Unit 5 Practice Questions
Which assessment finding calls for the most immediate action by the nurse? 1. Bluish color around the lips and earlobes 2. Yellow color of the skin and sclera 3. Bilateral erythema of the face and neck 4. Dark brown spotting on the chest and back
1
Which finding by the clinic nurse about a client who has been taking adalimumab to treat psoriasis is most indicative of a need for a change in therapy? 1. Temperature 100.9°F (38.3°C) 2. Patches of scaly skin on chest 3. Erythema on sun-exposed areas of skin 4. Client report of worsening depression
1
The charge nurse is supervising a newly hired RN. Which action by the new RN requires the most immediate action by the charge nurse? 1. Obtaining an anaerobic culture specimen from a superficial burn wound 2. Giving doxycycline with a glass of milk to a client with cellulitis 3. Discussing the use of herpes zoster vaccine with a 25-year-old client 4. Teaching a newly admitted burn client about the use of pressure garments
2
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction
C
A nurse is caring for a client who has stage 4 lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kübler-Ross' Five Stages of Grief, which stage is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance
C
Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting
D
A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to the student's verbalizations? a. "Are you worried about failing your exams?" b. "Have you been staying up late studying?" c. "Are you using any recreational drugs?" d. "Do you have trouble managing your time?"
a
A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient's condition, what would be a priority intervention for this patient? a. Monitoring food and drink temperatures to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Providing meals high in carbohydrates to promote healing
a
The nurse obtains this information about a 60-year-old client who has a shingles infection. Which finding is of most concern? 1. The client has had symptoms for about 2 days. 2. The client has severe burning-type discomfort. 3. The client has not had the herpes zoster vaccination. 4. The client's spouse is currently receiving cancer chemotherapy.
4
A 22-year-old woman who has been taking isotretinoin to treat severe cystic acne makes all these statements while being seen for a follow-up examination. Which statement is of most concern? 1. "My husband and I are thinking of starting a family soon." 2. "I don't think there has been much improvement in my skin." 3. "Sometimes I get nauseated after taking the medication." 4. "I have been experiencing a lot of muscle aches and pains."
1
The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) as staff members is planning the care for an 80-year-old client who has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to assign to an LPN/LVN? 1. Applying nystatin powder to the area three times daily 2. Cleaning the skinfolds every 8 hours and drying thoroughly 3. Evaluating the need for further antifungal treatment at least weekly 4. Assessing for ongoing risk factors for skin breakdown and infection
1
The health care provider (HCP) prescribes permethrin application for all family members of a client who has scabies. Which client information will be most important for the nurse to discuss with the HCP before client teaching about the medication? 1. The client has a newborn infant. 2. Burrows are noted on the wrists. 3. The client and family are homeless. 4. Family members are asymptomatic.
1
The nurse is planning hospital discharge teaching for four clients. For which client is it most important to instruct about the need to use sunscreen? 1. A 32-year-old client with pneumonia who has a new prescription for doxycycline 2. A fair-skinned 55-year-old client with psoriasis who works outside for 8 hours daily 3. A dark-skinned 62-year-old client who has had keloids injected with hydrocortisone 4. A 78-year-old client with a red, pruritic rash caused by an allergic reaction to penicillin
1
The nurse takes the health history of a client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon? 1. The client does not routinely use sunscreen. 2. The client has a family history of melanoma. 3. The client has not eaten anything for 8 hours. 4. The client takes 325 mg of aspirin daily.
4
Which personal protective equipment will the nurse need when planning a dressing change for a client with a methicillin-resistant Staphylococcus aureus-infected skin wound? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. Booties
1 2
A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is transferred to the emergency department. Which prescribed intervention will the nurse implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.
2
After reviewing the medical record for a client who has an oral herpes simplex infection after being treated with chemotherapy, which intervention has the highest priority? 1. Offer reassurance that herpes can be treated with antiviral medication. 2. Administer prescribed analgesics before meals. 3. Offer the client frequent small meals and snacks. 4. Encourage the client to maintain contact with some family members.
2
After the nurse has performed a skin assessment on a recently admitted 19-year-old client, which finding is the highest priority to report to the health care provider? 1. Mole 2 mm in diameter on the chest 2. Tenting of the skin on the forearms 3. Patches of vitiligo around both eyes 4. Scattered brown macules on the face
2
At the beginning of the shift, an unlicensed assistive personnel (UAP) tells the nurse, "I have several clients today who have wound infections. I will do my best, but if I put on a gown and gloves every time I go into their rooms, I will never get all the care done!" Which response by the nurse is best? 1. "I know you are busy, but please try to comply with the standard infection control measures because these clients have serious infections." 2. "Let's look at the client assignments for today and make changes so that you can give the needed care and maintain good infection control." 3. "If you are unable to follow infection control standards, perhaps you need a review class in correct use of personal protective equipment." 4. "Tell me what you think are the most important times to use personal protective equipment to prevent infections from spreading."
2
The nurse has just received a change-of-shift report for the burn unit. Which client should be assessed first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
2
Which actions will the nurse use when treating a client with a venous ulcer on the right lower leg? Select all that apply. 1. Position the right leg lower than the heart. 2. Use compression wraps consistently. 3. Administer analgesics before wound care. 4. Maintain a dry wound environment. 5. Encourage right ankle flexion exercises. 6. Clean wound with a nonirritating solution.
2 3 5 6
23 The nurse has just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. A 22-year-old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. A 34-year-old client who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 4. A 57-year-old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L (5.1 mmol/L)
3
A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should the nurse delegate to unlicensed assistive personnel (UAP) working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing
3
The charge nurse on a medical-surgical unit is working with a newly graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. A 34-year-old client who was just admitted to the unit with periorbital cellulitis 2. A 40-year-old client who needs discharge instructions after having skin grafts to the thigh 3. A 67-year-old client who requires a dressing change after hydrotherapy for a pressure ulcer 4. A 78-year-old client who needs teaching before a punch biopsy of a facial lesion
3
The home health nurse is caring for a 72-year-old client who has a stage II pressure ulcer, with risk factors of poor nutrition, bladder incontinence, and immobility. Which nursing action should be delegated to the unlicensed assistive personnel (UAP)? 1. Telling the client and family to apply the skin barrier cream in a smooth, even layer 2. Completing a diet assessment and suggesting changes in diet to improve the client's nutrition 3. Reminding the family to help the client to the commode every 2 hours during the day 4. Evaluating the client for improvement in documented areas of skin breakdown or damage
3
The home health nurse is caring for a client with a fungal infection of the toenails who has a new prescription for oral itraconazole. Which client information is most important to discuss with the health care provider (HCP) before administration of the itraconazole? 1. The client's toenails are thick and yellow. 2. The client is embarrassed by the infection. 3. The client is also taking simvastatin daily. 4. The client is allergic to iodine and shellfish.
3
The nurse is caring for a client who has just had a squamous cell carcinoma removed from the face. Which action can be assigned to an experienced LPN/LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for 1 week after surgery
3
When the nurse is evaluating a client who has been taking prednisone 30 mg/day to treat contact dermatitis, which finding is most important to report to the health care provider? 1. The glucose level is 136 mg/dL (7.6 mmol/L). 2. The client states, "I am eating all the time." 3. The client reports frequent epigastric pain. 4. The blood pressure is 148/84 mm Hg.
3
Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? 1. A 23-year-old client who has just been admitted with burns over 30% of the body after a warehouse fire 2. A 36-year-old client who requires discharge teaching about nutrition and wound care after having skin grafts 3. A 45-year-old client with infected partial-thickness back and chest burns who has a dressing change scheduled 4. A 57-year-old client with full-thickness burns on both arms who needs assistance in positioning hand splints
3
The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished. 1. Apply silver sulfadiazine ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing.
3 4 2 1 5
A client admitted to the emergency department reports new-onset itching of the trunk and groin. The nurse notes multiple reddened wheals on the chest, back, and groin. Which question should the nurse ask next? 1. "Do you have a family history of eczema?" 2. "Have you been using sunscreen regularly?" 3. "How do you usually manage stress?" 4. "Are you taking any new medications?"
4
After the nurse performs a skin assessment on a 70-year-old new resident in a long-term care facility, which finding is of most concern? 1. Numerous striae are noted across the abdomen and buttocks. 2. All the toenails are thickened and yellow. 3. Silver scaling is present on the elbows and knees. 4. An irregular border is seen on a black mole on the scalp.
4
The charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) is planning care for a resident with a stage III sacral pressure ulcer. Which nursing intervention is best to assign to an LPN/LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Braden scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning
4
Which of these actions will the nurse take first for a client who has arrived in the emergency department with sudden-onset urticaria and intense itching? 1. Ask the client about any new medications. 2. Administer the prescribed cetirizine. 3. Apply topical corticosteroid cream. 4. Auscultate the client's breath sounds.
4
25 In which order will the nurse take these actions which are needed for a client seen in the family medicine clinic and diagnosed with impetigo? 1. Obtain specimen for culture. 2. Apply topical antibiotic ointment. 3. Give the client a hand hygiene handout. 4. Clean off the crust from the lesion. 5. Apply a sterile dressing to the wound.
4 1 2 5 3
An example of situational stress is the stress related to a marriage or divorce. A. True B. False
: A. True
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain
A
a nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. which of the following findings should the nurse expect? (select all that apply) A. increase in incisional pain B. fever and chills C. reddened wound edges D. increased in serosanguineous drainage E. decrease in thirst
A B C
a client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. the nurse checks the surgical wound and finds it separated with viscera protruding. which of the following actions should the nurse take? (select all that apply) A. cover the are with saline soaked sterile dressings B. apply an abdominal binder snugly around the abdomen C. use sterile gauze to apply gentle pressure to the exposed tissue D. position the client supine with the hips and knees bent E. offer the client a warm beverage (herbal tea)
A D
a nurse is caring for a client who is at risk for developing a pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (select all that apply) A. keep the head of the bed elevated 30 degrees B. massage the clients bony prominences frequently C. apply cornstarch liberally to the skin after bathing D. have the client sit on a gel cushion when in a chair E. reposition the client at least every 3 hr while in bed
A D
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling."
A D E
a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) A. stage 3 pressure ulcer B. sutured surgical incision C. casted bone fracture D. laceration sealed with adhesive E. open burn area
A E
The ideal self constitutes the self one wants to be. A. True B. False
A. True
A false self might develop in individuals who have the emotional need to respond to the needs and ambitions that significant people, such as parents, have for them. A. True B. False
A. true
Mild anxiety narrows a person's perceptual fields so that the focus is on immediate concerns, with inattention to other communications and details. A. True B. False
Answer: B. False Rationale: Moderate anxiety narrows a person's perceptual fields so that the focus is on immediate concerns, with inattention to other communications and details.
The inflammatory response is a response of the central nervous system to pain. A. True B. False
Answer: B. False Rationale: The reflex pain response is a response of the central nervous system to pain.
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. "It's still too soon to expect to feel normal. Give it a little more time."
B
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A. "Sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."
B
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse? A. "It takes time to get over the loss of a loved one." B. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."
B
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things." D. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
B
a nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. their Hgb is 12 g/dl and BMI is 17.1. the incision is approximated and free of redness with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) A. extremes in age B. chronic illness C. low hemoglobin D. malnutrition E. poor wound service
B C D
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (Select all that apply.) A. Suggest coping skills for the client to utilize in this situation. B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen. E. Encourage the client in the expression of feelings and concerns.
B C E
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image disturbances? (Select all that apply.) A. 30-year-old male following laparoscopic appendectomy B. 45-year-old female following mastectomy C. 20-year-old female following left above-the-knee amputation D. 65-year-old male following cardiac catheterization E. 55-year-old male following stroke with right-sided hemiplegia
B C E
In the stress management technique known as anticipatory guidance, a person creates a mental image, concentrates on the image, and becomes less responsive to stimuli. A. True B. False
B. False
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply.) A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room."
C D E
Which defense mechanism is portrayed in the following scenario? After throwing his lunch tray on the floor, a patient complains to the nurse manager about the quality of the food he is being fed during his hospital stay. A. Denial B. Displacement C. Rationalization D. Reaction formation
C. Rationalization
Which term best describes a person's need to reach one's potential by pursuing a career in medicine? A. Self-esteem B. Self-concept C. Self-actualization D. Self-knowledge
C. Self-actualization
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what are anticipated clinical findings at this time. Which of the following is an appropriate response by the nurse? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone
D
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing."
D
A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? a. Realistic and positively motivating his development b. Unrealistic and negatively motivating his development c. Unrealistic but positively motivating his development d. Realistic but negatively motivating his development
a
A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) b. A young clergyperson whose vocal cords are paralyzed after a motorbike accident c. A 32-year-old accountant who survives a massive heart attack d. A 23-year-old model who just learned that she has breast cancer
a
A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? a. "I need to identify the problem first." b. "Listing alternatives is the initial step." c. "I will list alternatives after I develop the plan." d. "I do not need to evaluate the outcome of my plan."
a
A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance
a
A nurse is assessing a patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors
a b
A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery
a b e f
A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. a. The nurse makes a point to address the patient by name upon entering the room. b. The nurse avoids fatiguing the patient by performing all procedures in silence. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. e. The nurse ignores negative feelings from the patient since they are part of the grieving process. f. The nurse avoids conversing with the patient about her life, family, and occupation.
a c d
A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, "I've never been so scared in my life!" What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a. Increased heart rate b. Decreased muscle strength c. Increased mental alertness d. Increased blood glucose levels e. Decreased cardiac output f, Decreased peristalsis
a c d
A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. a. Teach the parents to reinforce their child's positive qualities. b. Teach the parents to overlook occasional negative behavior. c. Teach parents to ignore neutral behavior that is a matter of personal preference. d. Teach parents to listen and "fix things" for their children. e. Teach parents to describe the child's behavior and judge it. f. Teach parents to let their children practice skills and make it safe to fail.
a c f
A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? a. The patient will make above-B grades in all tests at school. b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. c. The patient reports that she feels more self-confident in her music and art, which she enjoys. d. The patient expresses that she is very smart in school.
b
A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance
b
A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? a. Lack of self-esteem b. Deficient self-knowledge c. Unrealistic self-expectation d. Inability to evaluate himself
b
A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression
b
A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? a. "I must breathe in and out in rhythm." b. "I should take my pulse and expect it to be faster." c. "I can expect my muscles to feel less tense." d. "I will be more relaxed and less aware."
b
"How important is it to you to believe that your work has value to others?" Which aspect of self-esteem might this nurse be assessing? A. Socialization and communication B. Competence C. Virtue D. Power
b. competence
People are born with a self-concept. A. True B. False
b. false
A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance
c
A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? a. Recommend that she discipline her daughter more strictly and consistently. b. Make a list of things her husband can do to give her more time and help her improve her parenting skills. c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. d. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.
c
A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? a. The nurse teaches a patient rhythmic breathing to perform prior to the procedure. b. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. d. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.
c
A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? a. An infant who learns to turn over b. A school-aged child who learns how to add and subtract c. An adolescent who is a "loner" d. A young adult who has a variety of friends
c
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote healing. B. The client needs to be given privacy at times for self-reflecting and organizing her life. C. The client's sense of loss can be lessened through retaining control of certain areas of her life. D. Performing ADLs is required prior to discharge from an acute care facility.
c
A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a. Decreasing pulse b. Increasing sleepiness c. Increasing energy levels d. Decreasing respirations
c
A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? a. Negative self-concept and low self-esteem b. Negative self-concept and high self-esteem c. Positive self-concept and fairly high self-esteem d. Positive self-concept and low self-esteem
c
A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a. Ineffective Coping related to the new parenting role b. Ineffective Denial related to ability to care for a newborn c. Anxiety related to change in role status d. Situational Low Self-Esteem related to fear of parenting
c
A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? a. "I love my child so much I 'hug him to death' every day." b. "I think children need challenges, don't you?" c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." d. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."
c
A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? a. There is no disturbance in self-concept. b. This patient has ego strength and high self-esteem but may have a disturbance of body image. c. The area of self-esteem has very low priority at this time and should be ignored until much later. d. It is probable that there are disturbances in self-esteem and body image.
d
A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? a. Negative self-concept b. Modesty (lack of conceit) c. Body image disturbance d. Low self-esteem
d
A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a. "Patient displays moderate anxiety related to her situation." b. "Patient manifests panic related to feelings of impending doom." c. "Patient describes severe anxiety related to her situation." d. "Patient expresses fear of her husband."
d
A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? a. Discouraging oververbalization of fears and anxieties b. Focusing on the outcome as opposed to the details of the surgery c. Providing time alone for reflection on personal strengths and weaknesses d. Mutually determining expected outcomes of the care plan
d
A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance
d
A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt and the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a. Arrange to have the infant removed from the home. b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse. d. Notify the care provider and recommend respite care for the mother.
d
