Chapter 09 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 09

Question 1

Type: MCSA

A patient is admitted after being bitten by a dog and tells the nurse he feels fine except for the bite. The nurse assesses that this patient is functioning within which phase of the general adaptation syndrome?

1. Transaction

2. Resistance

3. Alarm

4. Exhaustion

Correct Answer: 2

Rationale 1: There is no transaction stage within the general adaptation syndrome.

Rationale 2: In this stage, the body attempts to cope with the stressor by minimizing the stressors impact as much as possible. The patients statement is an attempt to return to normal as soon as possible.

Rationale 3: The alarm stage is the first stage of the general adaptation syndrome, when the fight-or-flight response is initiated.

Rationale 4: The exhaustion stage is the final stage, in which the adaptation the body made during the second stage cannot be maintained. This stage occurs only if the stress becomes overwhelming or is not removed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-1

Question 2

Type: MCSA

While being assessed, a patient tells the nurse that she has many stresses in her life. Which statement would the nurse evaluate as indicating external stress?

1. I am a workaholic.

2. My job has many rigid rules.

3. I feel like I have to please everyone.

4. I drink several cups of coffee in the morning and then switch to cola drinks in the afternoon.

Correct Answer: 2

Rationale 1: Being a workaholic is a stress that comes from within the patient and is an internal stressor.

Rationale 2: External stressors originate outside the body and are precipitated by changes in the external environment. They can be triggered by the actual physical environment, the social environment, the organizational environment, major life events, and trauma. Having to work within a set of rigid rules would be an external stressor.

Rationale 3: The need to please everyone comes from within and is an internal stressor.

Rationale 4: Using caffeine to excess can be an internal stressor or a response to stress.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-4

Question 3

Type: MCSA

The nurse is caring for a burn patient. Because of the amount of stress the patient is experiencing, the nurse realizes that the patient would benefit from which intervention?

1. An increase in activity

2. An increased supply of protein

3. Fluid restriction

4. Antinausea medication

Correct Answer: 2

Rationale 1: Increased activity is not a good stress-relieving option for this patient at this time.

Rationale 2: In the hypothalamus-pituitary-adrenal response to stress, the body stimulates the production of cortisol. Cortisol stimulates protein catabolism. The patient with burns undergoing surgery is experiencing a significant level of stress and would benefit from protein supplementation.

Rationale 3: Fluid restriction is not useful for the patient coping with severe stress. Patients who have been burned need fluid resuscitation, not restriction.

Rationale 4: The patient may need antinausea medication for another reason, but not as a treatment for stress.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-3

Question 4

Type: MCSA

The nurse is reviewing the serum laboratory values of a patient just admitted with traumatic injuries. Which laboratory value might be abnormally elevated because of the trauma?

1. Potassium

2. Hemoglobin

3. Glucose

4. Sodium

Correct Answer: 3

Rationale 1: There is no evidence to support that traumatic injuries cause an immediate increase in potassium levels.

Rationale 2: The patients hemoglobin might be low, depending on the amount of blood loss from the injuries.

Rationale 3: Stimulation of both the adrenal medulla and cortex in response to stress results in an increased blood glucose level.

Rationale 4: There is no evidence to support that traumatic injuries cause an immediate increase in sodium levels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-3

Question 5

Type: MCSA

A patient asks the nurse about free radicals and how they contribute to illness. How should the nurse respond?

1. Free radicals are cells also known as natural killer cells.

2. Free radicals are bad substances that clog the liver so it cannot get rid of body toxins.

3. Free radicals are substances that develop when we dont breathe deeply enough.

4. Free radicals are produced naturally in cells but can be harmful if their balance in the body is not maintained.

Correct Answer: 4

Rationale 1: Free radicals are not the same as natural killer cells.

Rationale 2: Not all free radicals are injurious to the body. The liver is not the only organ affected by free radicals.

Rationale 3: Shallow breathing is not the etiology of free radicals.

Rationale 4: Free radicals are produced in cells either as a by-product of metabolism or deliberately, as in phagocytosis. They have a useful function under controlled conditions but can damage cells if left uncontrolled.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-2

Question 6

Type: MCSA

A patient tells the nurse that she never had bowel problems until she started a new job that is highly demanding. What is the nurses best response to this patient?

1. You might have had the bowel problems all along but didnt realize it until recently.

2. There is no connection between the new bowel problems and your new job.

3. The new job might be a trigger for a stress reaction in your body, causing the new bowel problems.

4. Because of your new job you may be eating in different places. That can upset your stomach.

Correct Answer: 3

Rationale 1: The nurse does not have enough information on which to base this suggestion.

Rationale 2: Without more information, the nurse cannot be certain this statement is accurate.

Rationale 3: Stress can be a trigger for gastrointestinal problems. The stress circuit influences the stomach and intestines and can lead to problems such as diarrhea, constipation, cramping, and bloating. Excessive stomach acid can lead to gastric burning.

Rationale 4: Eating in different places than before might be implicated in gastrointestinal upset, but another cause is more likely.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-3

Question 7

Type: MCMA

At the completion of a patient assessment, the nurse reviews a list of the patients stated and observed behaviors. Which behaviors would indicate to the nurse that the patient is experiencing stress?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient stated an inability to sleep more than 2 hours per night.

2. The patient asked for water for a dry throat.

3. The patient commented on recent pleasant weather.

4. The patient sat quietly in the chair, hands resting in the lap.

5. The patients rate and depth of respirations are increased.

Correct Answer: 1,2,5

Rationale 1: Inability to sleep is a common unhealthy response to stress.

Rationale 2: Dryness of the throat or mouth can be associated with stress.

Rationale 3: The patient who is stressed is more likely to be apathetic than to be interested in surroundings such as weather.

Rationale 4: The patient who is stressed is more likely to be irritable and unable to sit still.

Rationale 5: The rate and depth of respirations increase due to dilation of bronchioles. This can be a physiological indicator of stress.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-4

Question 8

Type: MCSA

A student nurse is having difficulty establishing relationships with patients. What should this student be counseled to do?

1. Focus on the purpose of a therapeutic alliance.

2. Study cognitive theory.

3. Review the concepts of caring.

4. Develop self-awareness to focus on being helpful to patients.

Correct Answer: 4

Rationale 1: Simply focusing on why it is important to develop a therapeutic relationship is not the best method of developing that relationship.

Rationale 2: Cognitive theory does not assist with the development of a therapeutic nursepatient relationship.

Rationale 3: Reviewing the concepts of caring might help the nurse understand why a therapeutic relationship is important but will not help with the nurses personality development.

Rationale 4: One aspect of the nursepatient relationship is the nurses self-awareness. The nurse needs to expand insight into his or her own personality.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-6

Question 9

Type: MCSA

While changing a patients abdominal dressing, the nurse talks about aspects of wound care such as the need to check the skin and protect the wound from infection or injury. The nurse and patient are in which phase of the nurse-patient relationship?

1. Orientation

2. Working

3. Caring

4. Termination

Correct Answer: 2

Rationale 1: The orientation phase is the first phase of the relationship, in which introductions occur and the trusting relationship begins to develop.

Rationale 2: The working phase of the nurse-patient relationship describes the participation of both patient and nurse in interventions to achieve mutually agreed-upon goals. Most patient education occurs during this phase.

Rationale 3: Although the nurse-patient relationship takes place in a context of caring, there is no specific phase known as the caring phase.

Rationale 4: In the termination phase, the nurse and patient review what has occurred during the working phase and the progress toward goal achievement.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-6

Question 10

Type: MCSA

While conducting an assessment, the nurse asks the patient to rate her pain, with 1 being no pain and 10 being the worst pain she ever experienced. The nurse is utilizing which therapeutic communication technique?

1. Focusing

2. Encouraging comparison

3. Offering self

4. Accepting

Correct Answer: 2

Rationale 1: Focusing is a technique that helps when a patient moves quickly between topics.

Rationale 2: Encouraging comparison asks the patient to compare similarities and differences in experiences. Having the patient compare this pain to previous pain helps the patient quantify the amount of pain currently being experienced.

Rationale 3: Offering self describes the nurse making him- or herself available to the patient by either sitting or staying with the patient.

Rationale 4: Accepting occurs when the nurse conveys an attitude of reception and regard that is characterized by head nodding and eye contact.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-6

Question 11

Type: MCSA

A patient tells the nurse that he thinks he has cancer because every other male family member was diagnosed with cancer at the same age. The nurse responds, Everything will be all right. Which nontherapeutic communication technique has the nurse used?

1. Rejecting

2. Giving advice

3. Giving disapproval

4. Giving reassurance

Correct Answer: 4

Rationale 1: Rejecting is refusing to consider or showing contempt for the patients ideas.

Rationale 2: The nurse has not offered the patient any advice.

Rationale 3: The nurse has not indicated disapproval of the patients idea.

Rationale 4: Giving reassurance is a nontherapeutic technique that suggests there is no cause for anxiety and devalues the patients feelings. It would be more therapeutic for the nurse to ask the patient to discuss that a bit further.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-6

Question 12

Type: MCSA

A patient refuses to learn how to give himself insulin injections because he gave his father insulin injections and he died anyway. How can the nurse best facilitate this patients learning?

1. Provide a diagram of body areas where insulin injections should be given.

2. Talk with the patient about his fathers illness and how the insulin injections will help him control his own illness.

3. Ask the patient if he prefers to read about how to administer the injections.

4. Leave a needleless syringe at the patients bedside for him to practice with.

Correct Answer: 2

Rationale 1: Providing such a diagram would not support the patients need for affective learning.

Rationale 2: The patient has experience administering injections but also has an attitude or belief about insulin and the role it plays in diabetes management. The patient needs affective learning, or learning that involves changing an attitude, value, or feeling.

Rationale 3: The nurse should not ignore the patients statement by asking if he prefers written instructions.

Rationale 4: Leaving a needleless syringe at the bedside would not support the patients need for affective learning.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-7

Question 13

Type: MCSA

A patient tells the nurse that he is sick and will do whatever he is told to do. How should the nurse evaluate this statement?

1. The patient is exhibiting an internal locus of control.

2. The patient is responding to a perceived crisis.

3. The patient is demonstrating sick role behavior.

4. The patient is using denial as a coping mechanism.

Correct Answer: 3

Rationale 1: An internal locus of control is the perception that people have control over events that happen in their lives.

Rationale 2: There is no indication that the patient perceives this illness as a crisis.

Rationale 3: When individuals become ill and must be hospitalized, they are expected to behave in certain ways and assume a sick role. A sick role is a set of expectations that people who are ill must meet and that society, including caregivers, expects of them. The patient is expected to be cooperative, dependent, and undemanding.

Rationale 4: There is no indication that this patient is in denial.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-5

Question 14

Type: MCSA

A patient newly diagnosed with prostate cancer tells the nurse that his wife died a few weeks ago and he does not know how he is going to deal with this new health problem. What can the nurse do to help this patient?

1. Tell the patient that it seems overwhelming now, but everything is going to work out all right.

2. Suggest that the patient talk with a spiritual counselor.

3. Listen quietly while the patient talks.

4. Talk with the patient about his support systems and what he can do to maintain stability.

Correct Answer: 4

Rationale 1: The nurse should not minimize the patients losses by saying that everything will work out. The nurse has no way of knowing if this will occur.

Rationale 2: Suggesting that the patient talk with a spiritual counselor may or not be appropriate, but it does not immediately address the patients concerns.

Rationale 3: The nurse needs to do more than listen quietly while the patient talks.

Rationale 4: The best approach would be for the nurse to talk with the patient about his support systems and what he can do to maintain autonomy and stability. The patient is experiencing two lossesthe loss of his wife and the perceived loss of his healthand is still working through the stages of grief for his wife.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-5

Question 15

Type: MCMA

A patient is brought to the emergency department after being involved in a drive-by shooting. Which physiological changes associated with the alarm stage would make it difficult to assess this patient for injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients heart rate will be elevated.

2. The patients blood glucose will be elevated.

3. The patients urine output will be decreased.

4. The patients bowel sounds will be hyperactive.

5. The patients systolic blood pressure will be low.

Correct Answer: 1,2,3

Rationale 1: The patients heart rate will be elevated in the alarm stage. This elevation could be misinterpreted as a sign of hypovolemia.

Rationale 2: The fight-or-flight response in the alarm stage increases blood glucose so that more energy will be available. This increase could be misinterpreted as indicating diabetes.

Rationale 3: Constriction of blood vessels in the kidneys serves to provide more blood to essential organs such as the brain and muscles. Decreased blood flow to the kidneys results in decreased urine output.

Rationale 4: The alarm stage is characterized by decreased secretion by digestive glands and decreased peristalsis. Bowel sounds decrease. This may be misinterpreted as indicating bowel damage.

Rationale 5: Fight-or-flight in the alarm state results in increased systolic blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-1

Question 16

Type: MCMA

The nurse is developing a care plan to help a patient deal with the stress associated with a chronic illness. Which interventions should the nurse include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Remind the patient daily how lucky he is to have help available for dealing with his stressors.

2. Allow the patient to make as many personal care decisions as possible.

3. Assist the patient with gathering education about the disease process.

4. Assist the patient in developing positive coping mechanisms.

5. Avoid discussing the disease with the patient.

Correct Answer: 2,3,4

Rationale 1: Constantly reminding the patient that he is lucky is not therapeutic.

Rationale 2: Coping is influenced by the amount of control the individual is able to exert over the situation.

Rationale 3: Becoming educated about the illness can help to alleviate stress.

Rationale 4: Coping mechanisms can be positive as well as negative. The nurse should focus on positive coping mechanisms.

Rationale 5: The patient will benefit from an honest and calm discussion of the disease and its progress.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-3

Question 17

Type: MCMA

After assessing a patients response to stress, the nurse has determined the patient is an individualist. Which statements by the patient support this determination?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I prefer not to join a support group.

2. I can handle this situation if I just have enough time.

3. I cant change this situation, so I am going to have to adapt to it.

4. I wonder who can best help me with this problem.

5. I got myself into this situation, so I am going to have to get myself out of it.

Correct Answer: 1,2,5

Rationale 1: Individualists are less likely to seek social support in stressful situations.

Rationale 2: Individualists tend to value their ability to control stressful situations.

Rationale 3: This statement represents a more collectivist culture in which a greater emphasis is placed on controlling ones personal reactions to a stressful situation than on trying to control the situation itself.

Rationale 4: Seeking help with a problem is a collectivist characteristic.

Rationale 5: Individualists tend to emphasize personal autonomy and responsibility when dealing with stress and problems.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9-5

Question 18

Type: MCMA

The nurse is attempting to use the therapeutic communication technique of acceptance while interviewing a patient. Which nursing actions support this attempt?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Asking, What would you like to talk about today?

2. Making eye contact as appropriate

3. Nodding when the patient describes a symptom

4. Saying, Go on.

5. Saying, Let me see if I understand what you said.

Correct Answer: 2,3,4

Rationale 1: This question is an example of the therapeutic technique of a broad opening statement.

Rationale 2: Using eye contact appropriately demonstrates respect and acceptance.

Rationale 3: Nodding the head indicates acceptance and regard.

Rationale 4: This statement encourages the patient to continue talking and revealing useful data.

Rationale 5: This is the technique of clarification.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-6

Question 19

Type: MCMA

The nurse is preparing a teaching session for a group of adult patients. Which characteristics of adult learning should this nurse consider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Adults like to be able to use newly learned material immediately.

2. The adult learner has many experiences that influence the teaching session.

3. Adults cannot learn new affective skills.

4. Adult readiness to learn is influenced by social role.

5. The adult learners cognitive learning skills are limited by age.

Correct Answer: 1,2,4

Rationale 1: The adults readiness to learn is increased if the material is useful immediately.

Rationale 2: The adults previous life experiences can be used as a resource.

Rationale 3: Affective learning changes attitudes and values. There is no indication that adults are incapable of this kind of learning.

Rationale 4: The adults social role may affect readiness to learn.

Rationale 5: Cognitive learning can occur at any age.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-7

Question 20

Type: MCMA

The nurse has determined that a patient hospitalized with severe anxiety is now in the panic stage. Which nursing assessments support this determination?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients heart rate is 115 bpm sustained.

2. The patient cannot communicate needs in a clear manner.

3. The patient does not respond to events in the surroundings.

4. The patient is beginning to be restless.

5. The patients hands begin to show tremors.

Correct Answer: 1,2,3

Rationale 1: Tachycardia is a sign of panic.

Rationale 2: Inability to communicate clearly is a sign of panic.

Rationale 3: In the presence of panic, the patients perceptual fields close and there is limited, if any, response to the surroundings.

Rationale 4: Beginning restlessness occurs during moderate anxiety.

Rationale 5: Tremors begin in severe anxiety.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-5

 

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