slower period of growth. 3.growth stops for a while at age 2 years. 4.the basal metabolic rate decreases at this age.
ANS: 2 The rate of growth decelerates during the second year, with the child gaining an average of 2.5 kg (51/2 lb) in body weight.
An individual who takes the magicoreligious perspective of illness and disease is likely to believe that their illness was caused by: 1. germs and viruses. 2. supernatural forces. 3. eating imbalanced foods. 4. an imbalance within his or her spiritual nature.
ANS: 2 The third major way in which people view the world and explain the causation of illness is from a magicoreligious perspective. The basic premise of this explanatory model is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil.
Which of the following statements best describes the tasks of late adulthood? 1.Older adults must quickly try to resolve the conflicts of earlier times. 2.Older adults must accept that they cannot change the past and make peace with their lives. 3.Older adults generally feel great sadness and worry about death; this allows them to accept their mortality. 4.Older adults must never feel satisfied with their lives because it gives them goals to achieve in the future.
ANS: 2 This period relates to Erikson's last stage, with its key polarity of integrity versus despair. A successful resolution to this final conflict occurs when the adult accepts "one's one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions" (1963). The adult feels content with his or her one life on earth, satisfied that if it were possible to do it over again, he or she would live it the same way.
A woman brings her 15-month-old son in for a well-child visit. When asked questions about his pattern of behaviors and appetite, she seems at a loss for answers. What is the nurse's best response? 1.Contact social services because she may be neglecting her son. 2.Determine whether she is the primary provider of care for her son. 3.Assume that she knows her son's habits and may be hiding something unusual. 4.Discuss with her how important it is to observe growth and development patterns to see a delay early.
ANS: 2 When assessing infants and children, it is important to identify the primary provider of care because this individual may or may not be the biologic parent.
Why is the concept of prevention essential in describing health? 1.Disease can be prevented by treating the external environment. 2.The majority of deaths among Americans under age 65 years are not preventable. 3.Prevention places emphasis on the link between health and personal behavior. 4.The means to prevention is through treatment provided by primary health care practitioners.
ANS: 3 A natural progression to prevention now rounds out our concept of health. Guidelines to prevention place emphasis on the link between health and personal behavior.
Which statement correctly characterizes ageism? 1.Ageism indicates respect for the aged. 2.Ageism is most common in Asian cultures. 3.Ageism means discrimination on the basis of age. 4.Ageism is the result of true concern about the aged population.
ANS: 3 Ageism means discrimination based on age. It is a derogatory attitude that characterizes older adults as sickly, senile, useless, and a burden on the economy. The attitude stems in part from our cultural emphasis on youth, beauty, and vigor. Other cultures respect and revere their aging members.
The nurse is observing a mother with her 2-year-old child. In a period of just a few minutes the child has said "No" to her many times. He even says "No" when he would like to have said yes. Which statement about this child's behavior is true? 1.He is very spoiled and needs to be punished. 2.He is a toddler and is exhibiting ritualistic behavior. 3.He is trying to assert his autonomy through negativism. 4.He is just trying to test his limits and see how far he can get.
ANS: 3 As they test their powers, they sometimes clash with their parents' restrictions, and a battle of wills results. "No" seems to be their favorite word. This negativism is a normal part of the quest for autonomy.
A new mother asks the nurse, "Why does my baby cry so much?" Which statement by the nurse is correct? 1."You need to try to hold your baby for longer periods of time." 2."This means he is hungry. He needs to be fed more." 3."Your baby uses crying to tell us if he feels hungry, uncomfortable, or lonely." 4."We should examine him for signs of illness."
ANS: 3 Crying is the infant's first means of communication. For the first month, cries are undifferentiated. After 1 month of age, the infant alters the crying pitch and intensity to reflect hunger, discomfort, or loneliness.
Which of the following would be formulated by a nurse using diagnostic reasoning? 1.Nursing diagnosis 2.Medical diagnosis 3.Diagnostic hypothesis 4.Diagnostic assessment
ANS: 3 Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis.
Normal physical changes that occur during middle adulthood (40 to 64 years) include: 1.deterioration of internal organ systems. 2.increased muscle tone and decreased muscle strength. 3.increased abdominal fat deposits from decreased activity. 4.decreased sensory function and visual changes for far vision.
ANS: 3 During middle adulthood, the hair thins, an abdominal paunch grows from increased fat deposits and decreased activity, most organ systems remain constant, and sensory function remains intact except for some visual changes for near vision.
A father describes his adolescent son's "strange new clothes and hair style." He states that he is worried about the frequent changes his son seems to make in his appearance. The nurse explains that his son is: 1.possibly getting into trouble and should begin counseling. 2.experiencing a loss of self-esteem and may need help to overcome this difficult time. 3.experimenting with different identities, which is necessary to forming an identity of his own. 4.probably experimenting with drugs or alcohol because such behavior is unusual in an adolescent.
ANS: 3 Erikson believes the main conflict of the fifth stage in his theory to be identity versus role diffusion. Finding one's own identity is stressful. In the search for identity, teens often form cliques, wear fad clothing, and follow rock singers, movie stars, or charismatic heroes in an attempt to siphon identity from them.
The mother of a 2-month-old baby reports that she often lets the baby "cry it out" instead of going to her in the middle of the night. In talking over this practice with her, the nurse should make her aware that: 1. 2-month-old babies are old enough to learn to sleep through the night. 2. babies can become spoiled if they're picked up in the middle of the night. 3. babies are developing a sense of trust and need to be responded to when they cry. 4. babies are just developing the ability to manipulate and should not be picked up if it is unnecessary.
ANS: 3 Erikson viewed the mother as the primary caregiver. The crucial element in this stage (trust vs. mistrust) then, is the quality of the mother-child relationship. When the mother is responsive and consistent in her nurturing, the infant learns trust.
Which statement is accurate regarding one's ethnicity? 1.Ethnicity is dynamic and ever-changing. 2.Ethnicity is the belief in a higher power. 3.Ethnicity pertains to a social group within the social system that claims shared values and traditions. 4.It is learned from birth through the processes of language acquisition and socialization.
ANS: 3 Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, symbols, or food preferences. Answers 1 and 4 refer to culture, and answer 2 refers to religion.
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? 1.Establish priorities. 2.Identify expected outcomes. 3.Evaluate the individual's condition and compare actual outcomes with expected outcomes. 4.Interpret data and then identify clusters of cues and make inferences.
ANS: 3 Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse should evaluate the individual's condition and compare actual outcomes with expected outcomes.
Which of the following would be included in a holistic model of assessment? 1.Nursing goals for the patient 2.Anticipated growth and development patterns 3.A patient's perception of his or her health status 4.The nurse's perception of disease related to the patient
ANS: 3 Holistic health views the mind, body, and spirit as functioning as a whole within the environment. A holistic model includes the patient's perception of his or her health status, not the nurse's perception or goals.
An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: 1. contact the hospital administrator about the best course of action. 2. automatically get a curandero for her because it is not culturally appropriate for her to request one. 3. further assess her cultural beliefs and offer her assistance in contacting a curandero or priest if she desires. 4. ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.
ANS: 3 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless healing of body, mind, and spirit are all carried out (although the division of the person into parts is itself a Western concept).
An adolescent is beginning to develop the ability to deal with hypothetical situations and abstract thinking. The nurse would consider this finding: 1. advanced for this patient's age. 2. an expected finding only in the elderly. 3. a normal finding during this stage of development. 4. abnormal because abstract thinking should begin to take place in early childhood.
ANS: 3 In adolescence, thinking is no longer concrete. Adolescents can analyze and use scientific reasoning.
Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. Which statement would most accurately reflect "health" in an Asian with these naturalistic beliefs? 1. A person is able to work and produce. 2. A person is happy, stable, and feels good. 3. All aspects of the person are in perfect balance. 4. A person is able to care for others and function socially.
ANS: 3 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance.
Which statement about nursing diagnoses is true? They: 1.evaluate the etiology of disease. 2.are a process based on the medical diagnosis. 3.evaluate the response of the whole person to actual or potential health problems. 4.focus on the function and malfunction of a specific organ system in response to disease.
ANS: 3 Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems.
Erikson's stage of integrity versus despair could be described as: 1.an adjustment to the tasks of middle age. 2.being productive and contributing to society. 3.cataloging life events to gain a sense of satisfaction. 4.a time to review career goals and possibly change paths to avoid despair.
ANS: 3 One important task of late adulthood is performing a life review. Erikson's last ego stage has the key conflict of integrity versus despair. A successful resolution to this conflict occurs when the adult feels satisfied with his or her own life.
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis? 1.Identifying existing levels of wellness 2.Evaluating previous problems and goals 3.Identifying potential problems the individual may develop 4.Focusing on strengths and reflecting an individual's transition to higher levels of wellness
ANS: 3 Risk diagnoses are potential problems that an individual does not currently have but is particularly vulnerable to develop.
A 24-month-old child comes to the clinic for a well-child visit. His mother describes him as a child who falls apart if she changes even the smallest thing in his environment. The nurse tells his mother that this behavior: 1.is unusual in a toddler because negativism generally doesn't emerge until age 3. 2.indicates that he is insecure and probably hasn't successfully developed trust in infancy. 3.can be expected from a toddler because they typically experience ritualism and global thinking. 4.indicates that he has been spoiled and she should change things in his environment often to get him used to it.
ANS: 3 Ritualism emerges with negativity. A 2-year-old wants things done in the same way; any change in schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking. A change in one small part (such as a minor shift in room arrangement) changes the whole environment, and the 2-year-old child's equanimity disintegrates.
Second-level priority problems include which of the following? 1.Low self-esteem 2.Lack of knowledge 3.Abnormal laboratory values 4.Severely abnormal vital signs
ANS: 3 Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, or risks to safety or security).
Which statement is an appropriate component of one's spirituality? 1. Belief in the worship of God or gods 2. Attendance at a specific church 3. A personal effort to find purpose and meaning in life 4. Closely tied to one's ethnic background
ANS: 3 Spirituality refers to each person's unique life experience and his or her personal effort to find purpose and meaning in life. The other responses apply to religion.
Which of the following statements best characterizes resolution of Erikson's last ego stage, integrity versus despair? 1. The individual becomes more interested in society's extrinsic rewards. 2. The individual experiences a loss of recognition and authority. 3. The adult feels the need to pursue youthful activities as a culmination of life experiences. 4. The adult feels satisfied that if it were possible to do it over again, he or she would live it the same way.
ANS: 4 A successful resolution to Erikson's final stage of integrity versus despair comes when the adult feels content with his or her life on earth, satisfied that if it were possible to do it over again, he or she would live it the same way.
A mother notes that her 4-year-old child often chatters to herself while playing alone. She is worried that her child has a psychological problem. The nurse explains to her that: 1. she is just imitating what she hears around her. 2. this happens when a child is lonely or needs a playmate. 3. there is a concern about her child's psychologic development and further testing will be required. 4.this private speech is normal at this age and is a problem-solving tool as she works through unfamiliar situations.
ANS: 4 Children will chatter to themselves between the ages of 4 to 6 years, and this private speech is a problem-solving tool that is beneficial as they try new tasks or work through unfamiliar situations.
Which accurately describes the concept of culturally competent care? 1.The caregiver is able to speak the patient's native language. 2.The caregiver possesses some basic knowledge of the patient's cultural background. 3.The caregiver applies the proper background knowledge of a patient's cultural background to provide the best possible health care. 4.The caregiver understands and attends to the total context of the patient's situation.
ANS: 4 Culturally competent implies that the caregiver understands and attends to the total context of the individual's situation. This includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.
Culture has four basic characteristics. Which statement correctly reflects one of these characteristics? 1. Cultures are static and unchanging despite changes around them. 2. Cultures are never specific, which makes them hard to identify. 3. Culture is most clearly reflected in a person's language and behavior. 4. Culture adapts to specific environmental factors and available natural resources.
ANS: 4 Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources and is dynamic and ever changing.
What is the step of the nursing process that includes data collection by health history, physical examination, and interview? 1,Planning 2.Diagnosis 3.Evaluation 4.Assessment
ANS: 4 Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process.
Levinson proposed a view of middle adulthood that differed from Erikson's. Which of the following statements best illustrates Levinson's views? 1. The main task of middle-aged adults is to overcome boredom with life. 2. Career reassessment in middle age is rare because of the fear of change at this age. 3. Middle age is a time when adults push to meet the goals that were set at a younger age. 4. Middle-aged adults adjust goals and emerge with a new perception of the self and the environment.
ANS: 4 During the 40s, the person is involved in making choices and building a new life. The person accepts that some goals may not be met, takes stock, and emerges with a new perception of self and the environment.
Which of the following is an example of a first-level priority problem? 1. A patient with postoperative pain 2.A newly diagnosed diabetic who needs diabetic teaching 3.An individual with a small laceration on the sole of the foot 4.An individual with shortness of breath and respiratory distress
ANS: 4 First-level priority problems are those that are emergent, life-threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circula- tion, and monitoring abnormal vital signs).
If a mother hides a block under her baby's blanket and the baby looks for it, the nurse understands that the baby has begun to develop the concept of: 1.relativism. 2.object prehension. 3.separation anxiety. 4.object permanence.
ANS: 4 Gradually the infant learns that objects and people continue to exist even when they are no longer in sight. This starts around 7 months when the infant searches for an object that is partially hidden but does not search for one completely out of sight.
Which situation is most appropriate for an episodic history? 1.A patient's admission to a long-term care facility 2.A patient has sudden, severe shortness of breath 3.A patient's admission to the hospital for surgery the following day 4.A patient in an outpatient clinic has cold and flu-like symptoms
ANS: 4 In an episodic or problem-centered database, the nurse collects a "mini" database, smaller in scope than the completed database. It concerns mainly one problem, one cue complex, or one body system.
In the health promotion model, the focus of the health professional includes: 1.changing the patient's perceptions of disease. 2.identification of biomedical model interventions. 3.identifying negative health acts of the consumer. 4.helping the consumer choose a healthier lifestyle.
ANS: 4 In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle.
An example of objective information obtained during the physical assessment includes the: 1.patient's history of allergies. 2.patient's use of medications at home. 3.last menstrual period 1 month ago. 4.2 × 5 cm scar present on the right lower forearm.
ANS: 4 Objective data are the patient's record, laboratory studies, and information that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination.
A patient is in the hospital with a new diagnosis of lung cancer. He is anxious and talks to his oncologist about getting the "latest and best treatment out there." This reflect which time orientation? 1.Past 2.Current 3.Present 4.Future
ANS: 4 People who are focused on the future value progress and change and will inquire about the "latest" treatments and most modern equipment available for a problem.
An 8-year-old boy's father is very interested in seeing his child succeed in soccer. During the assessment, the nurse finds out that the child is a small boy who expresses a sincere interest in playing chess and who feels like a failure at soccer. Which statement is true in regard to this situation? 1.This father needs to decrease his expectations for his son. 2.This father needs to encourage his son to participate in team sports. 3.This child obviously has an introverted personality and should be "left alone." 4.This child should be given opportunities to achieve success in any area he chooses.
ANS: 4 Real achievement at this stage (industry vs. inferiority) builds a feeling of confidence, competence, and industry. The reality is that no one can master everything. If the child believes that he or she cannot measure up to society's expectations, the child loses confidence and does not take pleasure in the work.
A 42-year-old woman has come in for counseling. As the nurse administers the Hassles and Uplifts Scale questionnaire, the woman is told that this tool: 1. will indicate the level of stress in her life. 2. will show her areas of self-improvement needed to regain control in her life. 3. is unable to measure stress but can help her cope with the day-to-day hassles of life. 4.may show a relationship between daily stress and the occurrence of physical health problems.
ANS: 4 Research has shown a significant relationship between daily stress and concurrent or later occurrence of physical health problems.
Which of the following is the best definition of spirituality? 1. A personal search to discover a supreme being 2. An organized system of beliefs concerning the cause, nature, and purpose of the universe 3. A belief that each person exists forever in some form, such as a belief in reincarna- tion or the afterlife 4. That which arises out of each person's unique life experience and his or her personal effort to find purpose in life
ANS: 4 Spirituality arises out of each person's unique life experience and his or her personal effort to find purpose and meaning in life.
Which statement correctly describes the age-specific charts for the periodic health examination? 1.They are used to help identify the diagnosis of an illness. 2.They are helpful in identifying developmental delays in children. 3.They recommend that every individual receive an annual physical exam. 4.They list a frequency schedule for periodic health visits for a specific age group.
ANS: 4 The age-specific charts for the periodic health examination define a lifetime schedule of health care, organized into packages for eight specific age groups.
Erik Erikson's theory of psychosocial development proposes eight stages of ego development. Each stage involves a "bipolar issue." Which statement is true regarding these crises? 1.There is always an absolute resolution to each crisis. 2.Most people never resolve all the crises and therefore never complete all eight stages. 3.If the crisis cannot be resolved at a certain stage, a person generally skips that stage. 4.The issues can be resolved along a continuum, with a mix of positive and negative outcomes.
ANS: 4 The bipolar aspect means that the crisis can have a positive or a negative outcome and is resolved along a continuum. The crisis must be resolved for the person to continue into the next stage. Not everyone reaches absolute resolution to each crisis. The other responses do not illustrate the bipolar issue of Erik Erikson's stages of ego development.
A physician in the clinic is frequently bothered when patients arrive late for appointments. He is so irritated by this behavior that he often finds it hard to provide appropriate care to these individuals. What should he do first in trying to overcome his difficulty? 1.Identify the meaning of health to the patient. 2.Understand that these cultural practices are helpful to the patient. 3.Allow the patients to arrive late and build this into his schedule. 4.Examine his own culturally based values, beliefs, attitudes, and practices.
ANS: 4 The first step in understanding the health care needs of others is to understand one's own culturally based values, beliefs, attitudes, and practices.
A 42-year-old Asian patient is being seen at the clinic for an initial examination. The nurse knows that it is important to include cultural information in his health assessment to: 1.identify the cause of his illness. 2.make accurate disease diagnoses. 3.provide cultural health rights for the individual. 4.provide culturally sensitive and appropriate care.
ANS: 4 The inclusion of cultural considerations in health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.
The nursing process is a sequential method of problem solving that includes which five steps? 1.Assessment, treatment, evaluation, discharge, follow-up 2.Admission, assessment, diagnosis, treatment, discharge planning 3.Admission, diagnosis, treatment, evaluation, discharge planning 4.Assessment, diagnosis, planning, implementation, evaluation
ANS: 4 The nursing process is a method of problem solving that includes assessment, diagnosis, planning, implementation, and evaluation.
Which term best describes a proficient nurse? 1.A nurse who has little experience with a specified population and uses rules to guide performance 2.A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution 3.A nurse who sees actions in the context of daily plans for patients 4.A nurse who understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient
ANS: 4 The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than a list of tasks and is able to see how today's nursing actions apply to the point the nurse wants the patient to reach at a future time.
Erikson believes toilet training to be representative of which of his stages? 1.Initiative versus guilt 2.Integrity versus despair 3.Industry versus inferiority 4.Autonomy versus shame and doubt
ANS: 4 The quest for autonomy characterizes Erikson's second stage. The toddler wants to be autonomous and to govern his or her own body and experiences. Erikson believed that toilet training symbolizes this stage.
While examining an 18-month-old child, the nurse notes that he does not demonstrate skills typical for his age. He walks while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which of the following is an appropriate nursing diagnosis for this child? 1.Impaired parenting 2.Imbalanced nutrition 3.Situational low self esteem 4.Delayed growth and development
ANS: 4 The related factors listed are indicative of delayed growth and development.
At what age should the nurse expect to see an infant exhibiting social smiles? 1.At birth 2.At 2 weeks of age 3.At 4 weeks of age 4.At 6 to 8 weeks of age
ANS: 4 The social smile erupts at age 6 to 8 weeks.
The term subculture is used: 1.to fit as many people into the majority culture as possible. 2.to define small groups of people who do not want to be identified with the larger culture. 3.to single out groups of people who suffer differential and unequal treatment as a result of cultural variations. 4.to identify fairly large groups of people with shared characteristics that are not common to all members of a culture.
ANS: 4 The term subculture is used for fairly large aggregates of people who have shared characteristics that are not common to all members of the culture and that enable them to be thought of as a distinguishable subgroup.
A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse's best course of action? 1. The focus should be a full cardiac assessment. 2. He may be having difficulty after learning of his wife's cancer and is expressing psychosomatic complaints. 3. This patient is not in any danger at present and should be sent home with instruc- tions to contact his physician. 4. It is unclear what is happening with this patient and his assessment should include physical and psychosocial realms.
ANS: 4 Wide cultural variation exists in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., com- plaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart).
After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be: 1.objective. 2.reflective. 3.subjective. 4.introspective.
ANS:1 Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical exam
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the: 1.nursing diagnosis. 2.medical diagnosis. 3.admission diagnosis. 4.collaborative diagnosis.
An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Put the following patient situations in order according to level of priority: 1. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. 2. A teenager who was stung by a bee during a soccer match is having trouble breathing. 3. An older adult with a urinary tract infection is also showing signs of confusion and agitation.
Answer: 2,3,1
An adolescent tells the school nurse that he is being pressured by his friends to smoke marijuana. Which nursing diagnosis would be appropriate for this situation? 1.Compromised family coping 2.Decisional conflict 3.Social isolation 4.Ineffective role performance
Decisional conflict is an appropriate nursing diagnosis for an adolescent facing this situation.
