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Fundamentals Of Nursing 3rd ed by Wilkinson Treas Smith-Test Bank
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Fundamentals Of Nursing 3rd ed by Wilkinson Treas Smith-Test Bank
Description
WITH ANSWERS
Fundamentals Of Nursing 3rd ed by Wilkinson Treas Smith-Test Bank
Chapter 2. Critical Thinking & Nursing Process
MULTIPLE CHOICE
- Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:
| a) | Requires reasoned thought |
| b) | Asks the questions why or how |
| c) | Is a hierarchical process |
| d) | Demands specialized thinking skills |
ANS: A
The definitions listed in the text as well as definitions contained in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. The steps involved in critical thinking are not necessarily sequential, wherein mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytical process that contributes to reasoned decisions and sound contextual judgments.
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
- A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to:
| a) | Consider all the possible advantages and disadvantages |
| b) | Maintain an open mind about the proposed change |
| c) | Apply the Nursing Process to the situation |
| d) | Make a decision based on past experience with documentation |
ANS: B
A critical attitude enables the person to think fairly and keep an open mind.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first?
| a) | Make an assessment |
| b) | Make a diagnosis |
| c) | Plan outcomes |
| d) | Plan interventions |
ANS: A
Assessment is the first step of the Nursing Process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.
Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Easy
PTS: 1
- Which of the following is an example of practical knowledge? Assume all are true.
| a) | The tricuspid valve is located between the right atrium and ventricle of the heart. |
| b) | The pancreas does not produce enough insulin in type 1 diabetes. |
| c) | When assessing the abdomen, you should auscultate before palpating. |
| d) | Research shows pain medication given intravenously acts faster than medication given by other routes. |
ANS: C
Practical knowledge is knowing what to do and how to do it, such as how to make an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), facts (type 1 diabetes), and research (intravenous pain medication).
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- Which of the following is an example of self-knowledge? The nurse thinks, I know that I:
| a) | Should take the clients apical pulse for 1 full minute before giving digoxin |
| b) | Should follow the clients wishes even though it is not what I would want |
| c) | Have religious beliefs that may make it difficult to take care of some clients |
| d) | Need to honor the clients request not to discuss his health concern with the family |
ANS: C
Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- Which of the following is the most important reason for nurses to be critical thinkers?
| a) | Nurses need to follow policies and procedures. |
| b) | Nurses work with other healthcare team members. |
| c) | Nurses care for clients who have multiple health problems. |
| d) | Nurses have to be flexible and work variable schedules. |
ANS: C
Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking.
(High level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse administering pain medication every 4 hours is an example of which aspect of patient care?
| a) | Assessment data |
| b) | Nursing diagnosis |
| c) | Patient outcome |
| d) | Nursing intervention |
ANS: D
Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be: Patient reports pain is a 5 on a 1 to 10 scale. The nursing diagnosis would be pain. The nurse might define the patient outcome in this scenario as, The patient will state the level of pain is less than 4.
(High-level question, answer not stated verbatim)
Nursing Process: Interventions
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:
| a) | Terminology for the clients disease or injury |
| b) | A part of the clients medical diagnosis |
| c) | The clients presenting signs and symptoms |
| d) | A clients response to a health problem |
ANS: D
A nursing diagnosis is the clients response to actual or potential health problems.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Easy
PTS: 1
- What do critical thinking and the Nursing Process have in common?
| a) | They are both linear processes used to guide ones thinking. |
| b) | They are both thinking methods used to solve a problem. |
| c) | They both use specific steps to solve a problem. |
| d) | They both use similar steps to solve a problem. |
ANS: B
Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now:
| a) | Analyze the assessment data |
| b) | Consult standards of care |
| c) | Decide which interventions are appropriate |
| d) | Ask for the clients perceptions of her health problem |
ANS: A
The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the Nursing Process, which of the following would the nurse do first?
| a) | Determine whether she has gathered enough assessment data |
| b) | Judge whether the interventions achieved the stated outcomes |
| c) | Follow up to verify that care for the nursing diagnosis was given |
| d) | Decide whether the nursing diagnosis was accurate for the patients condition |
ANS: B
The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the Nursing Process steps and revising the care plan.
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
- In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. The nurse has demonstrated:
| a) | Full-spectrum nursing |
| b) | Critical thinking |
| c) | Nursing Process |
| d) | Nursing knowledge |
ANS: A
Full-spectrum nursing involves the use of critical thinking, nursing knowledge, Nursing Process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.
(High level question, answers not stated verbatim)
Nursing Process: Not applicable
Client Need: PHSI
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- It is important for nurses to be critical thinkers because:
| a) | All clients are unique and have individual needs and differences |
| b) | All nursing actions are based on theoretical knowledge |
| c) | Nurses choose their actions primarily by following professional guidelines |
| d) | Nurses provide care based on individual client preferences |
ANS: A
All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinkerit does not require critical thinking merely to do what the client prefers.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patients pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patients family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is:
| a) | Following model guidelines for specific interventions |
| b) | Using linear processes to think critically |
| c) | Moving back and forth between steps, and not thinking sequentially |
| d) | Using self-knowledge in the decision-making process |
ANS: C
Critical thinking is not sequential, and critical-thinking models are not applied sequentially. Critical-thinking models do not proceed from top to bottom, nor are they linear. Nurses may jump back and forth between the various steps. Critical-thinking models do not prescribe guidelines for specific interventions. Although self-knowledge may be used as part of a decision-making process, this is not the best answer to complete the statement. The only way self-knowledge is involved in this scenario is that the nurse recognizes that she is lacking some information/knowledge.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- Which is the best example of a critical-thinking attitude? The nurse:
| a) | Has extensive knowledge of principles and theories |
| b) | Has a lively curiosity and enjoys discovering new ways of doing things |
| c) | Applies the problem-solving process he was taught in nursing school |
| d) | Responds to patients mainly on the basis of what is socially approved |
ANS: B
Attitudes are more akin to feelings and traits than to intellectual skills. Therefore, extensive knowledge is not a good example of an attitude. Attitudes are addressed in nursing school but it is unlikely that one can teach attitudes. A problem-solving process does necessarily require critical thinking; moreover, applying a process simply because one learns it in school would mean the person is not demonstrating an attitude of intellectual independence. Society and culture do help to form attitudes, but that is not the same as basing actions on what is socially approved. Again, that would not demonstrate independent thinking or any of the other critical-thinking attitudes.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- What is the best description of the Nursing Process? The Nursing Process is:
| a) | A way to create nursing knowledge for use in practice |
| b) | A systematic view of a specific phenomenon in nursing |
| c) | A linear process for providing nursing care |
| d) | A systematic process for the delivery of nursing care |
ANS: D
The Nursing Process is central to nursing care. It is a systematic problem-solving process that guides all nursing actions. The process does not create knowledge. Knowledge is created through theoretical and practical research. The Nursing Process is not a view of a specific phenomenon. Finally, the Nursing Process is not linear; the steps are reflexive and overlapping.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Easy
PTS: 1
- The nurse is caring for a client with heart failure. She begins to obtain the clients history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process?
| a) | Assessment |
| b) | Planning interventions |
| c) | Planning outcomes |
| d) | Evaluation |
ANS: A
Obtaining the history, auscultating breath sounds, and obtaining vital signs are part of the assessment process. In the assessment step, the nurse gathers patient data and information. In the planning interventions step, the nurse chooses nursing activities aimed at meeting patient goals (and thus relieving the patients problem). In the planning outcomes phase, the nurse and patient identify goals for the patients healthexpected or desired outcomes of the care. After performing nursing activities, in the evaluation stage the nurse reassesses the patient to determine whether goals have been met.
Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process?
| a) | Assessment |
| b) | Planning interventions |
| c) | Implementation |
| d) | Evaluation |
ANS: C
Application of a medication to the coccyx area is an action. The nurse both plans and carries out the intervention. The nurse carries out (and records) interventions in the implementation phase. Evaluation is done after the plan (or nursing action) is implemented.
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse documents in the client plan of care that the wound treatment to the clients left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process?
| a) | Assessment |
| b) | Evaluation |
| c) | Planning outcomes |
| d) | Planning interventions |
ANS: B
Documenting nursing interventions and a patients immediate responses (e.g., expressed pain, became restless) is done in the implementation stage. However, in this scenario the nurse also documented that the wound was healing and she removed the nursing diagnosis from the care plan. This demonstrates evaluation.
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by:
| a) | Telling the client that shell be back to chat after she sees her other clients |
| b) | Calling the family to come and sit with the client |
| c) | Trying to determine the reasons for the clients crying |
| d) | Placing a do not disturb sign on the door to protect the clients privacy |
ANS: C
The nurse should try to find out why the client is crying so that she may intervene appropriately and correctly. Postponing talking with the client does not assist the client nor does it enable the nurse to make an appropriate intervention. Telling the client shell be back may cause the client to feel that her needs are less important. Calling the family may be helpful to the client once the nurse identifies why the client is crying. However, depending on the reason, the family may not be at all helpful. A do not disturb sign, without obtaining more information, may isolate the client. Upon further exploration, the nurse may discover that the client is already feeling alone and that she does not want or need privacy right now.
Nursing Process: Implementation
Client Need: PSI
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to:
| a) | Assist nurses in testing psychomotor skills |
| b) | Have a positive effect on a clients health outcomes |
| c) | Adequately use all aspects of the Nursing Process |
| d) | Assist nurses in completing their work on time |
ANS: B
The question is asking for the best answer to complete the statement. The best answer is to have a positive effect on a clients health outcomes, which is also a goal of nursing in general. The full-spectrum model may assist nurses in performing psychomotor skills and even in completing their work on timeespecially when something unexpected occurs. However, that is not the focus of the model. Full-spectrum nursing would likely improve the nurses problem-solving ability (as in the Nursing Process); however, that is not the end purpose of full-spectrum nursing. It is merely a means to achieving the purpose of positively affecting health outcomes.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- The nurse has gathered her assessment data and notes several significant changes in the clients health status. The clients weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data?
| a) | Diagnosis |
| b) | Planning |
| c) | Implementation |
| d) | Evaluation |
ANS: A
After gathering and analyzing the assessment data, the nurse should next formulate a nursing diagnosis. The other options are not done until after the problem has been diagnosed. The problem is used to plan goals, which are then used to plan interventions. After implementing the intervention(s), evaluation is done to identify change in health status and determine whether goals have been met.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
MULTIPLE RESPONSE
- Which aspects of healthcare are affected by a clients culture? Select all that apply.
| a) | How the client views healthcare |
| b) | How the client views illness |
| c) | Whether insurance will pay for healthcare services |
| d) | The types of treatments the client will accept |
| e) | When the client will seek healthcare services |
| f) | The environment in which the healthcare services are provided |
| g) | The ease of accessibility of healthcare services |
ANS: A, B, D, E
Culture impacts clients views of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to social environment and economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Moderate
PTS: 1
- Caring is a central concept in nursing that involves which of the following? Select all that apply.
| a) | Treating all clients with a similar disease in exactly the same way |
| b) | Responding compassionately to client needs |
| c) | Acting in ways to preserve human dignity |
| d) | Connecting with others to give and receive help |
| e) | Using active listening |
ANS: B, C, D, E
Treating all clients in exactly the same way just because they share similar disease processes does not consider their uniqueness nor honor their personhoodand thus does not reflect caring. The other options are all aspects of caring.
Nursing Process: Not applicable
Client Need: PSI
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
Chapter 12. Stress & Adaptation
MULTIPLE CHOICE
- When released in response to alarm, which of the following substances promotes a sense of well-being?
| a) | Aldosterone |
| b) | Thyroid-stimulating hormone |
| c) | Endorphins |
| d) | Adrenocorticotropic hormone |
ANS: C
Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralcorticoids.
Difficulty: Moderate
Client Need: PHSI
Cognitive Level: Knowledge
PTS: 1
- After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?
| a) | Alarm |
| b) | Resistance |
| c) | Exhaustion |
| d) | Recovery |
ANS: C
Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place.
Difficulty: Difficult
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?
| a) | Epinephrine |
| b) | Corticotrophin-releasing hormone |
| c) | Aldosterone |
| d) | Antidiuretic hormone |
ANS: A
During the shock phase of the general adaptation syndrome, epinephrine prepares the body to react in an emergency situation by increasing heart rate and blood pressure. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.
Difficulty: Moderate
Client Need: PHSI
Cognitive Level: Application
PTS: 1
- What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?
| a) | Promotes fluid retention by increasing the reabsorption of water by kidney tubules |
| b) | Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle |
| c) | Increases the use of fats and proteins for energy and conserves glucose for use by the brain |
| d) | Promotes fluid excretion by causing the kidneys to reabsorb more sodium |
ANS: A
Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.
Difficulty: Moderate
Client Need: PHSI
Cognitive Level: Knowledge
PTS: 1
- A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first?
| a) | Cellular inflammation |
| b) | Exudate formation |
| c) | Tissue regeneration |
| d) | Vascular response |
ANS: D
Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension
PTS: 1
- A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?
| a) | Anger |
| b) | Fear |
| c) | Anxiety |
| d) | Hopelessness |
ANS: C
NANDA International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely experiencing anxiety. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PSI
Cognitive Level: Application
PTS: 1
- A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, I hate this place; nobody knows how to take care of me or Id be home by now. Which response by the nurse is best in this situation?
| a) | You seem angry; whats going on that makes you hate this place? |
| b) | Im sorry that we arent caring for you according to your expectations. |
| c) | You were very sick; dont be angry; youre lucky to be alive. |
| d) | You shouldnt be angry with us; were trying to help you. |
ANS: A
You seem angry; whats going on . . . encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry or you shouldnt be angry diminishes the patients right to be angry.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PSI
Cognitive Level: Analysis
PTS: 1
- You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?
| a) | Hypochondriasis |
| b) | Somatization |
| c) | Somatoform pain disorder |
| d) | Malingering |
ANS: D
Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PSI
Cognitive Level: Application
PTS: 1
- After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?
| a) | Reaction formation |
| b) | Displacement |
| c) | Denial |
| d) | Conversion |
ANS: B
This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feelings, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: PSI
Cognitive Level: Application
PTS: 1
- A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?
| a) | Precrisis |
| b) | Impact |
| c) | Crisis |
| d) | Adaptive |
ANS: D
When a patient begins to think rationally and attempt to solve problems, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PSI
Cognitive Level: Application
PTS: 1
- A nurse identifies a patients nursing diagnosis as Diarrhea related to stress. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?
| a) | Monitor and record the frequency of stools on the graphic record |
| b) | Administer prescribed antidiarrheal medications as needed |
| c) | Encourage the patient to verbalize about stressors and anxiety |
| d) | Provide oral fluids on a regular schedule |
ANS: C
(Answer to specific patient scenario is not directly stated in text.)
The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PSI
Cognitive Level: Analysis
PTS: 1
- When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?
| a) | The patient will limit his intake of fat to 15% of the daily calories consumed. |
| b) | The patient will eat three meals per day at approximately the same time each day. |
| c) | The patient will limit his intake sweet and salty foods. |
| d) | The patient will consume no more than three alcoholic beverages a day. |
ANS: C
The nurse should advise the client to limit the intake of sugar (to avoid sugar highs and crashes) and salt (to avoid increasing blood pressure); limit the intake of fat to no more than 30% (not 15%) of daily calories (to prevent cardiovascular disease); eat smaller, more frequent meals (rather than three meals a day) to aid in digestion; and consume no more than two alcoholic beverages per day but not necessarily every day.
Difficulty: Moderate
Nursing Process: Planning
Client Need: PHSI
Cognitive Level: Application
PTS: 1
- At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful?
| a) | Decreased blood pressure |
| b) | Decreased peripheral skin temperature |
| c) | Increased heart rate |
| d) | Increased respiratory rate |
ANS: A
Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PHSI
Cognitive Level: Comprehension
PTS: 1
- The nurse caring for a patient with unresolved anger. For which associated complication should the nurse assess?
| a) | Depression |
| b) | Hypochondriasis |
| c) | Somatization |
| d) | Malingering |
ANS: A
Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger.
Difficulty: Easy
Nursing Process: Assessment
Client Need: PSI
Cognitive Level: Comprehension
PTS: 1
- Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope:
| a) | Could be used by the patient to hurt her |
| b) | Might cause the patient not to trust her |
| c) | Would distract her from focusing on the patient |
| d) | Will function as another stressor for the patient |
ANS: A
When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as a weapon to harm the nurse should be removed before entering the patients room. It is unlikely a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely dont even notice their presence.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- A patient is in crisis. After assessing the situation, what should the nurse do first?
| a) | Determine the imminent cause of the crisis |
| b) | Intervene to relieve the patients anxiety |
| c) | Decide on the type of help the patient needs |
| d) | Ensure the safety of both the nurse and patient |
ANS: D
The goals of crisis intervention are to assess the situation first. Then ensure safety of self and patient, defuse the situation, decrease the persons anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The nurse is presenting a workshop on stress and adaptation to a group of teenagers at the local high school. A teenager approaches the nurse and says, Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think? What is the most appropriate response by the nurse?
| a) | No amount of stress is healthy, especially if your heart is going faster. |
| b) | As long as you are getting through the test, I think you will be just fine. |
| c) | A little stress is not necessarily a bad thing. It can help you to focus. |
| d) | You may need to develop some additional stress-reducing activities. |
ANS: C
Stress is not necessarily bad. It can keep one alert and motivate one to function at a higher performance level. For example, when preparing for an examination the desire to succeed can create just enough anxiety to motivate the student to study. Conversely, if a person becomes too anxious he may be unable to focus on the task or think clearly. In this item, the student identifies that he feels some anxiety but is able to focus. The nurses response, as long as you are focusing and getting through the test is an acceptable one; however, this is not the best response as it will not assist the student in learning about and understanding mild stress and the motivating aspect of mild stress.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PSI
Cognitive Level: Application
PTS: 1
- An 18-year-old female has just been accepted to nursing school in another state. She says to her parents, I know I am going away to college, but I am nervous about going. What type of stressor is this student most likely experiencing?
| a) | External |
| b) | Developmental |
| c) | Situational |
| d) | Biophysical |
ANS: B
Developmental stressors are those that can be predicted to occur at various stages of a persons life. For example, most young adults face the stress of leaving home for college or beginning a new career. In this item, the young adult is expressing concern over a normal developmental stressor. Situational stressors are unpredictable. Biophysical stressors affect body function or structures, and external stressors are usually something external to a person, for example, death of a family member.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PSI
Cognitive Level: Comprehension
PTS: 1
- A client approaches the nurse in the health clinic and states, I have been dealing with my husbands illnesses for years. Now my children want me to start babysitting for my grandchildren. I dont know whether I can handle all this. What is the nurses interpretation of this womans statements?
| a) | Some events are producing more stress for her than other events. |
| b) | Her coping abilities are extended to her limit and she is unable to cope. |
| c) | When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. |
| d) | Coping strategies that she has used in the past are no longer successful for her now. |
ANS: C
When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. In this item, the client is verbalizing both a concern in caring for a family member over a long period of time and the possibility of dealing with a new stressor: babysitting grandchildren. Some events produce more stress than others. However, a person with good coping skills can usually adapt to a single stressful event, even a demanding one. This client has been managing one stressful event. It is the addition of another that is concerning her. In this item, we are unable to determine that coping strategies are no longer successful because we do not have any information on past coping strategies. Additionally, we cannot determine that she is unable to cope because she states, I dont know whether I can handle all this.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PSI
Cognitive Level: Analysis
PTS: 1
- The nursing student asks his instructor, Why do some of my patients get a headache when they have stress and others cry? The most appropriate response by the instructor is which of the following?
| a) | All patients react to stress differently. |
| b) | Stress responses can be physical, mental, behavioral, and spiritual. |
| c) | Some patients are more emotional than others. |
| d) | Some patients overreact to the stress they are experiencing. |
ANS: B
Responses to stress are holistic. This means they can be physical, psychological, mental, behavioral, spiritual, and social. It is important for a nurse to understand these responses to assist patients to develop healthy and adaptive coping skills. The most appropriate response is to cite the holistic responses to stress and not merely respond that all patients react to stress differently. All patients do react to stress differently; however, this is not the most comprehensive and explanatory response the instructor could make.
Difficulty: Moderate
Nursing Process: Planning
Client Need: PSI
Cognitive Level: Application
PTS: 1
- A 35-year-old female comes to the clinic for her annual physical. Upon examination, the nurse palpates a lump in the left breast. She informs the client of the finding and the client responds, Yes, I found it a few months ago too but just didnt want to think about it. The nurse recognizes that this client has been using which approach to coping with the lump?
| a) | Altering |
| b) | Adapting |
| c) | Changing |
| d) | Avoiding |
ANS: D
People use three approaches in coping with a stress. Altering the stressor is removing or changing the stressor. Adapting to the stressor involves changing ones thoughts or behaviors related to the stressor. Avoiding the stressor at times may be effective, but in this item it is maladaptive, as the client has coped by putting it out of her mind, thus avoiding earlier medical care.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PHSI
Cognitive Level: Comprehension
PTS: 1
- A 60-year-old male attends a smoking cessation class. He tells the nurse, Even though I smoke, I dont smoke around children, in my car, or in my house Which defense mechanism is this male exhibiting?
| a) | Displacement |
| b) | Rationalization |
| c) | Denial |
| d) | Repression |
ANS: B
Ego defense mechanisms are unconscious mental mechanisms that make a stressful situation more tolerable by decreasing the inner tension associated with the stressors. They protect the person from anxiety and assist with adaptation. When used sparingly, and for mild to moderate anxiety, they can be helpful. When overused, they become habits that give us a false illusion that we are coping. In this item, the male is using rationalization: the use of a logical-sounding excuse to cover up or justify true actions or feelings. The male is attending a cessation class, recognizing the desire to quit smoking, but he is rationalizing his smoking habit by citing all he does well in providing some socially acceptable rationales. Displacement is a transferring of emotions, ideas, or wishes from one object or situation to a substitute, inappropriate object. Denial is transforming reality by refusing to acknowledge thoughts, feelings, or desires. Repression is an unconscious burying or forgetting of painful thoughts, feelings, memories, ideas: pushing them from a conscious to an unconscious level. This is a step deeper than denial.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PSI
Cognitive Level: Analysis
PTS: 1
- A patient admitted to the cardiac unit is going to the cardiac catheterization lab for a procedure. The patient tells the nurse, I am so anxious about this. I am afraid the procedure might trigger a heart attack. What is the first action by the nurse?
| a) | Contact the physician for an anti-anxiety medication prior to the procedure. |
| b) | Assure the patient that this is a very common procedure for all cardiac patients. |
| c) | Instruct the patient prior to the procedure about what he can expect of the procedure. |
| d) | Offer the patient some stress-reducing techniques to use before the procedure. |
ANS: C
Because anxiety is a common response to illness, medical tests, and treatments, the nurse will use anxiety-relief interventions. In this patient scenario, instructing the patient about what to expect of the procedure will lessen anxiety and is the first and best action. Contacting the physician for an anti-anxiety medication is appropriate and many patients will receive a mild anti-anxiety medication prior to the procedure. Additionally, offering the patient some stress-reducing techniques and strategies can also be appropriate, for example, instructing him to take some deep breaths. However the first action by the nurse is to instruct the patient about the procedure.
Difficulty: Moderate
Nursing Process: Intervention
Client Need: PSI
Cognitive Level: Application
PTS: 1
- The nurse is working on an orthopedic unit in the local hospital. While assessing her patient the patient states, Ever since we had the earthquake in California I cant sleep for fear of another one happening during the night, and I just keep having flashbacks of the earthquake. The nurse knows that these patient statements are most consistent with:
| a) | Anxiety |
| b) | Lack of coping skills |
| c) | Post-traumatic stress disorder |
| d) | Crisis |
ANS: C
The statements by this patient are most consistent with post-traumatic stress disorder (PTSD): a specific response to a violent, traumatizing event such as a natural disaster (flood, earthquake) or physical or emotional abuse (war, rape). The victim experiences anxiety and flashbacks that may last for months or years. A crisis exists when an event in a persons life drastically changes the persons routine and he perceive it as a threat to self. Such events are usually sudden and unexpected such as a serious illness, death of a loved one, serious financial loss, and natural disaster. It is not common, however, for people in crisis to experience flashbacks. Flashbacks are most consistent with PTSD.
Difficulty: Moderate
Nursing Process: Intervention
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
MULTIPLE RESPONSE
- During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Select all that apply.
| a) | Rate of metabolism decreases. |
| b) | Liver converts more glycogen to glucose. |
| c) | Use of amino acids decreases. |
| d) |
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