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NURSING Test Bank for Medical Surgical Nursing 7th Edition

Chapter 01: Aspects of Medical-Surgical Nursing: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes? a. Physician’s orders b. Progress notes c. Nursing care plan d. Client health history ANS: C The nursing care plan provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes. DIF: Cognitive Level: Comprehension REF: p. 2 OBJ: 1 TOP: Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The nurse is performing behaviors and actions that assist clients and significant others in meeting their needs and the identified outcomes of the plan of care. What is the correct term for these nursing behaviors? a. Assessments b. Interventions c. Planning d. Evaluation ANS: B Caring interventions are those nursing behaviors and actions that assist clients and significant others in meeting their needs and the identified outcomes of the plan of care. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 1 TOP: Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse understands the importance of being answerable for all actions and the possibility of being called on to explain or justify them. What term best describes this concept? a. Reliability b. Maturity c. Accountability d. Liability ANS: C Accountability means that a person is answerable for his or her actions and may be called on to explain or justify them. DIF: Cognitive Level: Comprehension REF: pp. 6-7 OBJ: 3 | 5 | 7 TOP: Accountability KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 1. The nurse manager is providing an inservice about conflict resolution. What modes of conflict resolution should be addressed? (Select all that apply.) a. Suppression b. Accommodation c. Compromise d. Avoidance e. Collaboration f. Competition ANS: B, C, D, E, F The modes of conflict resolution include accommodation, collaboration, compromise, avoidance, and competition. DIF: Cognitive Level: Knowledge REF: p. 7|p. 8|Table 1.1 OBJ: 7 TOP: Conflict Resolution KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. What are the characteristics of an effective leader? (Select all that apply.) a. Effective communication b. Rigid rules and regulations c. Delegates appropriately d. Acts as a role model e. Consistently handles conflict f. Focuses on individual development ANS: A, C, D, E Characteristics of an effective leader include effective communication, consistency in managing conflict, knowledge and competency in all aspects of delivery of care, effective role model for staff, uses participatory approach in decision making, shows appreciation for a job well done, delegates work appropriately, sets objectives and guides staff, displays caring, understanding, and empathy for others, motivates and empowers others, is proactive and flexible, and focuses on team development. DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: Leadership KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. is defined as the process by which information is exchanged between individuals verbally, nonverbally, and/or in writing or through information technology. ANS: Communication Communication is defined as the process by which information is exchanged between individuals verbally, nonverbally, and/or in writing or through information technology. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 2 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. is the collection and processing of relevant data for the purpose of appraising the client’s health status. ANS: Assessment Assessment is the collection and processing of relevant data for the purpose of appraising the client’s health status. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 | 2 TOP: Assessment KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. is concerned with the ethical questions that arise in the context of health care. ANS: Bioethics Bioethics is concerned with the ethical questions that arise in the context of health care. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 3 TOP: Bioethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. Place the corresponding letter to each stage of conflict in the correct order. (Place the events in the appropriate sequence with capital letters. Do not separate answers with a space or punctuation. Example: ABCD.) a. Outcomes b. Conceptualization c. Frustration d. Action ANS: CBDA The stages of conflict in order are frustration, conceptualization, action, and outcomes. DIF: Cognitive Level: Comprehension REF: p. 7 OBJ: 7 TOP: Conflict KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. Place the corresponding letter to each key step in solving an ethical dilemma in the correct order. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Negotiate a plan. b. Clarify values. c. Ask if it is an ethical dilemma. d. Verbalize the problem. e. Gather information. f. Identify possible courses of action. g. Evaluate the plan over time. ANS: CEBDFAG The key step of solving an ethical dilemma in order are ask the question, is it an ethical dilemma, gather information, clarify values, verbalize the problem, identify possible course of action, negotiate a plan, and evaluate the plan over time. DIF: Cognitive Level: Analysis REF: p. 4 OBJ: 3 TOP: Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 02: Medical-Surgical Practice Settings Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. While a home health nurse is making the entry to a service assessment on a homebound patient, the spouse of the patient asks whether Medicare will cover the patient’s ventilator therapy and insulin injections. What is the best response by the nurse? a. “Yes, Medicare will cover both the ventilator therapy and the insulin injections.” b. “No, Medicare will not cover either of these ongoing therapies.” c. “Medicare will cover the ventilator therapy, but it does not cover the insulin injections.” d. “Medicare will cover the ongoing insulin therapy, but it does not cover a highly technical skill such as ventilator therapy.” ANS: C Medicare will cover skilled nursing tasks such as ventilator therapy, but common tasks that can be taught to the family or the patient are not covered. DIF: Cognitive Level: Application REF: pp. 12-13 OBJ: 3 | 4 TOP: Medicare Coverage for Home Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 2. The wife of a patient asks the nurse whether her husband would be considered for placement in a skilled nursing care facility when he is discharged from the general hospital. The patient is incontinent, has mild dementia but is able to ambulate with a walker, and must have help to eat and dress himself. What is the nurse’s most appropriate response? a. “Yes, your husband would qualify for a skilled care facility because of his inability to feed and dress himself.” b. “No, your husband’s disabilities would not qualify him for a skilled facility.” c. “Yes, your husband qualifies for placement in a skilled care facility because of his dementia.” d. “Yes, anyone who is willing to pay can be placed in a skilled nursing facility.” ANS: B Placement in a skilled nursing facility must be authorized by a physician. A clear need for rehabilitation must be evident, or severe deficits in self-care that have a potential for improvement and require the services of a registered nurse, a physical therapist, or a speech therapist must exist. DIF: Cognitive Level: Analysis REF: p. 13 OBJ: 6 TOP: Placement Qualifications for Skilled Nursing Facility KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. A nurse has noted that a newly admitted resident to an extended care facility stays in her room, does not take active part in activities, and leaves the meal table after having eaten very little. The nurse should analyze this relocation response as a. regression. b. social withdrawal. c. depersonalization. d. passive aggressive. ANS: B Social withdrawal is a frequent response to relocation. DIF: Cognitive Level: Application REF: p. 21 OBJ: 10 TOP: Relocation Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. A nurse clarifies to a new patient in a rehabilitation center what rehabilitation means. What statement made by the patient indicates a correct understanding? a. “I will return to my previous level of functioning.” b. “I will be counseled into a new career.” c. “I will develop better coping skills to accept his disability.” d. “I will attain the greatest degree of independence possible.” ANS: D The rehabilitation process works to promote independence at whatever level the patient is capable of achieving. DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: 7 TOP: Rehabilitation Goals KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 5. A nurse assesses a patient who needs to be reminded to take premeasured oral medications, wash, go to meals, and undress and come to bed at night, but coming and going as he pleases is considered safe for him. What facility placement would be most appropriate for this patient? a. Skilled care b. Intermediate care c. Sheltered housing d. Domiciliary care ANS: D Domiciliary care provides room, board, and supervision, and residents may come and go as they please. Sheltered housing does not provide 24-hour care. DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: 3 | 9 TOP: “Levels of Care, Criteria for Domiciliary Residence” KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 6. A nurse is making a list of the members of the rehabilitation team, so the different types of services available to patients may be taught to a group of families. Which lists should be used? a. Physical therapist, nurse, family members, and personal physician b. Occupational therapist, dietitian, nurse, and patient c. Rehabilitation physician, laboratory technician, patient, and family d. Vocational rehabilitation specialist, patient, and psychiatrist ANS: A The rehabilitation team usually consists of all of the choices except the laboratory technician, dietitian, and psychiatrist. (The mental health role is represented by the psychologist.) DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 7 TOP: Rehabilitation Team Members KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 7. A nurse explains the level of disability to a patient who was injured in a construction accident that resulted in the loss of both his right arm and right leg. This loss has affected his quality of life and ability to return to previous employment. At what level should the client be classified as being disabled? a. I b. II c. III d. IV ANS: B The patient is limited in the use of his right arm for feeding himself, dressing himself, and driving his car, which are three main activities of daily living. He may be able to work if workplace modifications are made. DIF: Cognitive Level: Application REF: p. 15 OBJ: 8 TOP: Levels of Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For which extended services for the disabled persons did this act provide? a. Covering the costs for the rehabilitation of disabled World War I servicemen by providing job training b. Extending protection to the disabled in the military sector, such as wheelchair ramps on military bases c. Extending protection to the disabled in private areas, such as accessibility to public restaurant bathrooms and telephones d. Affording disabled persons full access to all health care services ANS: C The ADA of 1990 extended the previous legislative Acts of 1920, 1935, and 1973. The ADA now covers private sector individuals and public businesses in particular. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Americans with Disabilities Act (ADA) of 1990 KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 9. A frail patient in a long-term care facility asks the nurse if a bath is to be given this morning. What is the best reply by the nurse to encourage independence and give the patient the most flexibility? a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday. Today is Tuesday.” b. “If you want to eat breakfast in the dining room with the others, you may sponge yourself off in your bathroom.” c. “When your daughter comes this evening, ask her if she can give you a bath.” d. “I will bring a basin of water for a sponge off for right now. After breakfast, we will talk about a bath schedule.” ANS: D The resident should be provided as much flexibility as possible and support for independence. DIF: Cognitive Level: Application REF: p. 22 OBJ: 11 TOP: Maintenance of Autonomy in Extended Care Facility KEY: Nursing Process Step: Implementation MSC: NCLEX Physiological Integrity: Basic Care and Comfort 10. A computer programmer who lost both legs is being retained by his employer, who has made arrangements for a ramp and a special desk to accommodate the patient’s wheelchair. What is the disability level of the computer programmer? a. I b. II c. III d. IV ANS: B Level II allows for workplace accommodation, which is the desk modification in this case. DIF: Cognitive Level: Analysis REF: p. 15 OBJ: N/A TOP: Reasonable Accommodation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. A partially paralyzed forklift operator is to be retrained by vocational rehabilitation services for less demanding office work. What law provides for this rehabilitation? a. Vocational Rehabilitation Act of 1920 b. Social Security Act of 1935 c. Rehabilitation Act of 1973 d. Americans with Disabilities Act of 1990 ANS: C The Rehabilitation Act of 1973 provided a comprehensive approach and expanded resources for public vocational training. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7 TOP: Rehabilitation Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. The home health care nurse performs all the following actions. Which is the only action that is reimbursable under Medicare payment rules? a. Observing a spouse cleaning and changing a dressing b. Taking a frail couple for a walk to provide exercise c. Watching a patient measure out all medications d. Teaching a patient to self-administer insulin ANS: D Medicare reimburses skilled techniques that are clearly spelled out; these include teaching but not return demonstration–type actions by patient or family. DIF: Cognitive Level: Comprehension REF: pp. 12-13 OBJ: 4 TOP: Medicare Reimbursable Actions KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 13. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse assess this patient? a. Disabled b. Disadvantaged c. Handicapped d. Impaired ANS: D Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired in this scenario. DIF: Cognitive Level: Analysis REF: p. 15 OBJ: 7 TOP: Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which law initially provided for rehabilitation of disabled Americans? a. Vocational Rehabilitation Act of 1920 b. Social Security Act of 1935 c. Rehabilitation Act of 1973 d. Americans with Disabilities Act of 1990 ANS: A The U.S. government has passed four pieces of legislation to identify and meet the needs of disabled individuals with each one being more inclusive. The first one was passed in 1920. DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 8 TOP: Rehabilitation Legislation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. A client was admitted to a long-term residential care facility. On what should the admitting nurse tell the family the concepts of long-term care are based? a. Amount of activities the resident can do for herself b. Maintenance care with an emphasis on incontinence c. Successful adaptation to the regulations of the home d. Maintenance of as much function as possible ANS: D Maintenance of function and encouraging autonomy and independence are some of the basic concepts of long-term care. DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: 11 TOP: Principles of Nursing Home Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 16. A 58-year-old patient with diabetes is recuperating from a broken hip and is concerned about how to pay for rehabilitation. The nurse should inform this patient that funds for rehabilitation are available from which resource? a. Vocational Rehabilitation Act of 1920 b. Rehabilitation Act of 1973 c. Disabled American Veterans Act of 1990 d. Title V, Health of Crippled Americans 1935 ANS: B The Rehabilitation Act of 1973 assists in paying for rehabilitation for those who are younger than 65 years of age and who will benefit from vocational rehabilitation through teaching. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Legislation for Funding Health Care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 17. What is an example of a description of community health nursing? a. Visiting patients in their homes after hospital discharge to assess their personal health status b. Asking a nursing assistant (NA) to identify the health services most needed in the patient’s personal life c. Meeting with residents of low-income housing to identify their health care needs d. Developing a hospital-based home health care service ANS: C Whereas community-based nursing looks at identified community needs and provides care at all levels of wellness and illness, community health nursing seeks to provide services to groups to modify or create systems of care. DIF: Cognitive Level: Comprehension REF: pp. 10-11 OBJ: 2 TOP: Defining Community-Based Nursing versus Community Health Nursing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 18. Home health nurses have some different nursing activities than those of community health nurses. Which statement best describes the home health nurse’s activities? a. Conducting health education classes in a senior citizens’ common residence building b. Conducting blood pressure screening on a regular basis at a local mall c. Visiting and assessing the home care and further teaching needs of a patient who has been recently discharged from the hospital d. Acting as a nurse consultant to a chronic psychiatric section in a state institution ANS: C The home health nurse works with individuals in the home; the other descriptors are community nurse activities. DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 1 | 5 TOP: Activities of the Home Health Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 19. Based on guidelines from the Americans with Disability Act (ADA), which question is an appropriate choice for the director of nurses to ask a nurse with an artificial leg who is applying for a staff position in an extended care facility? a. “How long have you had your prosthesis?” b. “How many flights of stairs are you able to climb without assistance?” c. “Are you able to lift a load of 45 lb?” d. “Has your disability caused you to miss work?” ANS: C Queries to disabled job applicants can be made relative to specific job functions, but they cannot be asked relative to the severity of the disability or the degree of disability in general. DIF: Cognitive Level: Application REF: p. 16 OBJ: 7 | 8 TOP: ADA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy? a. Selection of medication times b. Availability of his own small electrical appliances c. Smoking in the privacy of his own room d. Application of advance directives ANS: D The application of advance directives is an autonomous decision. Agency protocols relative to medication times, access to private electrical devices, and smoking are rarely waived; these policies are not in the control of the resident. DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 10 TOP: Autonomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation MULTIPLE RESPONSE 1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach family members in the home health care setting? (Select all that apply.) a. Insulin injection b. Sterile dressing changes c. Venipunctures d. Periodic Foley catheter insertions e. Instillation of eye drops f. Changing dressings on small wounds ANS: A, E, F Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley catheters are considered skilled, and the costs for these are reimbursed by Medicare. DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3 TOP: Skills Taught by Home Health Nurse KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The nursing care plan in a long-term care facility calls for the documentation of regressive behavior of a newly admitted 82-year-old resident who has had congestive heart failure and osteoarthritis. Of these behaviors observed by the nurse, which should be documented as regression? (Select all that apply.) a. Talks nonstop to staff and other residents. b. Wets and soils self several times a day. c. Wakes in the middle of the night and is unable to return to sleep. d. Wears the same clothes day after day. e. Cries frequently for no apparent reason. ANS: B, D, E Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they are not considered regressive. DIF: Cognitive Level: Analysis REF: pp. 20-21 OBJ: 10 TOP: Impact of Relocation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 3. From what do most quality-of-care problems in home health care result? (Select all that apply.) a. Patient’s noncompliance b. Family’s reluctance to participate in the care c. Inadequate documentation d. Limited funding e. Defective communication among care team members ANS: C, E Inadequate communication and incomplete documentation create most of the quality-of-care problems. DIF: Cognitive Level: Comprehension REF: pp. 11-12 OBJ: 2 TOP: Communication in Home Health Setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes incontinent of urine at night. What nursing interventions should be used to help restore self-toileting? (Select all that apply.) a. Waking the resident every 2 hours and escorting him to the bathroom b. Leaving a night-light on c. Discouraging the use of long-legged pajama bottoms d. Placing a urinal at the bedside e. Keeping the room uncluttered ANS: B, C, D, E Providing light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making the urinal available increase independence and alleviate situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but doing so also increases dependency on the staff. DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11 TOP: Independence in Long-Term Care Center KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse clarifies that an impairment that creates a measurable diminished capacity to work is a(n) . ANS: disability When there is a measurable impairment that changes the individual’s lifestyle, it is referred to as a disability. DIF: Cognitive Level: Knowledge REF: p. 15 OBJ: N/A TOP: Rehabilitation Concepts KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 2. What should the home health nurse do when teaching a family member the skill of injecting insulin effectively? Prioritize these nursing interventions for this situation. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Offer instruction at an appropriate pace. b. Write down the steps of the procedure. c. Assess the level of knowledge of the family member. d. Inquire about the preferred learning style. e. Evaluate the family member’s performance. ANS: CBDAE Effective teaching depends on assessing the level of knowledge, breaking down the skill in steps, offering instruction in the preferred style, pacing the instruction appropriately, and evaluating the performance. DIF: Cognitive Level: Application REF: p. 14 OBJ: 1 TOP: Home Health Teaching KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. Prioritize the steps in solving an ethical dilemma. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.) a. Evaluate the outcome. b. Plan an approach. c. Visualize the consequences. d. Take action. e. Identify the problem. ANS: EBCDA To solve an ethical dilemma, one must clearly identify the problem, plan an approach, visualize the consequences, take action, and evaluate the outcome. DIF: Cognitive Level: Comprehension REF: p. 11 OBJ: 7 TOP: Solving an Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What should be included in a patient’s care plan in consideration of cultural similarities? a. Family, educational background, and economic level should all be considered. b. Subtle communication involving languages should be considered. c. Families have strong patriarchal leaders. d. Culture is learned, shared, and expressed similarly among members. ANS: D Different cultures have some similarities and some differences. How the culture is expressed in health care settings will be diverse. DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: 4 TOP: Similarities among Cultures KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 2. What is the basis for the health–illness continuum? a. Prevention of acute illness b. Individual response to health or illness c. Promotion of health and wellness d. Variation in degree of health or illness ANS: D Currently, health and illness are viewed as relative states along a continuum. Individuals are at neither absolute health nor absolute illness but are in an ever-changing state of being. DIF: Cognitive Level: Comprehension REF: pp. 25-26 OBJ: 5 TOP: Current View of Health-Illness Continuum KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 3. What is the current concern of the health care system? a. Treating illness b. Preventing illness c. Promoting optimal function in the chronically ill d. Caring for patients with acute and chronic illness ANS: B Health promotion activities are directed toward maintaining or enhancing well-being as a protection against illness. DIF: Cognitive Level: Knowledge REF: pp. 25-26 OBJ: 2 | 5 TOP: Health Promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 4. What is the primary reason that family is an important unit in society? a. Offers unconditional love and acceptance. b. Provides emotional support and security. c. Is essential to life and society. d. Promotes cultural values and attitudes. ANS: B A family is defined as being joined together by bonds of sharing and emotional closeness. DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8 TOP: The Family Unit KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. What should a nurse assess when a patient comes from an extended family? a. Multiple wage earners b. Three generations living together c. Children from previous marriages d. Parents of different ethnic origins ANS: B The extended family consists of relatives of either spouse who live with the nuclear family. Children, regardless of their parentage, are considered part of the nuclear family. DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8 TOP: Types of Families KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. A nurse is designing a home care plan for a child with a congenital disease and is assessing the family values regarding home care. What is the best resource for the nurse to use? a. Current literature on congenital deformities b. General knowledge of the culture c. Patient’s family d. Written survey ANS: C Determining the family’s values, beliefs, customs, and behaviors that influence health needs and health care practice is important. The best source is the family itself. DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 11 TOP: Cultural Aspects KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. A nurse counsels a family regarding the stage of families with adolescents. Which developmental task is appropriate for the nurse to include? a. Maintaining relationships with the extended family b. Developing parental roles to meet the needs of children c. Maintaining a satisfying marital relationship d. Maintaining open communication between parent and children ANS: D The family developmental tasks at this stage include balancing freedom with responsibility and maintaining communication between parents and children. DIF: Cognitive Level: Comprehension REF: p. 34|Table 3.3 OBJ: 8 TOP: Family Life Cycles KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. Which developmental task should families master in later life? a. Becoming role models for their grandchildren b. Making a significant contribution to society c. Abandoning the parental role to grown children d. Maintaining a satisfactory living arrangement ANS: D The last stage of the family life cycle includes families in later life who are adjusting to retirement, the aging process, decreased self-esteem, and changes in status and health issues. Maintaining a satisfactory living arrangement is the primary developmental task. DIF: Cognitive Level: Comprehension REF: p. 34|Table 3.3 OBJ: 8 TOP: Family Life Cycles KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. Culture and social class usually set a precedent for different roles and responsibilities of each family member. Which example best demonstrates the healthiest family? a. The father assumes the role as breadwinner. b. The mother assumes the role as homemaker. c. The father or mother shares the roles of breadwinner and homemaker. d. The roles of breadwinner or homemaker can be shifted as needed. ANS: D A healthy family is one in which the opportunity to shift roles occurs easily from time to time. DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 8 TOP: Family Role StructureKEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. During a family counseling session, a patient, a mother of a 5-year-old son, states, “I don’t understand why my husband continually tries to get our son involved in T-ball. My son said the coach and his dad yelled at him and told him the game was lost because he couldn’t catch the ball.” What is the most important family interaction to maintain a healthy family unit? a. Maintain open communication among all family members. b. Encourage self-acceptance and self-esteem for all family members. c. Encourage all family members to participate in community events. d. Realize that not all family members may be able to fulfill assigned roles. ANS: B The most important influence on family interaction is the self-esteem of each member. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Family Interaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. For the past three evenings, shortly after their arrival in the hospital unit, the parents of a 14-year-old daughter begin to argue about the cost of the hospitalization and the time required to come to the hospital. The patient begins to cry and complains about her abdominal pain. What role is the patient assuming? a. Caretaker b. Martyr c. Blocker d. Scapegoat ANS: D A scapegoat usually assumes the role to maintain homeostasis, serving to divert attention from marital conflict between spouses. DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10 TOP: Family Role StructureKEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A patient, a 36-year-old mother of four children, is crying. She relates to you that her best friend just told her, “You are a good mother and you do everything perfectly, but I don’t think you enjoy it.” What role is the patient assuming? a. Caretaker b. Martyr c. Contributor d. Harmonizer ANS: B A martyr sacrifices everything for the sake of the family. DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10 TOP: Family Role StructureKEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 13. What is the basis for the roles children assume in families? a. Obligation b. Instinct c. Observation d. Rewards ANS: D Parents reward children for fulfilling certain roles, which children adopt and maintain as they mature. DIF: Cognitive Level: Comprehension REF: p. 34|p. 35 OBJ: 9 TOP: Family Role StructureKEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. A patient confides that her husband shares only the incidental happenings of his day at work as he reads the paper, and he never tells her that he loves her anymore. She is beginning to wonder if their marriage is getting stale. What communication pattern should the nurse recognize? a. Affective b. Affectional c. Functional d. Dysfunctional ANS: D One type of dysfunctional communication involves using chitchat about unimportant daily occurrences to avoid discussing meaningful issues or expressing feelings. DIF: Cognitive Level: Analysis REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. What should a nurse consider when discussing the communication patterns of families with the patient? a. Cultural aspects of the family b. Age of the family members c. Role adopted by each family member d. Number of members in the family ANS: A Although each option has significance, cultural aspects must be considered in determining the functioning level of the family as it affects the roles taken. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. A patient states that her 5-year-old daughter is always running up to relatives and friends and wants to give them a big hug and kiss. The patient asks if her daughter is appropriate in her actions. What is the most appropriate reply based on the concepts of functional communication? a. “Your daughter’s actions are definitely dysfunctional.” b. “Your daughter is just being a ‘little girl’ and will outgrow being so affectionate.” c. “Your daughter is going through a normal developmental phase.” d. “Does your mother-in-law show signs of affection toward your daughter?” ANS: C Physical expression of emotion usually dominates in early childhood and is normal in the developmental pattern. DIF: Cognitive Level: Application REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. For what should functional patterns of communication in the family setting provide a means? a. Nurturing b. Information c. Closeness d. Openness ANS: A Functional patterns of communication include emotional and affective communication that deals with the expression of feelings and nurturing. A healthy family is able to demonstrate a wide range of emotions and feelings. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. What does the manner in which a family unit adapts to stress affect? a. Ability to communicate and function b. Health and function c. Level of affective communication d. Ability to adapt and function ANS: B The manner in which a family handles stress can affect the health of the family. DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 11 TOP: Stress and Adaptation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 19. A patient who was recently diagnosed with cancer tells the nurse that she is so grateful for her children and family because she does not know what she would do without them. Which coping response is being exhibited? a. Internal family b. External family c. Family communication d. Social support ANS: A The internal family coping responses are those that the family relationships use as support. DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10 TOP: Coping Strategies KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. What is the main role of the nurse when assessing families and their coping strategies? a. Emotional support and reassurance b. Information and reassurance c. Emotional support and referral d. Elimination of the stressor ANS: B Families need information and reassurance. DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 10 TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. What is the best description of the current view of the family as a unit? a. Functioning together to provide security and support to its members b. Functioning to meet the needs of society and support its members c. A unit of two or more that shares common goals and mutual support d. A unit of two or more joined together by mutual bonds and identity ANS: D Friedman (1997) defined the family as “…two or more persons joined together by bonds of sharing and emotional closeness and who identify themselves as being part of the family.” DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 8 TOP: Family Role StructureKEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. A nurse reminds a patient that communication in the family unit involves continual exchange of information. Which is the best example of this concept? a. Determining the intent of the communication being sent b. Determining whether the communication is functional or dysfunctional c. Accepting individual differences d. Excluding emotional responses ANS: C Clear communication is a way of fostering a nurturing environment. Communication patterns in a functional family demonstrate an acceptance of individual differences, openness, honesty, and recognition of needs. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Family Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 23. What is the basis for the health–illness continuum? a. Prevention of acute illness b. Individual response to health or illness c. Promotion of health and wellness d. Variation in degree of health or illness ANS: D Currently, health and illness are viewed as relative states along a continuum. Individuals are at neither absolute health nor absolute illness but are in an ever-changing state of being. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: 2 | 5 TOP: Current View of Health-Illness Continuum KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 24. What should a nurse take into consideration regarding developmental tasks when planning patient care? a. All of the activities performed throughout life. b. Activities learned primarily in the middle years of life. c. Things to be learned and accomplished in each stage of life. d. All actions taken when confronted with specific problems. ANS: C Developmental processes are changes that present challenges that must be undertaken and mastered for a person to go on to the next stage successfully. DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 8 TOP: Developmental Tasks KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. Which behavior is not characteristic of a young adult’s developmental task? a. Living in his or her own apartment b. Accepting a place on the board of a community agency c. Interacting with a large group of friends d. Dating many different young women ANS: D As young adults enter their 30s and 40s, their focus is directed mainly toward raising a family and furthering their career. A heterosexual intimate relationship is not in keeping with developmental tasks. DIF: Cognitive Level: Comprehension REF: pp. 30-31 OBJ: 8 TOP: Developmental Tasks: Young Adulthood KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. What is included in the functional communication styles in a family? (Select all that apply.) a. Openness b. Subtlety c. Chitchat d. Spontaneity e. Self-disclosure ANS: A, D, E Functional communication is open and honest and has no subtlety or superficial chitchat. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9 TOP: Functional Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 2. A nurse makes a patient referral to a community resource. What benefit(s) will this referral provide? (Select all that apply.) a. Provision of helpful literature b. Ongoing and consistent assistance c. Reassurance to the family members that they are not alone d. A variety of free services e. Organization of a support group ANS: A, B, C, E Community resources can provide assistance, literature, and support in an ongoing and consistent manner, but the services are not always free. DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 12 TOP: Community Resources KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION 1. The process in which children mature and take on the values of their families and their society is called . ANS: enculturation Enculturation is the process of learning to be part of a culture. DIF: Cognitive Level: Comprehension REF: p. 26|p. 27|p. 33 OBJ: 3 TOP: Enculturation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. A nurse congratulates a patient for successfully coping with a family crisis. The state of having used coping strategies effectively is classified as . ANS: mastery Mastery is attained when coping skills are successful in coping with a crisis. DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10 TOP: Mastery KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 3. The nurse includes the family in patient care to maintain the family’s . ANS: self-esteem Self-esteem is supported and maintained when family is given opportunity to contribute to the planning of patient care. DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 8 TOP: Maintenance of Self-Esteem KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation Chapter 04: Health, Illness, Stress, and Coping Linton: Medical-Surgical Nursing, 7th Edition MULTIPLE CHOICE 1. What is the traditional view of health? a. Promotes optimal function. b. Views health and illness as separate concepts. c. Defines health as an absence of illness. d. Emphasizes the prevention of disease. ANS: B Traditionally, health and illness have been viewed as separate entities with a focus on the illness and not in attaining the highest quality of life possible when a cure is not possible. DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1 TOP: Traditional View of Health and Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 2. What is the current view of health? a. Promotes the highest quality of life possible, both mentally and socially. b. Includes mental, physical, social, and emotional adaptation to the environment. c. Includes the basic physiologic needs and self-actualization. d. Relies on alternative therapies for the treatment and cure of diseases. ANS: B A healthy person maintains stability and comfort by adapting physically, mentally, emotionally, and socially to internal and external events. DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1 TOP: Current View of Health and Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 3. During the initial gathering of data, a patient reveals a weight loss of 17 lb since the death of his spouse 5 weeks earlier. He says that he is not sleeping and has no appetite. What category of unmet needs should be considered by the nurse according to Maslow’s hierarchy of needs? a. Physiologic b. Safety and security c. Love and belonging d. Self-actualization ANS: A Physiologic needs include oxygen, fluids, and nutrition and must be met before the higher levels of needs are provided. DIF: Cognitive Level: Application REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 4. What is the major advantage of using Maslow’s hierarchy of needs when planning nursing care for patients? a. Establishes a nursing diagnosis. b. Improves problem-solving techniques. c. Prioritizes patient care. d. Establishes priorities of care. ANS: C Priorities for nursing care can be based on the level of human needs; physical needs take priority over security needs. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A nurse points out that a physiologic response to stress involves the total body. Which syndrome is this considered? a. General adaptation b. Local adaptation c. Negative feedback d. Total adaptation ANS: A General adaptation syndrome is the physiologic response of the whole body to stress. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 4 TOP: Stress Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 6. What are the ability to solve problems and to maintain self-confidence and the willingness to accept criticism incorporated in according to Maslow? a. Safety and security b. Self-esteem c. Self-actualization d. Love and belonging ANS: C Self-actualization is characterized by the ability to solve problems, the willingness to accept suggestions and criticism from others, and the maintenance of broad interests and communication skills. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2 TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies? a. General adaptation syndrome b. Local adaptation syndrome c. Counter-current response d. Neuroendocrine response ANS: B Local adaptation syndrome is a short-term, local response to a specific stressor. Examples include pain, blood clotting, and wound healing. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 | 6 TOP: Stress Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A nurse clarifies that a neuroendocrine response involves both the autonomic nervous system and the endocrine system. Which syndrome is this considered? a. Local adaptation b. Total adaptation c. Acute adaptation d. General adaptation ANS: D The neuroendocrine response primarily involves the autonomic nervous and endocrine systems and is considered part of the general adaptation syndrome, which is physiologic and affects the entire body. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 | 6 TOP: Stress Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. Which syndrome includes the alarm reaction stage, resistance stage, and exhaustion stage? a. Local adaptation syndrome b. General adaptation syndrome c. Total adaptation syndrome d. Absolute adaptation syndrome ANS: B After the initial alarm stage (of the general adaptation syndrome), the body stabilizes and physiologic processes return to normal levels. This is followed by the resistance stage. If the stressor lasts too long, the individual may enter the third stage of adaptation, which is exhaustion. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 4 TOP: Stress Response KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A nurse gives the example of when an individual becomes frightened and experiences an increased heart rate and mental activity along with increased blood flow to the skeletal muscles and dilated pupils. The person is experiencing an alarm reaction that helps the body defend against stressors. What type of response is the alarm reaction considered? a. Positive feedback response b. Negative feedback response c. Fight-or-flight response d. Homeostasis response ANS: C The alarm reaction causes the body to respond to stress physiologically. Hormone levels, heart rate, cardiac output, respiratory rate, oxygen intake, and mental energy are increased, and the pupils dilate. These reactions together are called the fight-or-flight response. DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 7 | 8 TOP: Stress Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A patient is being discharged from same-day surgery after a tonsillectomy. The nurse is aware that the patient will be in the phase of general adaptation syndrome, in which the body begins to heal after injury. Which stage is this considered? a. Alarm stage b. Resistance stage c. Exhaustion stage d. Initial stage ANS: B The resistance stage is characterized by adapting to the stressor. If the stressor can be overcome or repaired, as in a short-term illness or injury, the body begins to heal. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 4 TOP: Stress Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. An anxious co-worker who is to present a comprehensive report to the hospital board on innovative staffing patterns sits down at a table in the lunchroom and begins to tell you what will be presented in the report. Which coping strategy is this co-worker using? a. Event rehearsal b. Problem solving c. Event review d. Social support ANS: A Coping strategies include event rehearsal, confrontation, distancing or denial, self-control, social support, accepting responsibility, faith, problem solving, positive reappraisal, and event review. Event review is discussing situations. DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 9 TOP: Coping KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation 13. What is the best example for a nurse to use when explaining chronic illness? a. Acne b. Appendicitis c. Heart attack d. Asthma ANS: D Chronic illness, such as asthma, usually involves lifetime impairment or disability and requires long-term rehabilitation and medical or nursing treatment. Examples of chronic illness include coronary artery disease, diabetes, and endocrine disorders. Acne, appendicitis, and a heart attack are conditions that are acute in nature, although they may indicate a serious illness. DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1 TOP: Concept of Illness KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. A nurse assesses that smoking, drinking alcohol, and exercising compulsively may occur as responses to a stressful situation. What type of response should this be considered? a. External b. Withdrawal c. Denial d. Internal ANS: D Examples of internal resources are physiologic and psychologic responses such as smoking, drinking alcohol, eating, and crying. DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8 TOP: Adaptation to Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. Which type of response is demonstrated when an individual seeks help from family, friends, or a community resource during a time of stress? a. Internal b. External c. Physiologic d. Psychologic ANS: B Patients who deal with stress may use external responses, including help from family, friends, and service agencies in the community. DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8 TOP: Coping and Adaptation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. What is the term for activities directed toward maintaining or enhancing well-being against illness? a. Health promotion b. Health treatment c. Health evaluation d. Health assessment ANS: A Health promotion activities are directed toward maintaining or enhancing well-being as a protection against illness. DIF: Cognitive Level: Knowledge REF: pp. 48-49 OBJ: 5 TOP: Health Promotion KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. A home health nurse is assisting a patient who is chronically ill with congestive heart failure to reorder time. What is the best intervention to assist this patient? a. Encouraging the patient to get up earlier or to go to sleep later b. Developing a daily schedule that allows time for activities, as well as for medical regimens c. Giving up time-consuming activities such as watching television or answering e-mail messages d. Encouraging the patient to complete only one task a day ANS: B Reordering time is developing a schedule that includes not only a medical regimen, but it also includes social and interpersonal activities, as well as hobbies. DIF: Cognitive Level: Application REF: p. 49 OBJ: 14 TOP: Reordering Time KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. What type of illness are the common cold, appendicitis, and urinary tract infections considered? a. Chronic b. Disabling c. Emergency d. Acute ANS: D An acute illness or disease is one that has a relatively rapid onset and a short duration. DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1 TOP: Concept of Illness KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. What is the first step in helping patients to increase adaptability? a. Assess past methods of coping with stress. b. Suggest using past coping strategies. c. Determine external coping strategies. d. Determine what the patient perceives as stressful. ANS: A Nurses can help patients deal with stress by identifying the patient’s usual methods of coping or adapting. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 10 TOP: Adaptation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. How should a nurse describe a patient who has a functional interaction of the cognitive, affective, behavioral, and social dimensions of his personality? a. Effectively organized b. Personally satisfied c. Well rounded d. Mentally healthy ANS: D Mental health depends on the functional integration of the four dimensions of the personality. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them for decisions about her life. Which mental health characteristic is this patient lacking? a. Reality orientation b. Autonomous behavior c. Spontaneity d. Ethical decision making ANS: B Autonomy is a mark of mental health. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. What is an example of a positive stressor? a. Test anxiety b. Loss of a job c. Paying income tax d. Single motherhood ANS: A Test anxiety can be beneficial to promote study and sharpen focus. DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 7 TOP: Stress KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. Which action is an example of a person attempting to maintain homeostasis as a newcomer in a community? a. Joins a local church. b. Buys a new car. c. Stays in his or her apartment watching television. d. Spends hours writing e-mail messages to old friends. ANS: A The newcomer who attempts to balance the newcomer status with belonging is an example of homeostasis. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 TOP: Homeostasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 24. Which behavior best exemplifies developmental activities in a 13-year-old teenager? a. Going out with a group of friends b. Reading an exciting book c. Volunteering for the local hospital d. Choosing a career ANS: A Interacting in peer relationships is a major developmental task of this age group. DIF: Cognitive Level: Comprehension REF: p. 44 OBJ: 3 TOP: Growth and Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. In which stage is introspection a major characteristic? a. Middle-aged adult b. Middle childhood c. Early adulthood d. Older-age adult ANS: D Introspection is properly identified as an activity of older age. DIF: Cognitive Level: Knowledge REF: p. 44 OBJ: 3 TOP: Growth and Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 26. A nurse hears a 5-year-old patient who just started kindergarten uses rude vocabulary. What is the best response to this behavior? a. Ignore it. b. Speak to his teacher about it. c. Praise him when he speaks properly. d. Talk about it at the parent–teachers association. ANS: C Learned behaviors can be unlearned with rewards for the desired behavior. DIF: Cognitive Level: Application REF: p. 44 OBJ: 14 TOP: Behavioral Theory KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 27. Which patient is most likely to experience the greatest cultural impact on his coping with a chronic debilitating illness? a. A 26-year-old Latino man with a family b. A 30-year-old divorced white man with no dependents c. A 35-year-old Asian wife with a family d. A 65-year-old widowed black church pastor with married children ANS: A The Latino man will have to deal with the loss of his culturally expected role as the head of the household. DIF: Cognitive Level: Analysis REF: p. 44 OBJ: 9 TOP: Coping with Illness KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. A patient with low back pain confesses that he drinks heavily each night to help him sleep and control pain. What does this behavior exemplify? a. Alternate pain control methods b. Coping with a chronic condition c. Using a social coping mechanism d. Using a maladaptive coping method ANS: D This behavior is an example of maladaptive coping. Drinking is not an appropriate means of coping with chronic pain. DIF: Cognitive Level: Application REF: p. 46|p. 49 OBJ: 9 | 13 TOP: Coping with Illness KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 29. What information should a nurse provide to a Native American patient taking herbal remedies and nutritional supplements? a. Herbs and vitamins are not helpful. b. If herbs and vitamins are not harmful, then they will be integrated into the plan of care. c. Medical research has shown that such alternative remedies are a waste of money. d. In the hospital, no physician will prescribe anything other than accepted medical protocols. ANS: B Care planning for individuals with different cultural beliefs requires respect and individualization. DIF: Cognitive Level: Application REF: p. 44 OBJ: 10 TOP: Cultural Beliefs KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 30. When a patient is given a diagnosis of cancer, his first statement is, “What did I ever do to deserve God punishing me?” What does this exemplify? a. Maladaptive coping b. Behavioral emotionalism c. Spiritual distress d. Spiritual maladaptation ANS: C This is a response to spiritual distress. The patient is questioning the meaning of illness and suffering. DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 10 TOP: Spirituality KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 31. A star quarterback on the high school football team is injured in a motorcycle accident. He will be unable to play football again. Which patient problem is most appropriate when planning care specific to coping? a. Immobility b. Impaired self-concept c. Decreased socialization d. Inadequate comfort ANS: B Athletes who sustain injuries can have impaired self-concept related to their altered body image. DIF: Cognitive Level: Application REF: p. 45 OBJ: 11 TOP: Self-Concept KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 32. A wife of a critically injured husband has been at his bedside constantly for 2 days. As the nurse speaks to the wife, the wife sobs, “This is awful. I can’t take it anymore.” What is the wife experiencing? a. Fear b. Denial c. Compensation d. Stress ANS: D Long-term stress causes fatigue and an inability to solve problems. DIF: Cognitive Level: Application REF: p. 45 OBJ: 8 | 9 TOP: Emotions: Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 33. How does fear differ from anxiety? a. Fear is a useless emotion. b. Fear is an ineffective coping strategy. c. Fear is an irrational feeling. d. Fear is a response to a specific threat. ANS: D Fear is a response to a specific threat (e.g., a rattlesnake in the garden); anxiety is a response to a nonspecific threat (e.g., first day on a new job). DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 10 TOP: Emotions: Anxiety and Fear KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 34. An older Italian woman has an egg yolk in a bowl under her bed that she believes is absorbing the evil of her illness and making her feel better. Which action should a nurse implement? a. Move the egg yolk out of the way to the bathroom. b. Replace the egg yolk with a hard-boiled egg. c. Remove the egg for sanitary purposes. d. Include maintenance of the egg in the nursing care plan. ANS: D A nursing approach should help with coping, not incr

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