Unit 7: Biophysychosocial Practice Questiions

A nurse caring for older adults in a skilled nursing home observes physical changes in patients that are part of the normal aging process. Which changes reflect this process? Select all that apply. a.) fatty tissue is redistributed. b.) The skin is drier and wrinkles appear c.) Cardiac output increases d) Muscle mass increases e.) Hormone production increases f.) Visual and hearing acuity diminishes

*A,B,F*: Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause or andropause.

Abstract standards that provide a person with his/her code of conduct are: a.) values b.) attitudes c.) beliefs d.) personal philosophy

A

Building trust s important in: a.) the orientation phase of the relationship b.) The problem identification subphase of the relationship c.) all phases of the relationship d.) the exploitation subphase of the relationship

A

7A high school nurse is counseling parents of teenagers who are beginning high school Which issues would be priority topics of discussion for this age group? Select all that apply. a.) Influence of peer groups b.) Bullying c.) Water safety d.) Eating disorders e.) Risk-taking behavior f.) Immunizations

A, B, D, E: Appropriate topics of discussion for parents of adolescents include peer groups, bullying, eating disorders, and risk-taking behaviors. Discussing immunizations would be appropriate for parents of children from infants to school-age. Water safety would be taught in the preschool and school-aged years.

Which of the following are true statements about neurotransmitters? Select all that apply. A. Neurotransmitters are responsible for essential functions in human emotions and behaviors. B. Neurotransmitters are targets for the mechanism of action of many psychotropic medications. C. Neurotransmitters are only studied for their effect related to psychiatric disease processes. D. Neurotransmitters are nerve cells that generate and transmit the body's electrochemical impulses. E. Neurotransmitters are cholinergics, such as serotonin, norepinephrine, dopamie, and histamine.

A, B: Neurotransmitters are released from the presynaptic neuron and are considered the first messengers. They then connect to the post-synaptic neuron to provide a message. The message sent through a neurotransmitter plays a role in human emotions and behaviors. Because neurotransmitters send messages specific to emotions and behaviors, they have been found to be useful targets of psychotropic medications. Neurotransmitters are not limited to psychiatric diseases processes alone and are useful in the study and treatment of many disease processes. Neurons are nerve cells that generate and transmit the body's electrochemical impulses. Neurotransmitters assist the neurons in transmitting their message from one neuron to the next. There are many different groups of neurotransmitters, such as cholinergics, monoamines, amino acids, and neuropeptides. Those listed in this answer are not all cholinergics.

Which of the following are reasons for the utilization of the DSM-5 in the mental health-care system? Select all that apply. A. It is a convenient format for organizing and communicating clinical data. B. It is a means for considering the complexity of clinical situations. C. It is a means for describing the unique symptoms of psychiatric clients. D. It is a format for evaluating clients based on a regulated approach. E. It is a means to better understand the etiology of many psychiatric disorders.

A, B: The DSM-5 is a convenient format for organizing and communicating clinical data. It includes a list of psychiatric and medical conditions and facilitates a comprehensive and systematic evaluation. The DSM-5 is a means for considering the complexity of clinical situations. It addresses behavioral and physical symptoms, long-term problems, stressors, and functioning. The DSM-5 describes the commonalities versus uniqueness of individuals presenting with the same diagnosis. The DSM-5 is a format for evaluating clients based on common symptoms of psychiatric disorders, not a regulated approach to the diagnosis of mental illness. The DSM-5 is not used to better understand the etiology of different psychiatric disorders because it does not address etiology.

When the nurse creates an environment to facilitate healing, the nurse's actions are based on which of the following assumptions? Select all that apply. A. A therapeutic relationship can be a healing experience. B. A healthy relationship cannot be transferred to other relationships. C. Group settings can support ego strengths. D. Treatment plans can be formulated by observing social behaviors. E. Countertransference eases the establishment of the nurse-client relationship.

A, C, D: A therapeutic relationship is characterized by rapport, genuineness, and respect and can be a healing experience. Group processes provide learning experiences and support a client's ego strengths. During group processes and interactions, staff members can observe social behaviors, and this can determine client needs. Treatment plans can be customized to meet these needs. A healthy relationship can be a prototype for other healthy relationships. Countertransference refers to the nurse's behavioral and emotional response to the client. Unresolved feelings toward significant others from the nurse's past may be projected to the client. Countertransference is a hindrance to the establishment of the nurse-client relationship.

The nurse concludes that which behaviors indicate grief resolution in a bereaved client whose husband died a year ago? Select all that apply. A. Becoming future-oriented when discussing details of everyday life. B. Considering the opinions of the deceased prior to making decisions about everyday life. C. Experiencing occasional waves of grief triggered by pictures or events. D. Sharing stories of good times that the client and her husband shared over the years. E. Being unable to visit places that hold happy memories of times spent with her husband.

A, C, D: Grief resolution requires letting go of the past and looking forward to the future. The client needs to be able to put the loss in perspective and engage fully and effectively in daily life as an independent person. Having occasional grief triggered by pictures or events is consistent with healthy grief resolution. Being able to share stories of good times indicates healthy grief resolution. If decisions are made in the present only through memories of preferences of the deceased, the client has not let go of the past and grief is not resolving. To be unable to visit one year later places that used to be enjoyed with her spouse indicate inadequate resolution of grief.

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

To understand and participate in therapeutic communication, the nurse must understand which of the following? Select all that apply. A. More than half of all messages communicated are nonverbal. B. All communication is best accomplished in a "social" space context. C. Touch is always a positive form of communication to convey warmth and caring. D. Physical space between two individuals can affect the communication process. E. The use of silence never varies across cultures.

A, D: "Nonverbal communication" refers to messages sent by other than verbal or written means. It is estimated that more than half of all messages communicated are nonverbal, which include behaviors, cues, and presence. The physical space between two individuals has great meaning in the communication process. Space between two individuals gives a sense of their relationship and is linked to cultural norms and values. Studies of interactions of people in North America indicate that a person has four zones of interaction defined by the distance between two people. The zones are defined as public space, 12 feet; social space, 9 to 12 feet; personal space 4 feet to 18 inches; and intimate space, closer than 18 inches. Some clients may feel that social interactions in a social space context are too invasive and cause discomfort, whereas other clients may interpret an interaction in this space as supportive. Touch can convey warmth and positive regard but also may be interpreted in many other ways depending on the client's perception of the intended message. The use of silence various across cultures: for instance, among European Americans, one stops talking when the other starts; but among Hispanic Americans, one does not stop speaking before the other begins; and among Asian Americans, a few moments elapse between responses.

A client states, "My wife is unfaithful. I think I am not worth anything." Which of the following describes this assessment information? Select all that apply. A. This is subjective information or a "chief complaint." B. This information must be validated by significant others. C. This objective information must be verified by individuals other than the client. D. This information needs objective measurement by a mood rating scale. E. This information indicates the use of defense mechanisms.

A, D: Statements by clients are considered subjective data. Subjective data are reported by the client and significant others in their own words. An example of this is the "chief complaint", which is expressed by the client during the intake interview. Subjective data are data expressed in the client's own words and can be made objective by the use of a mood scale measurement tool. Mood or anxiety scales are similar to pain scales. These scales objectively measure subjective data. Subjective data does not need to be validated. Subjective data are from an individual's perspective. Objective data, which must be verified by individuals other than the client and family, include physical examination findings, results of psychometric tests, rating scale scores, and lab tests, not the client's or family's expressed feelings. It is a premature assumption on the part of the evaluator to determine that this client is using defense mechanisms.

The nurse is providing postmortem care for a client. Which intervention would be appropriate prior to allowing the family to visit? Select all that apply. A. Prepare the body to look as clean and natural as possible. B. Keep the sheet over the client's face until the family is comfortably seated in the room. C. Wear sterile gloves to pack the anal canal with gauze. D. Remove the external tubes and drains. E. Call the physician to verify the time of death before taking the body to the morgue.

A, D: The body is to be handled with dignity. The body is cleaned and linens are freshened. All external tubes and drains are removed. A sheet is pulled up to cover the client's shoulders. While gloves should be worn during postmortem care, sterility is not an issue. State laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, verification of the time of death is not required prior to the family being allowed to view the client after death.

Which of the following actions reflect the nurse's role of advocate in an in-patient psychiatric setting? Select all that apply. A. The nurse speaks on behalf of a mentally ill client to ensure adequate access to needed mental health services. B. The nurse focuses on improving the mentally ill client's and family members' self-care knowledge and skills. C. The nurse explains unit rules and ensures that new clients fit comfortably into the therapeutic environment. D. The nurse continually monitors the client in the milieu for side effects of a new psychotropic medication. E. The nurse talks with the treatment team to support a shy client's request for less-sedating medications.

A, E: Advocacy is an essential role of the psychiatric nurse. Often, mentally ill clients cannot identify their personal problems or communicate their needs effectively. A nurse advocate stands alongside clients and empowers them to have a voice when they are weak and vulnerable. In the role of teacher, not advocate, the nurse assists the client and family members in attaining a greater ability to live with the effects of mental illness within the community (option B). Ensuring that new clients fit comfortably into the therapeutic environment is one of the many roles of the milieu manager, not the role of advocate. When the nurse monitors the client in the milieu for side effects of psychotropic medications, the nurse is functioning in the role of medication manager, not advocate.

Which of the following assessment information would be evaluated as objective data? Select all that apply. A. Clinical Institute Withdrawal Assessment (CIWA) score of 10. B. Client's statements of generalized anxiety. C. Complaints of anorexia. D. Client states, "I can't keep my thoughts together." E. Client's mood rating of 5 on a 0-10 pain scale.

A, E: Objective data includes scores of rating scales developed to quantify data. A CIWA score rates symptoms of alcohol withdrawal. Objective data include scores of rating scales developed to quantify data. A mood scale has a client objectively rate his or her mood from 0 to 10, on a 1-10 scale. These scales take the subjective data of mood and present it as objective data. Generalized anxiety is a subjective symptom. Objective symptoms may be assessed, such as elevated blood pressure and pulse rate, bu the statement of anxiety is a subjective symptom. Anorexia, or loss of appetite, is a subjective symptom. You may be able to measure the amount of food that a client consumes, but the feeling of appetite loss is subjective. "I can't keep my thoughts together" is a subjective symptom expressed by the client.

A terminally ill client questions the nurse about the difference between a living will and power of attorney. What is the nurse's best response? A. "A living will allows you to indicate treatments to be omitted, while durable power of attorney appoints another to make those decisions on your behalf." B. "A lawyer carries out a living will, while a designated family member or friend carries out advanced directives." C. "In a living will, you specify treatments to be carried out if you become unable to make decisions. A durable power of attorney allows you to include both treatments be to carried out and those to be omitted." D. "The living will indicates when you wish life support to be discontinued, while a durable power of attorney gives that power to someone else."

A: A living will is written by the client and includes desires for use of different types of treatment in case of a life-threatening illness. A durable power of attorney is a legal document designating an individual to make legal decisions if the client is unable to make choices independently. (A durable power of attorney is the SAME as a medical power of attorney.)

A patient who has been in the US 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 Identify Disturbance b.) Body Image Disturbance c.) Self-Esteem Disturbance d.) Altered Role Performance

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

A nurse is caring for an 80 year old patient who is living in a long term care facility. To help this patient adapt to the present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a.) Tell me about how you celebrated Christmas when you were young. b.) Tell me how you plan to spend your time this weekend. c.) Did you enjoy the choral group that performed here yesterday? d.) Why don't you want to talk about your feelings?

A: Asking questions about events in the past can encourage the older adult to relive and restructure life experiences. Asking about a recent event, upcoming plans, or feelings would be unlikely to encourage reminiscence.

Which is a nursing intervention that would promote the development of trust in the nurse-client relationship? A. Simply and clearly providing reasons for policies and procedures. B. Calling the client by name and title such as "Mr. Hawkins." C. Striving to understand the motivations behind the client's behavior. D. Taking the client's ideas into consideration when planning care.

A: By being given simple and clear reasons for policies and procedures, the client can count on consistency from the nurse in the implementation of these policies and procedures. This consistency promotes the development of trust in the nurse-client relationship. Calling the client by name and title ("Mr. Hawkins") shows respect but does not directly promote trust. Striving to understand the motivations behind the client's behavior is an empathetic intervention but does not directly promote trust. Taking the client's ideas into consideration when planning care shows that the nurse respects the client's wishes, but this intervention does not directly promote trust

Which is a nursing intervention to establish trust with a client who is experiencing concrete thinking? A. Being consistent in adhering to unit guidelines. B. Calling the client by name. C. Sharing what the client is feeling. D. Teaching the meaning of any idioms used.

A: Concrete thinking focuses thought processes on specifics rather than generalities and immediate issues rather than eventual outcomes. Being consistent in adhering to unit guidelines is one way to establish trust with a client who is experiencing concrete thinking. Calling the client by name is a way to establish trust by showing respect but does not address concrete thinking. When the nurse shares what the client is feeling, the nurse is experiencing sympathy. This does not assist the client who is experiencing concrete thinking. A concrete thinker has an inability to perceive abstractions. Knowledge of the meaning of an idiom like "the grass is always greener on the other side of the fence" may not assist the client with the ability to perceive abstractions, leading to frustration and potential anger. Attempts to educate in this area may decrease the client's trust in the nurse.

A 90-year-old client expresses a wish to diet at home after being told that an esophageal stricture prevents swallowing. The client refuses a feeding tube. The family fully supports this decision. What would be the most appropriate resource for the nurse to call? A. Hospice care B. The rabbi C. An attorney D. The medical examiner's office

A: Hospice specializes in end-of-life care. A rabbi is an important person during the end of life, but there is not an immediate need to make this call. An attorney or medical examiner is not necessary at this time.

A mother tells the nurse that she is worried about her 4 year old daughter because she is "overly attached to her father and won't listen to anything I tell her to do." What would be the nurse's best response to this parental concern? a.) Tell the mom that this is normal behavior for preschooler. b.) Tell mother that she and her family should see a counselor. c.) Tell the mom that she should try to spend more time with her daughter. d.) Tell the mother that her child should be tested for autism

A: Preschoolers according to Freud, are in the phallic stage, with the biologic focus primarily genital. The child has a sexual desire for the opposite sex parents, but as means of defense strongly identifies with the same-sex parent. This is normal behavior for a preschooler, and the family does not need counseling or autism testing. Spending more time with the child is always a good idea, but is not the solution to this concern.

A nurse is counseling a husband and wife who has decided that the wife will get a job so that the husband can go to pharmacy school. Their 3 teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12-16 hours weekly, while attending school, stage, "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: The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

In a psychiatric in-patient setting, the nurse observes an adolescent client's peers calling the client names. In this context, which statement by the nurse exemplifies the concept of empathy? A. "I can see that you are upset. Tell me how you feel." B. "Your peers are being insensitive. I would be upset also." C. "I used to be called names as a child. I know it can hurt feelings." D. "I get angry when people are treated cruelly."

A: This empathetic statement appreciates the client's feelings and objectively communicates concern for the client. This statement focuses on the situation versus the client's feelings about the situation and sympathetically rather than empathically communicates the nurse's versus the client's feelings. This is a sympathetic rather than empathetic statement that focuses on the nurse's, not the client's, feelings. Because the nurse's statement represents past personal problems, this can be considered a sympathetic statement in which the nurse overidentifies with the client

Confidentiality means respecting the client's right to keep his/her information private. When can the nurse share information about the client? Select all that apply. a.) The client threatens to harm a family member. b.) Sharing the information is the client's best interest. c.) The client gives written permission. d.) The client's legal guardian ask for information e.) The client is discharged to the parent's care. f.) The client admits to domestic abuse.

ACD

"Get the stuff from him" is an example of which type of message?

Abstract'' "Get the stuff from him" is an example of an abstract message. In concrete messages, words are explicit and need no interpretation. Concrete messages are clear, direct, and easy to understand.

The emotional frame of reference by which one sees the world is created by: a.) values b.) attitudes c.) beliefs d.) personal philosophy

B

Which of the following are examples of non-therapeutic communication blocks? Select all that apply. A. "You acted out in group. It made the other clients uncomfortable." B. "Why did you refuse your medication this afternoon?" C. "I'm so sorry you feel that way. It is a feeling typical of hospitalized clients." D. "You just think that you are not getting better. You'll see. Everything will work out." E. "What I am hearing you say is that everyone is out to get you."

B, C, D: Option B is an example of the non-therapeutic block to communication of "requesting an explanation." It involves asking the client to provide reasons for thoughts, feelings, behaviors, and events. Asking why a client did something or feels a certain way can be intimidating and implies that the client must defend his or her behavior or feelings. Option C is an example of the non-therapeutic block to communication of "belittling." Belittling minimizes the client's concerns and causes the client to feel insignificant or unimportant. When one is experiencing discomfort, it is no relief to hear that others are or have been in similar situations. Option D is an example of the non-therapeutic block to communication of "giving reassurance." Reassurance by the nurse indicates to the client that there is not cause for anxiety. By devaluing the client's feelings, the client may be discouraged from further expression of feelings. Option A is an example of "nonthreatening feedback." Nonthreatening feedback is therapeutic because it is descriptive rather than evaluative and focuses on the client's behavior, rather than personal characteristics of the client. Option E is an example of the therapeutic communication technique of "reflection." Reflection is used when directing back what the nurse understands in regard to the client's ideas, feelings, questions, and content. Reflection is used to put the client's feelings in the context of when or where they occur.

A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings related to the normal aging process would the nurse be likely to observe? Select all that apply? a.) Patients with wrinkles on the face and arms due to increased skin elasticity. b.) A patient with skin pigmentation caused by exposure to sun over the years. c.) A patient with thinner toenails with a bluish tint to the nail beds. d.) A patient healing from a hip fracture that occurred due to porous and brittle bones. e.) Bruising on a patient's forearms due to fragile blood vessels in the dermis. f.) Decreased patient voiding due to increased bladder capacity.

B, D, E: Exposure to sun over the years can cause older adults' skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura. Wrinkling and sagging of the skin occur with decreased (not increased) skin elasticity. Older adults' toenails may become thicker (NOT thinner), with a yellowish tint (not blue) to nail beds. Voiding becomes more frequent in older adults because bladder capacity decreases by 50%.

Which of the following are examples of therapeutic communication techniques? Select all that apply. A. "Tell me about your drunk-driving record." B. "How does this compare with the time you were sober?" C. "That's good. I'm glad that you think you can stop drinking." D. "I think we need to talk more about your previous coping mechanisms." E. "What led up to your taking that first drink after 5 sober years?"

B, D, E: Option B is an example of the therapeutic technique of "encouraging comparisons," which asks that similarities and differences be noted. Option D is an example of the therapeutic technique of "focusing," which poses a statement that helps the client expand on a topic of importance. Option E is an example of the therapeutic technique of "placing the event in time or sequence," which clarifies the relationship of events in time so that the nurse and client can view them in perspective. Option A is an example of the non-therapeutic block to communication of "probing." This approach may put the client on the defensive and block further interaction. It would be better to say, "Tell me how your drinking is affecting your life." Option C is an example of the non-therapeutic block to communication of "approving/disapproving," which sanctions or denounces the client's ideas or behaviors. It would be better to say, "Let's explore ways that you can use to successfully stop drinking."

Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. A.) S - Senility B.) P - Problems with feedings C>) I - Irritability D.) C - Confusion E.) E - Edema of the legs F.) S - Skin breakdown

B, D, F: The SPICES acronym is used to identify common problems in older adults and stands for: S - Sleep disorders P - Problems with eating/feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin of breakdown

A client with terminal lung cancer is receiving total brain radiation therapy to control hand tremors due to multiple metastatic lesions. As the nurse assists him to his wheelchair he says, "I'm hoping this treatment will let me see my first tomatoes on the Fourth of July. It makes me want to cry to think I won't make it until then." According to Kubler-Ross, this statement contains elements of which stage of death and dying? Select all that apply. A. Denial B. Bargaining C. Anger D. Depression E. Acceptance

B, D: During bargaining, clients "negotiate" to meet a life goal, such as going through radiation to ses one more crop of tomatoes bloom. Feelings of sadness evidenced by wanting to cry are consistent with the stage of depression. Denial would be evidenced by a refusal to accept the diagnosis of terminal cancer. There is no evidence in the client's words that he is feeling anger. Acceptance would be shown when the client has come to terms with the illness and anticipated death.

Which of the following are examples of the therapeutic communication technique of "clarification"? Select all that apply. A. "Can we talk more about how you feel about your father?" B. "I'm not sure what you mean when you use the word 'fragile.'" C. "I notice that you seem angry today." D. "How does your mood today compare with yesterday?" E. "Can you help me understand what you mean by a 'difficult childhood'?"

B, E: These are examples of "clarification" and is an attempt by the nurse to check the nurse's understanding of what has been said by the client and helps the client to make his or her thoughts or feelings more explicit. Option A is an example of the therapeutic communication technique of "focusing," not "clarification." The nurse uses focusing to direct the conversation on a particular topic of importance or relevance to the client. Option C is an example of the therapeutic communication technique of "making observations," not "clarification." This technique lets the client know that the nurse is attentive and aware of the client's situation, actions, and emotional expressions. It is the verbalization of what is perceived. Option D is an example of the therapeutic communication technique of "encouraging comparison," not "clarification." This technique helps the client to note similarities and differences.

A nurse caring for patients in a primary care setting refers to the Erikson's theory that middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which patient statement is an example of this finding? a.) I'm helping my parents move into an assisted living facility. b.) I spend all of my time going to the doctor to be sure I'm not sick. c.) I have enough money to help my son and his wife when they need it. d.) I earned this gray hair and I like it.!

B: According to Erikson, the middle adult is in a period of generality versus stagnation. The tasks are to establish and guide the net generation, accept middle age changes, adjust to the needs of aging parents and reevaluate goals and accomplishments. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs.

A nurse working with adolescents in a group home discusses the developmental tasks appropriate for adolescents with the staff. What is an example of a primary developmental task of the adolescent? a.) working hard to succeed in school b.) Spending time developing relationships with peers c.) Developing athletic activities and skills d.) Accepting the decisions of parents

B: Adolescents who are obese are at high risk for disturbed body image. Risk for injury would be appropriate for a risk taker, a risk factor for delayed development may be ADHD, and social isolation may occur with low self-esteem.

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

B: Based simply on the facts give, the 55 yo news reported would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergy-person's ability to preach, the 32 YO massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

Which is the goal for the orientation phase of the nurse-client relationship? A. Explore self-perceptions B. Establish trust C. Promote change D. Evaluate goal attainment

B: The establishment of trust is the goal of the *orientation phase.* During this phase, a contract is established with the client. Exploring self-perceptions is necessary for the therapeutic use of self and is the goal of the pre-interaction phase, not orientation phase, of the nurse-client relationship. Promoting client change is the goal of the *working* phase, not orientation phase, of the nurse-client relationship. During this phase, effective interventions and problem-solving occur. Evaluating goal attainment and therapeutic closure is the goal of the *termination* phase, not orientation phase, of the nurse-client relationship.

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: The patient's inability to list more than 3 items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

A 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: This patient's concern is with body image. The information provided does not suggest a nursing diagnosis for Personal Identify Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

Ideas that one holds as true are: a.) values b.) attitudes c.) beliefs d.) personal philosophy

C

The client tells the nurse "My biggest problem right now is trying to deal with divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse will convey empathy? a.) Can you tell me about it? b.) I'm so sorry. No wonder you're upset. c.) Sounds like it has been a difficult time. d.) You must be devastated

C

Rank the following statements using Maslow's hierarchy of needs, starting with the basic level of attainment and progressing toward self-actualization. A. "I am glad I can now be assertive in controversial situations." B. "My wife and I are planing a second honeymoon for our 20th anniversary." C. "Using my CPAP machine consistently has eliminated my sleep apnea." D. "I change my smoke alarm batteries every year on New Year's Day." E. "Getting my graduate degree was a wonderful 50th birthday gift to myself."

C, D, B, A, E: Sleeping is one of many basic physiological needs, which should be attained first under Maslow's hierarchy of needs. Smoke alarms are an assistive device to maintain safety and security, which should be attained second under Maslow's hierarchy of needs. An intimate relationship shows attainment of love and belonging, which should be attained third under Maslow's hierarchy of needs. To assert oneself is a behavior that exemplifies self-esteem, which should be attained fourth under Maslow's hierarchy of needs. A sense of self-fulfillment and accomplishment is an example of self-actualization, which should be attained fifth under Maslow's hierarchy of needs.

Place the following nursing interventions in order as they would proceed through the phases of the nurse-client relationship. A. Plan for continued care B. Promote client's insight C. Examine personal biases D. Formulate nursing diagnoses

C, D, B, A: First, in the pre-orientation phase of the nurse-client relationship, the nurse would examine any personal biases. Second, in the orientation phase, the nurse would formulate nursing diagnostic statements. Third, in the working phase, the nurse would attempt to promote client insight. Fourth, in the termination phase, the nurse would plan for continued client care.

A nurse caring for adults in a provider's office researching aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. a.) Chemical reactions in the body produce damage to the DNA b.) Free radicals have adverse effects on adjacent molecules. c.) Decrease in size and function of the thymus results in more infections. d.) There is much interest in the role of vitamin supplementation e.) Lifespan depends on a great extent to genetic factors. f.) Organism wear out from increased metabolic functioning.

C, D: The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, resulting in more infections. THere is much interest in Vitamin supplements (Such as Vit. E) to improve immune function. THe cross-linkage theory proposed that a chemical reaction produces damage to the DNA and cell death. The free radical theory states that free radical - molecules w/ separated high-energy electrons -formed during cellular metabolism can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on a genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stresors.

On an in-patient psychiatric unit, which of the following actions exemplify the nurse's role of teacher? Select all that apply. A. The nurse assesses potentially stressful characteristics of the environment and develops strategies to eliminate or decrease stressors. B. The nurse orients new clients to the unit and helps them to fit comfortably into the environment. C. The nurse presents information to help the client and family members to understand the effects of mental illness. D. The nurse is the guardian of the therapeutic environment. E. The nurse holds a group to discuss medication side effects.

C, E: In the role of teacher, the nurse assists the client and family members in coping with the effects of mental illness. Helping the client to understand his or her illness, its signs and symptoms, the medications and potential side effects, and various coping techniques all are interventions of the nurse functioning in the role of teacher. The nurse also assists the client to understand treatments, including medication actions and their side effects. Holding this teaching group is an intervention that reflects the nurse's role of teacher. Environmental assessment is within the nurse's role as milieu manager, not the role of teacher. One of the roles of the milieu manager, not the teacher, is to orient new clients and assist them in fitting comfortably into the milieu. The guardian of the therapeutic environment is the psychiatric nurse in teh role of milieu manager, not teacher.

Which of the following are examples of the non-therapeutic block to communication of "giving reassurance"? Select all that apply. A. "That's good. I'm glad that you....." B. "Hang in there, every dog has his day." C. "Don't worry, everything will work out." D. "I think you should......" E. "I'm sure you can beat this addiction."

C, E: Options C and E are examples of the nontherapeutic block to communication of "giving reassurance." The use of this block indicates to the client that there is no cause for anxiety. This block involves giving the client a false sense of confidence and devaluing the client's feelings. It also may discourage the client from further expression of feelings if the client believes those feelings would only be downplayed or ridiculed. Option A is an example of the nontherapeutic block to communication of "approving/disapproving," which sanctions or denounces the client's ideas or behaviors. Option B is an example of the nontherapeutic block to communication of "making stereotyped/superficial comments," which offers meaningless cliches or trite expressions. In option D, when the nurses uses the nontherapeutic block to communication of "giving advice," the nurse tells the client what to do. This implies that the nurse knows what is best and the client is incapable of any self-direction.

Which of the following statements are examples of the therapeutic communication technique of "focusing"? Select all that apply. A. "You say you're angry, but I notice that you're smiling." B. "Are you saying that you want to drive to Hawaii?" C. "Tell me again about Vietnam and your feelings after you were wounded." D. "I see you staring out the window. Tell me what you're thinking." E. "Yesterday you described your relationship with your mom. Let's continue that topic."

C, E: These are examples of the therapeutic communication technique of "focusing." The nurse uses focusing to direct the conversation to a particular topic of importance or relevance to the client. In option A, the nurse uses a therapeutic technique of "confrontation" to bring incongruence or inconsistencies into awareness. In option B, the nurse is using a therapeutic technique of "clarification" in an attempt to check the understanding of what has been said by the client and helps the client make his or her thoughts or feelings more explicit. In option D, the nurse is "making an observation" and using the therapeutic technique of "broad opening," which helps the client initiate the conversation and puts the client in control of the content.

A 4-year-old child is unable to consider another child's ideas about playing house. This situation is an example of which concept of Piaget's theory of cognitive development? A. Object permanence B. Reversibility and spatiality C. Egocentrism D. Formal operations

C: According to Piaget, egocentrism occurs during the stage of preoperational thought (2 to 6 years). Personal experiences are thought to be universal, and the child is unable to accept the differing viewpoints of others. During Piaget's stage 1 of cognitive development (birth to 2 years), object permanence is developed. With this ability, the infant/toddler comes to recognize that an object will continue to exist when it is no longer visible. The 4-year-old presented in the question has moved beyond this cognitive stage of development. During Piaget's stage 3 of cognitive development (6 to 12 years), reversibility and spatiality are developed. With this ability, the child recognizes that changes in the shape of objects do not necessarily change the amount, weight, volume, or ability of the object to return to its original form. The 4-year-old presented in the question has not reached this cognitive stage of development. Formal operations (12 to 15 years) is the fourth stage of Piaget's theory of cognitive development. At this stage, the individual is able to think and reason in abstract terms. The 4-year-old presented in the question has not reached this cognitive stage of development.

A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a.) Most older adult live in their own homes. b.) Healthy older adults live in their own homes c.) Old age means mental deterioration d.) Older adults want to be attractive to others.

C: Although response time may be longer, intelligence does not normally decrease because of aging. Most older adult own their own homes. Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others.

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 them to death' every day. B.) I think my 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: Each option with the exception of C is correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

Which of the following are specific tasks of the working phase of a therapeutic relationship? Select all that apply. a.) Begin planning for termination b.) Build trust c.) Encourage expressions of feelings d.) Establish a nurse-client contract e.) Facilitate behavior change f.) Promote self-esteem

CEF

A 25-year-old client diagnosed with major depressive disorder remains in his room and avoids others. According to Erickson, what describes this client's developmental task assessment? A. Stagnation B. Despair C. Isolation D. Role confusion

C: Isolation is the negative outcome of Erikson's "young adulthood" stage of development, intimacy versus isolation. This stage ranges from 20 to 30 years of age. The major developmental task for young adulthood is to form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort. The 25-year-old client falls within the age range for young adulthood and is exhibiting behaviors associated with isolation. Stagnation is the negative outcome of Erikson's "adulthood" stage of development, generativity versus stagnation. Adulthood's stage ranges from 30 to 65 years of age. The major developmental task for the adulthood stage is to achieve the life goals established for oneself, while considering the welfare of future generations. The client described does not fall within the age range of the adulthood stage. Despair is the negative outcome of Erikson's "old age" stage of development, ego integrity versus despair. This stage ranges from age 65 years until death. The major developmental task for this stage is to review one's life and derive meaning from positive and negative events. Through this process, one needs to achieve a positive sense of self-worth. The client described does not fall within the age range of the old age stage. Role confusion is the negative outcome of Erikson's "adolescence" stage of development, identity versus role confusion. This stage ranges from 12 to 20 years of age. The major developmental task for this stage is to integrate the tasks mastered in the previous stages into a secure sense of self. The client described does not fall within the age range of adolescence.

While the nurse is discussing a client's likely death with family members, one of the adult children asks, "We plan on taking turns being here for now, but we all want to be here at the time of mother's death. Is there any way we can tell when that time is close?" What is the nurse's best response? A. "Often, people become lucid for about 15 minutes during the last hour before death. Watch for your mother to become more alert with clearer eyes, focus on faces, and clear her throat. Call the others in at that time." B. "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." C. "The arms and legs become more bluish in color and are cool to touch. Breathing becomes irregular and shallow and will change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." D. "You can expect muscles to become more rigid, with staring eyes and mouth closed. The head is pulled back with neck rigidity. Don't be alarmed when you hear a death rattle in her throat."

C: Peripheral circulation decreases and shifts to vital organs. The vascular system collapses, causing decreasing pulse and blood pressure. The gag reflex is lost, and mucus accumulates in the back of the throat. Respirations decrease in rate and become irregular. Vision is blurred near the time of death. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, bu the imminence of clinical death can be detected. Muscle rigidity typically occurs after death.

A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be developmentally appropriate for this age group? a.) playing video games. b.) playing peek-a-boo c.) playing in a sand box d.) playing board games

C: Playing in a sand box with toys that emphasize gross motor skills and creativity is a developmentally appropriate activity for a toddler. Video games are appropriate for school-aged children and adolescents, but should be monitored. Playing peek-a-boo is developmentally appropriate for an infant, and playing board games usually begins with preschool and older children.

A nurse is performing a psychological assessment at a 19 yr patient who has Down 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: The data point to the patient having a positive self-concept (I'M a good helper) and fairly high self-esteem (realizes his strengths and limitation). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

Which client situation is an example of normal ego development? A. A client calls out in pain to get his or her needs met. B. A client complains of poor self-esteem because of punishments from his or her past. C. A client exhibits the ability to assert himself or herself without anger or aggression. D. A client feels guilty about wanting to have sexual relations outside of marriage.

C: The ego is considered the "reality principle" and begins to develop between 4 and 6 months of age. The ego experiences the outside world and then adapts and responds to it. The ego's main goal is to maintain harmony between the id and the superego. The ability to assert oneself without anger or aggression is an example of healthy ego development. The id is the locus of instinctual drives - the "pleasure principle". It endows an infant with drives that seek to satisfy needs and achieve immediate gratification. Id-driven behaviors are impulsive and may be irrational. Option A is an example of id, not ego, development. Between 3 and 6 years of age, a child begins to develop his or her superego by being rewarded or punished for "good" and "bad" behavior. The superego internalizes values and morals set forth by the primary caregivers. This is considered the "perfection principle". The superego is important in that it assists the ego in controlling the impulses of the id. When the superego becomes penalizing, self-esteem issues can arise. Options B and D are examples of superego, not ego, development.

A mother of a 10 year old daughter tells the nurse: "I fell incompetent as a parents 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 to improve her parenting skills. c.) Assist the mother to identifying 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: The first intervention priority with a mother who feels incompetent to parents a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improve her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

A 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: The first intervention priority with a mother who feels incompetent to parents a daughter is to assist the mother to identify what is preventing her from being an effective patents and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

The nurse is interviewing a client admitted to an in-patient psychiatric unit with a diagnosis of depressive disorder. Which is the primary goal in the assessment phase of the nursing process for this client? A. To build trust and rapport. B. To identify goals and outcomes. C. To collect and organize information. D. To identify and validate the medical diagnosis.

C: The primary goal in the assessment phase of the interview is to collect and organize data, which would be used to identify and prioritize the client's problems. Trust and rapport are needed to build a nurse-client relationship, but this is not the primary purpose of the assessment phase. Identification of goals and outcomes occurs during the planning, not assessment, phase of the nursing process. The identification and validation of the medical diagnosis is not within the scope of practice for the registered nurse.

A depressed client discussing marital problems with the nurse says, "What will I do if my husband asks me for a divorce?" Which response by the nurse would be an example of therapeutic communication? A. "Why do you think that your husband will ask you for a divorce?" B. "You seem to be worrying over nothing. I'm sure everything will be fine." C. "What has happened to make you think that your husband will ask for a divorce?" D. "Talking about this will only make you more anxious and increase your depression."

C: The therapeutic technique of "exploring," along with reflective listening, draws out the client and can help the client feel valued, understood, and supported. Exploring also gives the nurse the necessary assessment information to intervene appropriately. Option A is an example of "requesting an explanation," which requests the client to provide the reasons for thoughts, feeling and behaviors, which can be an unrealistic expectation. It also may put the client on the defensive. Option B is an example of "giving false reassurance" by indicating to the client that there is no cause for fear or anxiety. This blocks any further interaction and expression of feelings by the client. Option D is an example of "rejection," which shows contempt for the client's need to voice and express fears and anxiety.

A 33 yr 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: This patient's self concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

The nurse working with a terminally ill client wishes to support the client's decisions concerning end-of-life care. To do this appropriately, the nurse should plan to do which of the following? A. Be comfortable in assisting the client with euthanasia when requested to do so. B. Ask another nurse to provide care if the client has a belief system that differs from own belief system. C. Respect the client's wishes about death to the extent possible by law. D. Encourage the client to request a do-not-resuscitate order because of terminal illness.

C: To uphold client autonomy, the nurse needs to consider the client's wishes while also acting with the law. Euthanasia constitutes illegal nursing practice in the United States at this time. To act ethically, the nurse should provide care to clients according to need, regardless of belief systems. Clients who are diagnosed with terminal illness may or may not be ready for do-not-resuscitate orders, depending on anticipated life expectancy, quality of current life, and psychosocial variables.

A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. What is the leading cause of cognitive impairment in old age? a.) Stroke b.) Malnutrition c.) AD d.) Loss of cardiac reserve

C; Dementia, AD, Depression, and delirium may occur and cause cognitive impairment, AD is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressive from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. The leading causes of death in adults aged 65+ are heart disease, cancer, chronic respiratory disease, stroke, AD, and diabetes.

Which type of cue is being used when the client states, "Nothing can help me"?

Cues are considered to be either covert or overt. Covert cues are vague or hidden messages that need interpretation and exploration. Overt cues are clear statements of intent, such as "I want to die."

Managed care is designed to: a.) control health-care costs by limiting access to care. b.) keep the health care costs from increasing over time. c.) limit the amount of money paid to physicians and hospitals. d.) maintain a balance between the quality and costs of health care

D

Which scenario describes an individual in Erikson's developmental stage of "old age" exhibiting a negative outcome of despair? A. A 60-year-old woman having difficulty taking care of her aged mother. B. A 50-year-old man reviewing the positive and negative aspects of his life. C. A 65-year-old man openly discussing his life's accomplishments and failures. D. A 70-year-old woman angry about where her life has ended up.

D: A 70-year-old would be in Erikson's developmental stage of "old age" (65 years old to death). The developmental task conflict of this stage is ego integrity versus despair. The major developmental task in old age is for an individual to review one's life and derive meaning from positive and negative events. The 70-year-old woman presented is exhibiting behaviors reflecting the negative outcome of despair. The 60-year-old and 50-year-old would be in Erikson's developmental stage of "adulthood" (30 to 65 years old), not "old age" (65 years old to death). The developmental task conflict of this stage is generativity versus stagnation. The example given presents someone exhibiting behaviors reflective of stagnation, the negative outcome of this stage. A 65-year-old would be in Erikson's developmental stage of "old age" (65 years old to death). The developmental task conflict of this stage is ego integrity versus despair. The example reflects someone who is exhibiting the desire to discuss all aspects of life events and is experiencing the positive, not negative, outcome of ego integrity.

An experienced nurse tells a less-experienced nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a.) Harassment b.) Whistle blowing c.) EA D.) Ageism

D: Ageism is the form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant person takes advantage of or overpowers a less dominant person; it may involved sexual harassment or power struggles. Whistle blowing involves reporting illegal or unethical behavior in the workplace. EA is an international act or failure to act by a caregiver that causes or creates a risk of harm to an older adult.

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 Identify Disturbance b.) Body Image Disturbance c.) Self-Esteem Disturbance d.) Altered Role Performance

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

Which assessment is most important when evaluating signs and symptoms of mental illness? A. The decreased amount of creativity a client exhibits. B. The inability to face problems within one's life. C. The intensity of an emotional reaction. D. The client's social and cultural norms.

D: It is important when assessing for mental illness that social and cultural norms be evaluated. The context of cultural norms determines if behaviors are considered acceptable or aberrant. For example, belief in reincarnation can be acceptable in one culture and considered "delusional" in another. The amount of creativity a client exhibits is not reflective of mental health or illness. Some individuals are innately more creative than others. The inability to face a problem is not specific to mental illness. Many individuals not diagnosed with a mental illness have difficulty facing problems, such as a diabetic refusing to adhere to an American Diabetes Association (ADA) diet. Intensity of emotional reactions is not indicative of mental illness. Grief, an expected response to a perceived loss, can vary in intensity from person to person and be affected by cultural norms.

A nurse providing health services for a 55+ community setting formulates diagnoses for patients. Which of the following nursing diagnoses would be most appropriate for many middle adults? a.) Risk for imbalanced nutrition: less than body requirements. b.) Delayed growth and development c.) Self Care deficit d.) Caregiver role strain

D: Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24 hr care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Risk for imbalanced nutrition: less than body requirements would be most appropriate for an adolescent with an eating disorder or an older adult who has condition (such as ill-fitting dentures, financial restraints, or GI issues) preventing proper nutrition. Delayed growth and development would be most appropriate for infancy to school-age patients and self-care deficit would be most appropriate for older adults whose health prevents them from performing ADLs.

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

A resource person's function is to give specific answers to specific questions, as a counselor's function is to: A. Identify learning needs and provide information required by the client. B. Encourage the client to be an active participant in designing a nursing plan of care. C. Serve as a substitute figure for another person. D. Listen as a client reviews feelings related to difficulties experienced in life.

D: The nurse functioning as a counselor uses interpersonal communication techniques to assist clients in learning to adapt to difficulties or changes in life experiences. These techniques allow the experiences to be integrated with, rather than dissociated from, other experiences in life. The nurse functioning in the role of a resource person provides specific information that the client can understand and use to benefit health and well-being. The nurse functioning as a teacher, not a counselor, identifies learning needs and provides information required by the client to improve health situations. The nurse functioning as a surrogate, not a counselor, serves as a substitute figure for another person. The nurse may be perceived by the client as a mother figure, sibling, teacher, or someone who has provided care in the past. The nurse has the responsibility for exercising professional skill in aiding the relationship to move forward.

A client states, "I don't know what the pills are for or why I am taking them, so I don't want them." Which is an example of the therapeutic communication technique of "giving information"? A. "You must take your medications to get better." B. "The doctor wouldn't prescribe these pills if they were harmful." C. "Do you feel this way about all of your medications?" D. "This medication will help to improve your mood."

D: The nurse is "giving information" about the therapeutic effect of the client's medication because the nurse has assessed from the client's statement that information is needed. Option A is an example of "giving advice," which is nontherapeutic because the statement does not allow the client to make personal decisions. Option B is an example of "defending", which is nontherapeutic because this statement would put the client on the defensive. Option C is an example of "exploring", which is incorrect because the client has provided you with information by stating, "I don't know what the pills are for."

A 36 yr woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiance of 3 months. Three weeks later, her fiance has not yet contact her. The patient states that she is very busy and she's too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What does this data suggest? a.) There is no disturbance of self-concept. b.) This patient has ego strength and high self-esteem but may have a disturbance of body image. c.) The are 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: The traumatic nature of this patient's injuries, her fiance's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

A psychiatric-mental health nurse is working to develop a therapeutic relationship with a client. When doing so, which element would the nurse integrate as critical to building this relationship?

Self-awareness Building of the therapeutic relationship begins with the nurse's self-awareness. Effective communication skills are important, but it is the nurse's self-awareness that forms the foundation of the awareness. Without self-awareness, nurses will find it impossible to establish and maintain therapeutic relationships The therapeutic relationship is not based on friendship or dependent on social skills.

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. A Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. B Explain to the family what will happen at each phase of the weaning and offer support. C Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. D Tell the family that death will occur almost immediately after the patient is removed from the ventilator. E Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. F Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on one's own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a.) actual b.) Perceived c.) Psychologcal d.) Anticipatory e.) Physcal f.) Maturational

a, b, c. The loss experienced by the woman is actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss, perceived loss is experienced by the person but is intangible to others, and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss, physical loss is loss that is tangible and perceived by others, and maturational loss is experienced as a result of natural developmental processes.

A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. A The family arranges for a funeral for their loved one. B The family arranges for a memorial scholarship for their loved one. C The coroner pronounces the patient's death. D The family arranges for hospice for their loved one. E The patient is diagnosed with terminal cancer. F The patient's daughter writes a poem expressing her sorrow.

a, b, f. Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life), that make up the outward expressions of grief. People who are bereaved are in a state of grieving from loss of a loved one.

A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? A The nurse places the patient in a sitting position while the family visits. B The nurse places identification tags on both the shroud and the ankle. C The nurse removes soiled dressings and tubes. D The nurse makes sure a death certificate is issued and signed.

a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

A 70-year-old female patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? A Patient B Daughter C Doctor D Ethics consult team

a. Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilities unless she asks them to do this. The ethics consult team is not a decision-making body; it can make recommendations but has no authority to order anything.

A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse caring for the patient that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse and husband both agree that this seems to be all that therapy is now doing for her. The nurse would suggest that the husband speak to his wife's physician about which type of order? A Comfort-measures-only B Do-not-hospitalize C Do-not-resuscitate D Slow-code-only

a. Comfort-measures-only order. The wife would want all aggressive treatment to be stopped at this point and all care to be directed to a comfortable, dignified death.

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association regarding assisted suicide? A.) The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. B.) The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. C.) After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." D.) The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The American Nurses Association (ANA, 1994, 2013) issued position statements stating that assisting in suicide and participating in active euthanasia are in violation of the Code for Nurses, the ethical traditions and goals of the profession, and its covenant with society.

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? A Acceptance B Anger C Bargaining D Denial

a. The patient's statement reflects the acceptance stage of death and dying defined by Kübler-Ross.

The primary purpose of the Community Mental Health Center Act of 1963 was: a.) getting better treatment in larger, more urban areas. b.) moving patients to their home community for treatment. c.) providing former patients with employment opportunities d.) removing the stigma of living in an institution.

b

A nurse is caring for terminally ill patients in a hospital setting. Which example describes appropriate end-of-life care? A To eliminate confusion, taking care not to speak too much when caring for a comatose patient B Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient C Referring to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father D Telling a dying patient to sit back and relax and performing patient hygiene for the patient because it is easier than having the patient help

b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body; many patients retain a sense of hearing almost to the moment of death; therefore nurses should explain to the comatose patient the nursing care being given. The nurse should address caregiver role endurance by actively listening to family members who are experiencing it. Because it is good to encourage dying patients to be as active as possible for as long as possible, it is generally not good practice to perform basic self-care measures the patient can perform simply because it is "easier" to do it this way.

A nurse is visiting a male patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family and wants to live. Which response by the nurse would be most appropriate? A "You can't be feeling this way. You know you are going to die." B "It does seem unfair. Tell me more about how you are feeling." C "You'll be all right; who knows how much time any of us has" D "Tell me about your pain. Did it keep you awake last night?"

b. The nurse would want to validate that what the patient is saying has been heard and invite him to share more of his feelings, concerns, and fears.

A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? A "Oh, don't worry about that now. You need to sleep." B "What seems to be concerning you the most?" C "I have talked to your wife and she told me she will be fine." D "I have to go and give medicines, you should discuss this with your wife."

b. Using an open-ended question allows the patient to continue talking. False reassurances are not helpful. Also, the patient's feelings and restlessness should be addressed as soon as possible.

A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? A Abbreviated B Anticipatory C Dysfunctional D Inhibited

c. Dysfunctional grief extends the mourning period for an abnormally long time, characterized by abnormal or distorted expressions of grief.

All of the following diagnoses may apply to a young couple who gave birth to a premature infant with serious respiratory problems who has been in the neonatal intensive care unit for the last 3 months. The couple has a 22-month-old son at home. Which diagnosis would be most appropriate based on the following assessment data: report of chronic fatigue and decreased energy, guilt about neglecting son at home, shortness of temper with one another, and apprehension about continued ability to go on this way? A Grieving B Ineffective Coping C Caregiver Role Strain D Powerlessness

c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided.

A patient tells a nurse that he has no one he trusts to make health care decisions for him should he become incapacitated. What should the nurse suggest he prepare? A Combination advance medical directive B Durable power of attorney for health care C Living will D Proxy for health care

c. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. A durable power of attorney for health care appoints an agent (proxy) the person trusts to make decisions in the event of subsequent incapacity. The combination advance medical directive also appoints a proxy for the patient.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? A Inform the family that there is no need for them to wash the body since the mortician typically does this. B Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. C Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. D Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.