Chapter 42 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 42

Question 1

Type: MCSA

The nurse elects to use a scale of stressful life events to assess the level of a newly admitted clients stress. How should the nurse explain the use of this scale to the client?

1. We will consider only the negative life events that have happened to you recently.

2. You should try to remember any stressful event that has occurred to you in the last 10 years to include in the scale.

3. This scale will give us a definite stress level number that can be used to compare your stress to others your age.

4. This scale will give us some idea about your stress related to both positive and negative recent events in your life.

Correct Answer: 4

Rationale 1: The scales take into consideration both positive and negative events.

Rationale 2: Stress scales focus on recently occurring events.

Rationale 3: The scales are only an idea of stress level because each individual reacts to stressful events differently.

Rationale 4: Stress scales are useful to give the client and others an idea of the amount of stress that both positive and negative recent life events have placed on the client.

Global Rationale: Page Reference: 1079

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 2

Type: MCSA

The client has just received news of the death of a relative. Over the next few hours, what physiologic response would the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?

1. Drop in blood pressure from 130/80 to 120/75

2. A more bounding pulse

3. Slight increase in urine output

4. Some decrease in oxygen saturation

Correct Answer: 2

Rationale 1: Blood pressure rises in response to angiotensin production.

Rationale 2: During this shock phase the sympathetic nervous system is stimulated, resulting in increased myocardial contractility which would be reflected in the client as a bounding pulse.

Rationale 3: Norepinephrine release decreases blood flow to the kidney, which could make urine output decrease..

Rationale 4: The bronchial tree dilates, allowing more oxygen intake that would result in increased oxygen saturation.

Global Rationale: Page Reference: 1080-1081

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 3

Type: MCSA

The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety?

1. The students perception and learning is enhanced.

2. The students attention is focused solely on studying for the examination.

3. The students only topic of conversation is the examination.

4. The student cannot talk about the examination without crying.

Correct Answer: 1

Rationale 1: With mild anxiety, the students perception and learning will be enhanced.

Rationale 2: Focusing only on studying for the examination would indicate a moderate anxiety level.

Rationale 3: Severe anxiety is the level at which the examination would consume all of the students energy.

Rationale 4: Panic is the state in which the student might lose control of emotions regarding the examination.

Global Rationale: Page Reference: 1082

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 4

Type: MCSA

While attempting to choose a nursing diagnosis, the nurse must decide whether the client is experiencing anxiety or fear. What key point would help the nurse make this decision?

1. Anxiety is a milder form of fear.

2. Fear results in a physiologic response, while anxiety is psychologic.

3. The source of fear is identifiable, but anxiety may be vague.

4. Anxiety is generally based in reality, fear is not.

Correct Answer: 3

Rationale 1: Fear and anxiety are different, so anxiety is not just a milder form of fear.

Rationale 2: Both fear and anxiety can have physiologic and psychologic components.

Rationale 3: The source of fear is identifiable, but anxiety is vague.

Rationale 4: Fear and anxiety can both be based in reality or may not be based in reality.

Global Rationale: Page Reference: 1082

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 5

Type: MCSA

The new nurse feels overwhelmed by the demands of working on a busy acute care unit and maintaining a growing family. What strategy should this nurse employ to lessen this stress?

1. Spend the lunch hour completing documentation while eating a sandwich.

2. Set the alarm earlier in order to get to work early.

3. Focus on work instead of on family until more familiar with the environment.

4. Differentiate between have to do and nice to do at work.

Correct Answer: 4

Rationale 1: The nurse should not try to eat lunch while working. This will not help reduce feeling overwhelmed at work.

Rationale 2: Adequate sleep and rest is one way to reduce feeling overwhelmed and stressed. Getting up earlier may cause enhanced feelings of stress because of fatigue

Rationale 3: The nurse needs time to relax by spending time on family and other activities.

Rationale 4: This nurse should differentiate between what is essential care at work, and what is nice to do but can be eliminated on days when stress is high and resources are limited.

Global Rationale: Page Reference: 1086

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Discuss types of coping and coping strategies.

Question 6

Type: MCSA

The nurse is caring for a critically ill child. While the nurse is preparing to administer a treatment to the child, the childs mother becomes distraught and begins to cry loudly while stroking the childs face. What is the nurses best response to this occurrence?

1. Tell the mother that she needs to control herself for the benefit of her child.

2. Distract the mother by having her straighten the linens on the bed.

3. Explain the procedure that will occur with the treatment.

4. Take the mother out of the room and comfort her.

Correct Answer: 4

Rationale 1: While the mothers expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse.

Rationale 2: This mother is too upset to distract by smoothing linens.

Rationale 3: Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.

Rationale 4: In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her.

Global Rationale: Page Reference: 1090

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 7

Type: MCSA

A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the nurse do in response to this outburst?

1. Call the charge nurse and refuse to take care of this client until he is under control.

2. Apologize to the client for the unit rules, but tell him the rules must be followed.

3. Tell the client that it is understandable that he is upset, but the no smoking rule is not negotiable.

4. Tell the client that he is acting like a child and that such behavior will not be tolerated.

Correct Answer: 3

Rationale 1: The nurse cannot refuse to care for the client once the assignment has been accepted, since this may constitute client abandonment.

Rationale 2: The nurse should not assume responsibility for the anger by apologizing.

Rationale 3: Telling the client that it is understandable that he is upset serves to show that the nurse accepts his right to be angry, but that the anger is the clients.

Rationale 4: Admonishing the client by saying that he is acting like a child is not professional and will most likely serve to destroy any hope of resolving this issue.

Global Rationale: Page Reference: 1090

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe interventions to help clients minimize and manage stress.

Question 8

Type: MCSA

A client tells the nurse about being laid off from work, the spouse wanting a divorce, and being ill with a chest cold for a month. What statement should the nurse make that reflects understanding of a client in crisis?

1. Once you reach the crisis state, you may remain there for several months until you recover.

2. People generally find it easier to work through a crisis if someone is working with them.

3. Men often handle crisis better individually, while women do better with a counselor.

4. Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible.

Correct Answer: 2

Rationale 1: A crisis results in such a state of disequilibrium that it is generally self-limiting and not a long-term event.

Rationale 2: In general, people are more successful in working through a crisis if they have someone to help them.

Rationale 3: The need for help during a crisis is not dependent upon the clients gender.

Rationale 4: Experiencing a crisis may actually offer the family or individual a potential for growth and change.

Global Rationale: Page Reference: 1090

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 9

Type: MCSA

The nurse manager suspects the nursing staff is experiencing burnout because of complaints and an increase in absenteeism. The nurses also appear tired and anxious. What can the manager do to help reduce this burnout?

1. Ask the physician staff to take over some of the tasks they routinely ask the nurses to do.

2. Make certain that the nurses are well prepared for their responsibilities.

3. Assign each nurse to spend 30 minutes with the hospital psychologist daily.

4. Ask administration to require 30 minutes of exercise at the end of each shift.

Correct Answer: 2

Rationale 1: Asking physicians to assume nursing tasks is not appropriate.

Rationale 2: In this situation, the best alternative is to be certain that the nurses are well prepared for the responsibilities of their jobs, as the frustration of being unprepared leads to burnout.

Rationale 3: Counseling cannot be made a requirement for the staff.

Rationale 4: Exercise cannot be made a requirement by the organizations administration.

Global Rationale: Page Reference: 1090 1091

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe interventions to help clients minimize and manage stress.

Question 10

Type: MCSA

The nurse identifies that a client has not met the expected outcome established for the nursing diagnosis Ineffective Individual Coping. What nursing action is priority?

1. Revise the nursing diagnosis.

2. Reassess the patient, looking for previously unknown stressors.

3. Rewrite the interventions used to address the problem.

4. Explore reasons why the outcome was not achieved.

Correct Answer: 4

Rationale 1: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

Rationale 2: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

Rationale 3: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

Rationale 4: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

Global Rationale: Page Reference: 1092

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 09 Describe interventions to help clients minimize and manage stress.

Question 11

Type: MCSA

The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for the nurse to understand the clients needs. The nurse suspects the client has progressed to which anxiety level?

1. Mild

2. Moderate

3. Severe

4. Panic

Correct Answer: 3

Rationale 1: Mild anxiety causes an increase in questioning.

Rationale 2: Moderate anxiety results in voice tremors and pitch changes.

Rationale 3: At severe levels, communication is difficult to understand.

Rationale 4: Communication may not be understandable at all when the client reaches the panic stage.

Global Rationale: Page Reference: 1082-1083

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the three stages of Selyes general adaptation syndrome.

Question 12

Type: MCSA

The physician has just told the client that the results of a biopsy performed yesterday reveal no malignancy. During discharge teaching the nurse finds the client to be easily distractible and unable to focus. What is the nurses best interpretation of this situation?

1. The client did not understand that there is no malignancy.

2. Anxiety can result from both positive and negative stimuli.

3. Since there is no malignancy present, the client feels there is no need for teaching.

4. These findings reflect mild anxiety, but the client should retain information taught despite this distractibility.

Correct Answer: 2

Rationale 1: There is no indication that the client doesnt understand the report.

Rationale 2: Anxiety can be the result of both positive and negative stimuli.

Rationale 3: There is no indication that the client discounts the need for teaching.

Rationale 4: The amount of information retained may be drastically reduced by this level of anxiety, so the nurse should take extra pains to ascertain if the client understands the teaching.

Global Rationale: Page Reference: 1079

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Differentiate four levels of anxiety.

Question 13

Type: MCSA

A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What defense mechanism is this client exhibiting?

1. Compensation

2. Denial

3. Displacement

4. Identification

Correct Answer: 2

Rationale 1: Compensation is covering up weaknesses by emphasizing a strength or by overachievement.

Rationale 2: Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them.

Rationale 3: Displacement is transferring emotional reactions from one object or person to another object or person.

Rationale 4: Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected.

Global Rationale: Page Reference: 1085

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify behaviors related to specific ego defense mechanisms.

Question 14

Type: MCSA

The victim of domestic abuse tells the nurse, I know my spouse didnt mean to hurt me. The situation just got out of hand. The nurse recognizes that the client is exhibiting which of the following?

1. Intellectualization

2. Introjection

3. Projection

4. Minimization

Correct Answer: 4

Rationale 1: Intellectualization is a defense mechanism in which an uncomfortable or painful reality is evaded by using a rational explanation that removes personal significance from the event.

Rationale 2: Introjection is a form of identification in which the person adopts another persons norms or values, even if those norms or values are contrary to what the person would have previously assumed.

Rationale 3: Projection is blaming another person or the environment for ones own unacceptable thoughts, shortcomings, or failures.

Rationale 4: Minimization is not acknowledging the significance of a behavior.

Global Rationale: Page Reference: 1085

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify behaviors related to specific ego defense mechanisms.

Question 15

Type: MCSA

The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the clients husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism?

1. Reaction formation

2. Rationalization

3. Regression

4. Reparation

Correct Answer: 1

Rationale 1: Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel.

Rationale 2: Rationalization is justification of behaviors by faulty logic and by ascribing socially acceptable motives to the behavior.

Rationale 3: Regression is resorting to an earlier, more comfortable level of functioning that is less demanding.

Rationale 4: Reparation is not a recognized defense mechanism.

Global Rationale: Page Reference: 1085

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify behaviors related to specific ego defense mechanisms.

Question 16

Type: MCSA

The parents of a school-age client, who was sexually abused by a minister, wants to know why someone who is sexually attracted to children would choose to go into the ministry. The nurse explains that the displacement of sexual drives into socially acceptable activities is the defense mechanism of:

1. Repression

2. Sublimation

3. Substitution

4. Undoing

Correct Answer: 2

Rationale 1: Repression is an unconscious mechanism by which threatening thoughts and feelings are kept from becoming conscious.

Rationale 2: Sublimation is displacement of sexual drives into more socially acceptable activities.

Rationale 3: Substitution is a mechanism in which highly valued, unacceptable, or unavailable objects are replaced by less valuable, acceptable, or available objects.

Rationale 4: Undoing is an action or words designed to cancel out some disapproved thoughts, impulses, or acts or in which the person acts to make reparation for a wrong.

Global Rationale: Page Reference: 1085

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify behaviors related to specific ego defense mechanisms.

Question 17

Type: MCSA

The assessment of a client undergoing testing for an anxiety disorder reveals an increased heart rate, an increased respiratory rate, a low-normal hematocrit, and a low blood sugar. Which finding is contrary to what could be explained by a normal response to anxiety?

1. The heart rate

2. The respiratory rate

3. The hematocrit

4. The blood sugar

Correct Answer: 4

Rationale 1: The normal response to anxiety is increased heart rate.

Rationale 2: The normal response to anxiety is an increased rate and depth of respirations.

Rationale 3: The normal response to anxiety is the retention of sodium and water which might reflect in a low-normal hematocrit due to increased blood volume.

Rationale 4: The blood sugar generally increases because of the release of glucocorticoids and gluconeogenesis.

Global Rationale: Page Reference: 1082-1083

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 18

Type: MCSA

What intervention can the nurse plan to help reduce the anxiety and stress experienced by a hospitalized client?

1. Explain all procedures in detail before performing them.

2. Let the client make the majority of decisions about the plan of care.

3. Control the environment of healing.

4. Demonstrate staff competence by using multiple nurses for care.

Correct Answer: 3

Rationale 1: Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan.

Rationale 2: A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.

Rationale 3: The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable.

Rationale 4: Using multiple nurses for care can increase anxiety.

Global Rationale: Page Reference: 1090

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe interventions to help clients minimize and manage stress.

Question 19

Type: MCSA

The parents of an adolescent who has a history of depression are concerned because the physician has prescribed an SSRI antidepressant for their child. What information should the nurse use to formulate a response to these parents concerns?

1. These medications are addictive and difficult to discontinue when the depressive incident is past.

2. It is difficult for teenagers to manage the dosage regimen for many of these drugs because they must be taken with a full meal.

3. There is an FDA warning regarding antidepressant use in teenagers and the increased risk of suicide.

4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3 to 4 days of the first dose.

Correct Answer: 3

Rationale 1: While the client may come to depend upon the medication relieving depression, the drugs are not addictive.

Rationale 2: The medications must be taken with sufficient water, but a full meal is not necessary.

Rationale 3: The major concern regarding use of antidepressants and teenagers is the increased risk for suicide.

Rationale 4: Most of the SSRI antidepressant medications take at least 1 to 2 weeks to improve symptoms.

Global Rationale: Page Reference: 1084

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe interventions to help clients minimize and manage stress.

Question 20

Type: MCSA

A 2 year old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. The nurse interprets this clients behavior as being caused by:

1. The parents may have been abusing this child.

2. The child is probably developmentally delayed secondary to multiple hospitalizations.

3. The child is reacting as a normal 2-year-old.

4. The child could be suffering from a clinical depression.

Correct Answer: 3

Rationale 1: There is no evidence of parental abuse.

Rationale 2: There is no evidence that the client is developmentally delayed.

Rationale 3: Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner.

Rationale 4: There is no evidence that the client is depressed.

Global Rationale: Page Reference: 1092

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 21

Type: MCSA

During an assessment, the nurse learns that a client has been having periodic upper respiratory infections since experiencing the death of a close family member. The nurse identifies this clients reaction to stress as being a:

1. Stimulus.

2. Response.

3. Transaction.

4. Negotiation.

Correct Answer: 1

Rationale 1: Stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that can increase the individuals vulnerability to illness.

Rationale 2: Stress that is considered as a response is defined as the nonspecific response of the body to any kind of demand made upon it.

Rationale 3: Stress that is a transaction refers to any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual, social system, or tissue system. The individual responds to perceived environmental changes with adaptive or coping responses.

Rationale 4: Negotiation is not a type of stress reaction.

Global Rationale: Page Reference: 1079

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Differentiate the concepts of stress as a stimulus, as a response, and as a transaction.

Question 22

Type: MCSA

After hearing the diagnosis of cancer, a client becomes withdrawn and refuses to talk with friends or family. The nurse realizes this client is demonstrating which type of reaction to stress?

1. Stimulus.

2. Response.

3. Combination.

4. Transaction.

Correct Answer: 4

Rationale 1: Stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that can increase the individuals vulnerability to illness.

Rationale 2: Stress that is considered a response is defined as the nonspecific response of the body to any kind of demand made upon it.

Rationale 3: Combination is not a type of reaction to stress.

Rationale 4: Stress that is a transaction refers to any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual, social system, or tissue system. The individual responds to perceived environmental changes with adaptive or coping responses such as being withdrawn.

Global Rationale: Page Reference: 1082

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Differentiate the concepts of stress as a stimulus, as a response, and as a transaction.

Question 23

Type: MCSA

The nurse identifies that a client is experiencing the resistance stage of the general adaption syndrome when what is assessed?

1. Client is unable to focus on activities and events.

2. Client is exhausted, and spends time sleeping.

3. Localized swelling and inflammation of a leg wound.

4. Capillary blood glucose level 180 mg/dL.

Correct Answer: 3

Rationale 1: The clients inability to focus on activities and events is not a characteristic of the resistance stage of the general adaption syndrome.

Rationale 2: The clients being exhausted and sleeping are characteristics of the stage of exhaustion within the general adaption syndrome.

Rationale 3: In the second stage in the general adaption syndrome, the stage of resistance is when the bodys adaption takes place. The body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it, such as with localized swelling and inflammation of a leg wound.

Rationale 4: An elevated capillary blood glucose level is a finding associated with the alarm stage of the general adaption syndrome.

Global Rationale: Page Reference: 1080

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the three stages of Selyes general adaptation syndrome.

Question 24

Type: MCMA

A client is experiencing the shock phase within the general adaption syndrome. The nurse realizes that this phase affects which hormones?

Standard Text: Select all that apply.

1. Epinephrine.

2. Estrogen.

3. Norepinephrine.

4. Cortisol.

5. Progesterone.

Correct Answer: 1,3,4

Rationale 1: In the alarm phase of the general adaption syndrome, epinephrine secretion is increased, which affects heart rate, breathing, and blood-clotting mechanisms.

Rationale 2: Estrogen is not affected in the alarm phase of the general adaption syndrome.

Rationale 3: In the alarm phase of the general adaption syndrome, norepinephrine secretion is increased, which decreases blood flow to the kidney and increases renin release.

Rationale 4: In the alarm phase of the general adaption syndrome, cortisol is released, which causes protein catabolism and gluconeogenesis.

Rationale 5: Progesterone is not affected in the alarm phase of the general adaption syndrome.

Global Rationale: Page Reference: 1080-1081

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the three stages of Selyes general adaptation syndrome.

Question 25

Type: MCSA

A client newly diagnosed with colon cancer finishes dinner and turns on the nightly news. The nurse suspects the client is experiencing which cognitive indicator of stress?

1. Problem solving.

2. Self-control.

3. Structuring.

4. Daydreaming.

Correct Answer: 2

Rationale 1: Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. The person assesses the situation or problem, analyzes or defines it, chooses alternatives, carries out the selected alternative, and evaluates whether the solution was successful.

Rationale 2: Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge. When self-control prevents panic and harmful or nonproductive actions in a threatening situation, it is a helpful response that conveys strength. Self-control carried to an extreme, however, can delay problem solving and prevent a person from receiving the support of others, who might perceive the person as handling the situation well, as cold, or as unconcerned.

Rationale 3: Structuring is the arrangement or manipulation of a situation so that the threatening events do not occur.

Rationale 4: Daydreaming is likened to make-believe. Unfulfilled wishes and desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality.

Global Rationale: Page Reference: 1084

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 26

Type: MCMA

A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress because what was assessed?

Standard Text: Select all that apply.

1. Dilated pupils.

2. Diaphoretic.

3. Tachycardia.

4. Flaccid muscle tone.

5. Excessive oral secretions.

Correct Answer: 1,2,3

Rationale 1: Pupils dilate to increase visual perception when serious threats to the body arise.

Rationale 2: Sweat production or diaphoresis increases to control elevated body heat due to increased metabolism.

Rationale 3: The heart rate increases to transport nutrients and by-products of metabolism more efficiently.

Rationale 4: Muscle tension increases to prepare for rapid motor activity or defense.

Rationale 5: The mouth might be dry, and would not have an increase in oral secretions.

Global Rationale: Page Reference: 1080, 1083

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 27

Type: MCMA

The nurse is concerned that a client diagnosed with a chronic illness is experiencing depression. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Weight gain.

2. Irritability.

3. No appetite.

4. Constipation.

5. Complaints of headache and dizziness.

Correct Answer: 2,3,4,5

Rationale 1: Physical signs of depression include weight loss, not weight gain.

Rationale 2: Behavioral signs of depression include irritability.

Rationale 3: Physical signs of depression include loss of appetite.

Rationale 4: Physical signs of depression include constipation.

Rationale 5: Physical signs of depression include headache and dizziness.

Global Rationale: Page Reference: 1083

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify physiological, psychological, and cognitive indicators of stress.

Question 28

Type: MCSA

While assessing a clients ability to cope after being diagnosed with a chronic illness, the client admits to an increase in drinking and smoking. The nurse recognizes the client is utilizing which type of coping strategy?

1. Short-term.

2. Long-term.

3. Adaptive.

4. Effective.

Correct Answer: 1

Rationale 1: Short-term coping strategies can reduce stress to a tolerable limit temporarily, but are ineffective ways to deal with reality permanently. They can even have a destructive or detrimental effect on the person. An example of short-term strategies is using alcoholic beverages or drugs.

Rationale 2: Long-term coping strategies can be constructive and practical, and include talking with others, eating a healthy diet, exercising regularly, balancing leisure time with working, and using problem solving in decision making instead of anger or other non-constructive responses.

Rationale 3: Adaptive coping helps the person to deal effectively with stressful events and minimizes distress associated with them.

Rationale 4: Effective coping results in adaptation.

Global Rationale: Page Reference: 1086

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Discuss types of coping and coping strategies.

Question 29

Type: MCSA

The adult daughter of an older client, who provides and pays for the clients care and needs, tells the nurse that her time is limited because of work responsibilities. The client complains that all the daughter ever does is work. What basic need is being affected by the daughters stress?

1. Love and belonging.

2. Self-actualization.

3. Physiological.

4. Self-esteem.

Correct Answer: 4

Rationale 1: The effects of stress on the basic need of love and belonging include becoming isolated and withdrawn, becoming overly dependent, and blaming others for problems.

Rationale 2: The effects of stress on the basic need of self-actualization include being preoccupied with ones own problems.

Rationale 3: The effects of stress on basic physiological needs include an altered elimination pattern, a change in appetite, and an altered sleep pattern.

Rationale 4: The effects of stress on the basic need of self-esteem include becoming a workaholic.

Global Rationale: Page Reference: 1086

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 30

Type: MCMA

The nurse asks a client what strategies he uses to cope with stress. The client does not respond. What should the nurse do?

Standard Text: Select all that apply.

1. Document the client has no stress.

2. Move on with the assessment.

3. Ask the client whether crying is done.

4. Suggest that the client use humor or exercise.

5. Question the use of anger.

Correct Answer: 3,4,5

Rationale 1: The nurse should not document that the client has no stress.

Rationale 2: The nurse should not move on with the assessment.

Rationale 3: If the client does not adequately describe how stressful situations are handled, the nurse should prompt by asking the client whether crying is done.

Rationale 4: If the client does not adequately describe how stressful situations are handled, the nurse should prompt by suggesting the client use humor or exercise.

Rationale 5: If the client does not adequately describe how stressful situations are handled, the nurse should ask the client about using anger or being angry.

Global Rationale: Page Reference: 1089

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Discuss types of coping and coping strategies.

Question 31

Type: MCMA

During a health interview, the nurse decides to focus the assessment questions on the middle-aged clients amount of stress because what was assessed?

Standard Text: Select all that apply.

1. Caring for aging parents.

2. Needing to wear glasses to read.

3. Newly married.

4. Choosing a career.

5. Not having the same amount of stamina and energy.

Correct Answer: 1,2,5

Rationale 1: Stressors common in middle adulthood include caring for aging parents.

Rationale 2: Stressors common in middle adulthood include physical changes of aging, including having to wear glasses to read.

Rationale 3: Stressors in young adulthood include being newly married.

Rationale 4: Stressors common in adolescence include choosing a career.

Rationale 5: Stressors common in middle adulthood include physical changes of aging, including not having stamina and energy.

Global Rationale: Page Reference: 1079

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 32

Type: MCMA

The nurse is preparing to assess a clients stress and coping patterns. What will be included in this assessment?

Standard Text: Select all that apply.

1. Clients perception of stressors.

2. Manifestations of stress.

3. Employment status.

4. Coping strategies.

5. Weight changes.

Correct Answer: 1,2,4,5

Rationale 1: When obtaining the nursing history, the nurse should pose questions about the clients perception of stressors.

Rationale 2: When obtaining the nursing history, the nurse should pose questions about manifestations of stress.

Rationale 3: Employment status is not a part of either the nursing history or physical examination when assessing a clients stress and coping patterns.

Rationale 4: When obtaining the nursing history, the nurse should pose questions about past and present coping strategies.

Rationale 5: When obtaining the nursing history, the nurse should assess for indicators of stress to include weight changes.

Global Rationale: Page Reference: 1086-1087

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify essential aspects of assessing a clients stress and coping patterns.

Question 33

Type: MCSA

A client diagnosed with a chronic illness tells the nurse that the spouse is not helping the client with household activities, which is causing stress. The nurse identifies which diagnosis as being appropriate for the client at this time?

1. Defensive Coping.

2. Disabled Family Coping.

3. Compromised Family Coping.

4. Ineffective Coping.

Correct Answer: 3

Rationale 1: Defensive Coping is the repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.

Rationale 2: Disabled Family Coping is when the behavior of a significant person disables her capacities and the clients capacities to effectively address tasks essential to either persons adaption to the health challenge.

Rationale 3: Compromised Family Coping is applicable if a usually supportive primary person provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that might be needed by the client to manage or master adaptive tasks related to her health challenge.

Rationale 4: Ineffective Coping is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources.

Global Rationale: Page Reference: 1087

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 08 Identify nursing diagnoses related to stress.

Question 34

Type: MCSA

A client repeatedly tells the nurse that all will be well and Im fine in response to learning of a health problem that requires immediate surgery. The nurse realizes the diagnosis appropriate for the client at this time would be:

1. Compromised Family Coping.

2. Ineffective Coping.

3. Disabled Family Coping.

4. Defensive Coping.

Correct Answer: 4

Rationale 1: Compromised Family Coping is applicable if a usually supportive primary person provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that might be needed by the client to manage or master adaptive tasks related to his health challenge.

Rationale 2: Ineffective Coping is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources.

Rationale 3: Disabled Family Coping is when the behavior of a significant person disables his capacities and the clients capacities to effectively address tasks essential to either persons adaption to the health challenge.

Rationale 4: Defensive Coping is the repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.

Global Rationale: Page Reference: 1087

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 08 Identify nursing diagnoses related to stress.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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