Nurs 220 Exam 14 Review | UPDATED Questions with 100%
Verified Answers
Q1: To evaluate a client's personal identity, the nurse should consider what three aspects of the client's self?
A: Personal identity can be evaluated from the standpoint of three aspects of self; the ideal self, the real self, and the
public self. Rationale: The ideal self reflects the qualities an individual believes he or she should possess, as well as
those he or she aspires to develop. The real self represents an individual's perceived true self; it may include
observations about self or self perceived qualities that the individual hides from others or does not readily share. The
public self is formed on the basis of how the individual wishes to be perceived by others.
Q2: Which hormone is one of the primary mediators of stress?
A: The two primary stress mediators are glucocorticoids (e.g. cortisol) and catecholamines (e.g. epinephrine).
Rationale: Serotonin is a neurotransmitter that is involved in some mood and anxiety disorders, but it is not a primary
mediator of stress. Somatostatin is a hormone released by the pituitary gland. It is not involved in the stress
response. Glucagon is secreted by the pancreas to increase blood glucose levels.
Q3: The nurse is caring for a client who is hospitalized with pneumonia. Which of the following will the nurse
assess when determining the impact of the illness on the family? Select all that apply A) The duration of the
illness B) The effect of the illness on future family functioning C) The cause of the illness D) The meaning of
the illness to the family E) The financial impact of the illness
A: A) The duration of the illness B) The effect of the illness on future family functioning D) The meaning of the illness to
the family E) The financial impact of the illness The impact on the family is assessed by the duration of the illness as
well as its effect on the family finances and functioning. Other factors include residual effects of the illness, meaning
of the illness to the family, and its significance to family systems. The cause of the illness is not a factor that
determines the impact on the family.
Q4: What is the major effect of a health crisis on family structure?
A: Serious illness or injury may result in changes in family roles, responsibilities, and functions. Rationale: Illness may
precipitate a health crisis in a family. Regardless of how the family adapts to an illness, members of the family must
constantly adjust roles and responsibilities to manage the need of the ill family member.
Q5: The nurse is assessing his client's self concept. The client is status postmyocardial infarction and is
due to be discharged tomorrow. Which of the following focuses will give the nurse the most information
about the client's self concept? select all that apply. A) Body image B) Gender identity C) Selfesteem D) Role
performance E) Sexual orientation
A: A) Body image C) Selfesteem E) Sexual orientation The nurse assessing selfconcept focuses on the client's
personal identity, body image, selfesteem, and role performance. Sexual orientation and gender identity do not
always provide information about selfconcept.
,Q6: It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a
minister to see him. Family is at the bedside. What action would the nurse take to address the client's
spiritual distress on this day?
A: Contact the chaplain to request to see the client today. Rationale: Even on a holy day, there is usually a spiritual
caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other
options may bring some relief to the client, but they still ignore his request for a spiritual caregiver.
Q7: The nurse is caring for a woman who was involved in a car accident. The client's husband was killed in
the accident. The couple has two teenage children. Which statement explains how this tragedy will be
approached by the family?
A: Family disorganization may occur. Rationale: The death of a family member often has a profound effect on the whole
family especially if the deceased, as in this situation, was the head of the family. Family disorganization would be
common, but as the family begins to recover, a new sense of normalcy develops and the family reintegrates its roles
and functions. Families need support from extended family members, their community, and spiritual advisers. The
other options are not considered normal patterns of family grieving, and the nurse should be alert for problems that
may develop if these are present.
Q8: Occupationspecific stressors that are ongoing and unmanaged can lead to what extreme form of
stress?
A: Burnout Rationale: Eustress is good stress that leads to accomplishment and victory. Distress is bad stress that is
associated with inadequacy, insecurity, and loss. Although occupation specific stressors can be a type of distress,
distress is not the specific term for the extreme form of stress caused by ongoing and unmanaged stress. The term
used for that form of extreme stress us burnout. Burnout in nurses can lead to reduced quality of care and decreased
patient satisfaction. Allostasis refers to changes necessary to achieve homeostasis
Q9: Which of the following most accurately describes the family burden associated with mental illness? A) It
is the overall level of distress experienced as a result of the mental illness. B) It is the pattern of negative
attitudes that lead people to fear individuals with mental illness. C) It is the measurable or quantifiable
impacts of mental illness on the family. D) It is the assessment that visualizes the way the family interacts
with the community.
A: A) It is the overall level of distress experienced as a result of the mental illness Family burden is the overall level of
distress experienced as a result of the mental illness. Stigma is the pattern of negative attitudes that lead people to
fear in discriminate against individuals with mental illness and their families. Objective burdens are a type of family
burden that is measurable or quantifiable. An echo map is an assessment tool that helps nurses visualize how the
family can interacts with the external community environment.
, Q10: The nurse is assessing a client's spirituality. Which of the following findings would suggest that the
client experiences of spirituality as a source of strength? A) The client uses the telephone to inform family
members of an unwanted diagnosis. B) The client reads spiritual material every morning. C) The client asks
to watch a religious service on television. D) The client says she has no desire to meet with a chaplain. E)
The client tells the nurse she is convinced she will be punished in the afterlife.
A: B) The client reads spiritual material every morning. E) The client tells the nurse she is convinced she will be
punished in the afterlife. Regularly reading spiritual material and asking to watch a religious service on Television are
actions that suggest the client views spirituality as a source of strength in contrast, focusing on possible punishment
in the after life would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a
chaplain might indicate spiritual distress, or it might indicate that the diagnosis on the phone is unrelated to
spirituality.
Q11: What is the term for the change that takes place in response to a stressor?
A: The change that takes place in response to a stressor is adaptation Rationale: When a person is in a threatening
situation, immediate and often involuntary responses occur.
Q12: A couple recently married. Both the husband and the wife have previously been married and had two
children. What is given to this type of family?
A: The blended family is one that is formed when parents bring unrelated children from previous relationships together
to form a new family. Rationale: An extended family includes relatives; a nuclear family is the traditional
father/mother/children; a cohabiting family is composed of member who live together but are not married.
Q13: Despite the presence of a large number of older adult residents of Asian heritage, a long term care
facility has not integrate the Asian concepts of hot and cold into meal planning. The nurses at the facility
should recognize this as an example of:
A: Cultural blindness. Rationale: Not taking into consideration the importance of cultural practices either aware or
unaware of the actions.
Q14: What is the purpose of the affective and coping function of the family?
A: The affective and coping function of the family is necessary to provide emotional comfort to family members and to
help members establish an identity to be maintained in times of stress. Rationale: The physical function provides a
safe environment for growth and development, the economic function ensures financial assistance, and the
socialization function transmits values, attitudes, and beliefs.
Q15: What is the name given to the evaluative and affective component of the selfconcept?
A: Self esteem is the evaluative and affective component of the selfconcept. Sometimes termed selfrespect,
selfapproval, or selfworth.
Verified Answers
Q1: To evaluate a client's personal identity, the nurse should consider what three aspects of the client's self?
A: Personal identity can be evaluated from the standpoint of three aspects of self; the ideal self, the real self, and the
public self. Rationale: The ideal self reflects the qualities an individual believes he or she should possess, as well as
those he or she aspires to develop. The real self represents an individual's perceived true self; it may include
observations about self or self perceived qualities that the individual hides from others or does not readily share. The
public self is formed on the basis of how the individual wishes to be perceived by others.
Q2: Which hormone is one of the primary mediators of stress?
A: The two primary stress mediators are glucocorticoids (e.g. cortisol) and catecholamines (e.g. epinephrine).
Rationale: Serotonin is a neurotransmitter that is involved in some mood and anxiety disorders, but it is not a primary
mediator of stress. Somatostatin is a hormone released by the pituitary gland. It is not involved in the stress
response. Glucagon is secreted by the pancreas to increase blood glucose levels.
Q3: The nurse is caring for a client who is hospitalized with pneumonia. Which of the following will the nurse
assess when determining the impact of the illness on the family? Select all that apply A) The duration of the
illness B) The effect of the illness on future family functioning C) The cause of the illness D) The meaning of
the illness to the family E) The financial impact of the illness
A: A) The duration of the illness B) The effect of the illness on future family functioning D) The meaning of the illness to
the family E) The financial impact of the illness The impact on the family is assessed by the duration of the illness as
well as its effect on the family finances and functioning. Other factors include residual effects of the illness, meaning
of the illness to the family, and its significance to family systems. The cause of the illness is not a factor that
determines the impact on the family.
Q4: What is the major effect of a health crisis on family structure?
A: Serious illness or injury may result in changes in family roles, responsibilities, and functions. Rationale: Illness may
precipitate a health crisis in a family. Regardless of how the family adapts to an illness, members of the family must
constantly adjust roles and responsibilities to manage the need of the ill family member.
Q5: The nurse is assessing his client's self concept. The client is status postmyocardial infarction and is
due to be discharged tomorrow. Which of the following focuses will give the nurse the most information
about the client's self concept? select all that apply. A) Body image B) Gender identity C) Selfesteem D) Role
performance E) Sexual orientation
A: A) Body image C) Selfesteem E) Sexual orientation The nurse assessing selfconcept focuses on the client's
personal identity, body image, selfesteem, and role performance. Sexual orientation and gender identity do not
always provide information about selfconcept.
,Q6: It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a
minister to see him. Family is at the bedside. What action would the nurse take to address the client's
spiritual distress on this day?
A: Contact the chaplain to request to see the client today. Rationale: Even on a holy day, there is usually a spiritual
caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other
options may bring some relief to the client, but they still ignore his request for a spiritual caregiver.
Q7: The nurse is caring for a woman who was involved in a car accident. The client's husband was killed in
the accident. The couple has two teenage children. Which statement explains how this tragedy will be
approached by the family?
A: Family disorganization may occur. Rationale: The death of a family member often has a profound effect on the whole
family especially if the deceased, as in this situation, was the head of the family. Family disorganization would be
common, but as the family begins to recover, a new sense of normalcy develops and the family reintegrates its roles
and functions. Families need support from extended family members, their community, and spiritual advisers. The
other options are not considered normal patterns of family grieving, and the nurse should be alert for problems that
may develop if these are present.
Q8: Occupationspecific stressors that are ongoing and unmanaged can lead to what extreme form of
stress?
A: Burnout Rationale: Eustress is good stress that leads to accomplishment and victory. Distress is bad stress that is
associated with inadequacy, insecurity, and loss. Although occupation specific stressors can be a type of distress,
distress is not the specific term for the extreme form of stress caused by ongoing and unmanaged stress. The term
used for that form of extreme stress us burnout. Burnout in nurses can lead to reduced quality of care and decreased
patient satisfaction. Allostasis refers to changes necessary to achieve homeostasis
Q9: Which of the following most accurately describes the family burden associated with mental illness? A) It
is the overall level of distress experienced as a result of the mental illness. B) It is the pattern of negative
attitudes that lead people to fear individuals with mental illness. C) It is the measurable or quantifiable
impacts of mental illness on the family. D) It is the assessment that visualizes the way the family interacts
with the community.
A: A) It is the overall level of distress experienced as a result of the mental illness Family burden is the overall level of
distress experienced as a result of the mental illness. Stigma is the pattern of negative attitudes that lead people to
fear in discriminate against individuals with mental illness and their families. Objective burdens are a type of family
burden that is measurable or quantifiable. An echo map is an assessment tool that helps nurses visualize how the
family can interacts with the external community environment.
, Q10: The nurse is assessing a client's spirituality. Which of the following findings would suggest that the
client experiences of spirituality as a source of strength? A) The client uses the telephone to inform family
members of an unwanted diagnosis. B) The client reads spiritual material every morning. C) The client asks
to watch a religious service on television. D) The client says she has no desire to meet with a chaplain. E)
The client tells the nurse she is convinced she will be punished in the afterlife.
A: B) The client reads spiritual material every morning. E) The client tells the nurse she is convinced she will be
punished in the afterlife. Regularly reading spiritual material and asking to watch a religious service on Television are
actions that suggest the client views spirituality as a source of strength in contrast, focusing on possible punishment
in the after life would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a
chaplain might indicate spiritual distress, or it might indicate that the diagnosis on the phone is unrelated to
spirituality.
Q11: What is the term for the change that takes place in response to a stressor?
A: The change that takes place in response to a stressor is adaptation Rationale: When a person is in a threatening
situation, immediate and often involuntary responses occur.
Q12: A couple recently married. Both the husband and the wife have previously been married and had two
children. What is given to this type of family?
A: The blended family is one that is formed when parents bring unrelated children from previous relationships together
to form a new family. Rationale: An extended family includes relatives; a nuclear family is the traditional
father/mother/children; a cohabiting family is composed of member who live together but are not married.
Q13: Despite the presence of a large number of older adult residents of Asian heritage, a long term care
facility has not integrate the Asian concepts of hot and cold into meal planning. The nurses at the facility
should recognize this as an example of:
A: Cultural blindness. Rationale: Not taking into consideration the importance of cultural practices either aware or
unaware of the actions.
Q14: What is the purpose of the affective and coping function of the family?
A: The affective and coping function of the family is necessary to provide emotional comfort to family members and to
help members establish an identity to be maintained in times of stress. Rationale: The physical function provides a
safe environment for growth and development, the economic function ensures financial assistance, and the
socialization function transmits values, attitudes, and beliefs.
Q15: What is the name given to the evaluative and affective component of the selfconcept?
A: Self esteem is the evaluative and affective component of the selfconcept. Sometimes termed selfrespect,
selfapproval, or selfworth.
