NUR 155 Exam 3 | Questions and Answers | 2025 Update | 100% Correct- Galen

NUR 155 Exam 3 | Questions and Answers | 2025 Update | 100% Correct- Galen 1. A client was given the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the nurse’s attorney explain is applied to this situation? 1. Common law 2. Public law 3. Administrative law 4. Stare decisis 2. The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement and enforce the nurse practice act regulations? 1. Statutory law 2. Administrative law 3. Common law 4. Public law 3. The admitting nurse explains the process of signing forms to allow for the client's insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. Which type of law did the nurse explain to the client? 1. Contract law 2. Tort law 3. Statutory law 4. Administrative law 4. The nurse forgets to put the call light within the client's reach and then leaves the room. The client reaches for it and falls out of bed. With what should the nurse expect to be charged? 1. Assault 2. Battery 3. Negligence 4. Criminal intent 5. A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action6. Before applying for re-licensure, the nurse attends continuing education programs. Which action is the nurse performing to adhere to the state board of nursing expectation? 1. Licensure 2. Competency 3. Credentialing 4. Certification 7. The high school graduate desiring to attend nursing school reviews the schools for accreditation. Which regulatory body’s actions is the student analyzing? 1. State board of nursing 2. NLNAC 3. CCNE 4. ANA 8. MCSA The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action? 1. Physician 2. Pharmacist 3. Hospital 4. Nurse 9. A hospital receives notice of being sued for an action performed by a nurse. The nurse realizes that which doctrine is being implemented in this c 1. Contractual relationship 2. Stare decisis 3. Respondent superior 4. Res Ipas loquitur 10. A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. "Just sign the form, and I'll make sure your physician talks to you before he begins the procedure." 2. "I'll explain whatever you don't understand." 3. "You should have asked your physician when he was in here." 4. "I'll call your physician back in the room to answer your questions." response.11. The client presents her hand when the nurse makes this statement: "I need to start an IV so you can get your antibiotics." Which behavior did the client demonstrate? 1. Informed consent 2. Express consent 3. Implied consent 4. Compliance 12. An adult client who cannot read needs surgery and is competent to make his own decisions. What is the best action that the nurse should take? 1. Tell the client in the nurse's own words what the surgical procedure involves. 2. Read the consent form to the client and have the client state understanding. 3. Make sure the physician explains the procedure to the client. 4. Have a family member who can read sign the consent form. 13. An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent? 1. The physician should have the client's wife sign the consent form. 2. The physician should wait until the effects of the medication wear off and have the client sign the form. 3. Because the client has been medicated, the nurse should thoroughly explain the consent form to the client. 4. This would be considered an emergency situation and consent would be implied. 14. A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. Which action should the nurse take? 1. Read the consent form and have the client sign it anyway. 2. Explain the form to the best of the nurse’s ability using pictures and gestures. 3. Have the hospital interpreter explain the procedure. 4. Proceed with surgery, as implied consent would be the case in this situation. 15. The nurse manager learns that vital signs delegated to unlicensed assistive personnel (UAP) were not recorded accurately. With which care provider should the manager discuss this finding? 1. The UAP 2. The nurse3. Both the UAP and the nurse 4. The team leader 16. A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the client's back and arms. When questioned, the client is distracted and ambiguous with her answers. Which action should the nurse take? 1. Report the situation to law enforcement. 2. Report the situation to social services. 3. Question the adult child who brought the client to the ED. 4. File a written report in the client's chart. 17. A nurse who has been a longtime employee of a hospital, providing bedside care to clients, was seriously injured and is paralyzed from the shoulders down, with limited use of the upper arms. Through rehabilitation, the nurse is able to mobilize with a wheelchair and has no cognitive or psychological deficits. The nurse wants to return to the same position held prior to the injury. Under the guidelines of the ADA, what should the hospital do? 1. The hospital is required to accommodate the nurse. 2. The hospital must find another job for the nurse. 3. The hospital should claim undue hardship to accommodate this nurse. 4. The hospital terminate the nurse's employment. 18. A nurse on the unit notices that a co-worker exhibits a pattern of behavior suggestive of drug abuse. What should the nurse do? 1. Report the situation to the unit charge nurse. 2. Send an anonymous letter to the director of nursing. 3. Let other co-workers know about the situation. 4. Report the situation, then let management take care of it. 19. A nurse's co-worker makes a practice of telling offensive jokes or stories with a sexual undertone during the shift. Which action should the nurse take first? 1. Ignore the co-worker and walk away. 2. Report the incident to the nurse manager. 3. Tell the co-worker to stop the activity because the conduct is offensive. 4. Ask to be scheduled opposite this co-worker.20. A nurse who is opposed to abortion works in a hospital where abortions are performed. According to the Supreme Court's conscience clause, which action should the nurse take? 1. The nurse should not take action, because the nurse cannot interfere with a woman's constitutional right to privacy. 2. The nurse should voluntarily terminate employment. 3. The nurse should counsel women before they have an abortion. 4. The nurse should refuse to participate in abortions. 21. A client woke in the middle of the night, confused and unaware of the surroundings. Although the call light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell. Which element of malpractice should the client’s attorney realize is missing in this case? 1. Foreseeability 2. Damages 3. Injury 4. Duty 22. A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter placed, saying "That's not part of the surgery." What should the nurse do? 1. Explain that this is part of the surgical prep and continue with the procedure. 2. Explain that the client has already signed the consent, and place the catheter. 3. Respect the client's wishes and document accordingly. 4. Offer to call the physician. 23. The nurse documents in a client's medical record: "The client is a drug addict and is always asking for more medication than what is necessary." With what might the nurse be charged? 1. Defamation 2. Slander 3. Libel 4. Incompetence 24. The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize that these laws apply? 1. Giving CPR to a client brought to the emergency department when the client later is found to have a "Do Not Resuscitate" order 2. Giving first aid to a child injured in a sporting event 3. Permitting a nursing student to try to insert an airway in an unconscious client 4. Leaving the scene of an emergency to call for help 5. Helping deliver the baby of a neighbor during a snowstorm25. When providing client care the nurse demonstrates practices that are designed to provide legal protections from liability. Which actions is the nurse demonstrating? Standard Text: Select all that apply. 1. Checking the client’s name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 4. Delegating only those tasks that he or she can’t personally perform 5. Reviewing the five rights of medication administration when the client states, “This doesn’t look like my usual pill” 26. The clinical nursing instructor determines that a nursing student understands the legal responsibilities to clients when providing care. What did the instructor observe to come to this conclusion? Standard Text: Select all that apply. 1. Prepared to discuss the client’s medical diagnosis in pre-conference 2. Overheard stating, “My care is held to the same standards as that of the unit nurses” 3. Offers to stay with the client who is about to experience a painful diagnostic procedure 4. Addresses the staff and clients respectfully and by their full names 5. Asks for help with a dressing change involving techniques he or she has not yet performed alone 27. While working a scheduled shift the nurse focuses on actions to protect the privacy of a client with local notoriety. What actions should the nurse take at this time? Standard Text: Select all that apply. 1. Secure the client’s medical record. 2. Review the client’s care with the media. 3. Remove the client’s name from the door. 4. Permit family to view the client’s record. 5. Fax the client’s lab values with a cover sheet. 28. The nurse manager is concerned that a staff nurse’s care demonstrates gross negligence. What actions did the manager use to make this determination? Standard Text: Select all that apply.1. Removed a client’s central line 2. Reconnected contaminated intravenous tubing to a client 3. Accessed the computerized documentation system with a password 4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom 5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel Chapter 5 1. A student is attending a school with a high first-time pass rate on the NCLEX®. Which student statement articulates a belief that the nursing student has about faculty in the program? 1. Expect high academic standards from their students 2. Are concerned with job placement of their graduates 3. Are most concerned with the successful licensure of each student 4. Work hard to make sure students are successful 2. A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing? 1. Human dignity 2. Social justice 3. Autonomy 4. Altruism 3. Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents’ decision? 1. Showing respect for the family 2. Respecting the parents' decision 3. Referring the parents to social services 4. Asking to be assigned to a different client 4. A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an afterhours clinic. Which professional value is the nurse demonstrating? 1. Human dignity 2. Altruism 3. Social justice4. Integrity 5. A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client's scheduled procedure; and documented the situation in the client's medical record. What did this nurse demonstrate? 1. Altruism 2. Integrity 3. Social justice 4. Human dignity 6. A pregnant client says her main concern is that her baby will be born healthy, even though she admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling? 1. Values transmission 2. Values clarification 3. Morals 4. Ethics 7. A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification? 1. Choosing 2. Prizing 3. Acting 4. Clarifying 8. A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered by the physician. Which action demonstrates the nurse's respect for the client's autonomy? 1. Telling the client that he will have to "tough it out" 2. Calling the physician for further orders 3. Telling co-workers that this client has no pain tolerance 4. Believing the client is drug seeking 9. A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning?1. "This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make." 2. "I need to try and help the family understand the client's decision so they can work through this situation together." 3. "This client's health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death." 4. "The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die." 10. The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision? 1. Teleological theory 2. Deontological theory 3. Utilitarianism 4. Caring theory 11. A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling? 1. Autonomy 2. Justice 3. Beneficence 4. Nonmaleficence 12. The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent? 1. "I won't lie to you. It may be easier for you if you step out until we get the line in." 2. "We'll take every care not to hurt your child." 3. "It shouldn't be too bad and I'll be quick." 4. "We do this all the time, so don't worry." 13. A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check forcall light placement before leaving a client’s room. What behavior did the student demonstrate? 1. Justice 2. Fidelity 3. Responsibility 4. Accountability 14. The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code? 1. It is a formal statement. 2. It contains the same standards as legal standards. 3. It is shared by group members. 4. It reflects legal judgments. 5. It serves as a standard for professional actions. 15. A 20-year-old client with Down syndrome is diagnosed with an illness. Even though the client is able to live in an assisted environment and work part-time for a local bookstore, the parents of the client are adamant about not initiating a course of treatment whose side effects are unknown with Down syndrome clients. According to the nursing code of ethics, to whom is the nurse's first loyalty? 1. The client 2. The parent 3. The physician 4. The nurse 16. A hospice nurse has been working closely with a client who, on several occasions, has asked about guidance and support in ending her life. What information should the nurse use when making an ethical and moral decision about this client’s request? 1. Passive euthanasia is an easy decision to arrive at. 2. Legal issues are not the same as moral or ethical ones. 3. Active euthanasia is supported in the Code for Nurses. 4. Assisted suicide is illegal in all states. 17. A client with terminal cancer is refusing food and fluids, and pushes the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." What should the nurse do? 1. Honor the family's wishes and have them sign a consent form.2. Talk to the physician so he or she can move forward with the family's wishes. 3. Honor the client's refusal and help the family come to terms with the situation. 4. Take the case to the hospital's ethics committee. 18. A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, what must the nurse do? 1. Honor the client's wishes. 2. Not disclose any information to anyone. 3. Respect the client's privacy and confidentiality. 4. Communicate only necessary information. 19.The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client? 1. Help the client look for available community resources that may be of assistance. 2. Tell the client that she needs to take the prescribed amount. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss. 20. The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble? Standard Text: Select all that apply. 1. Promote health. 2. Restore health. 3. Inform the public about minimum standards of nursing conduct. 4. Provide self-regulation in the profession. 5. Prevent illness. 6. Alleviate suffering. 21. The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a client’s health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse? Standard Text: Select all that apply. 1. Reporting a medication error that he was responsible for making 2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the health care provider to clarify a confusing prescription for a client’s pain22. The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decisionmaking process? Standard Text: Click and drag the options below to move them up or down. Choice 1. Interviewing the client regarding details of the problem Choice 2. Discussing the various results of the identified possible actions to resolve the problem Choice 3. Determining what, if any, ethical issues exist Choice 4. Determining whether affected parties are in ethical conflict Choice 5. Assessing all involved parties concerning their ethical beliefs regarding the problem 23. A client with lung disease is strongly urged to stop smoking but likes to smoke and does not know what to do. In what order should the nurse take the following actions to help this client clarify values? Standard Text: Click and drag the options below to move them up or down. 1. Choose freely. 2. List alternatives. 3. Affirm the choice. 4. Act with a pattern. 5. Examine consequences of choices. 6. Examine feelings about the choice. 24. The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment? Standard Text: Select all that apply. 1. Discuss codes of ethics with the students. 2. Recommend that the students avoid ethical issues. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences.Chapter 36 1. The continuous quality improvement team is monitoring the nursing care of cleancontaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection 2. The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected 3. A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this client’s care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. 4. After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer 5. The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top. 6. The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? 1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes. 7. The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the client's permission. 4. has to obtain special assessment equipment. 8. A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure ulcer development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development. 9. A client’s laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure 10. A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause 1. decreased oxygen supply to tissues. 2. suppression of the inflammatory process necessary for healing. 3. a decrease in the amount of nutrients such as glucose in the blood.4. blood vessel constriction, which impairs waste product removal. 11. On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? 1. Notify the client's surgeon. 2. Cover the area with a large saline-soaked dressing. 3. Position the client in bed with knees bent. 4. Pack the wound with nonadherent gauze. 12. A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client’s legs? 1. Defer the assessment because the stockings are in place. 2. Remove the stockings for this assessment. 3. Review the morning assessment, but don't repeat it unless a problem occurs. 4. Assess the skin when the client removes the stockings at bedtime. 13. Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take? 1. Place a tourniquet above the wound. 2. Remove the dressing and place direct pressure on the wound. 3. Add an additional dressing to the wound without removing the original. 4. Remove the dressing and replace it with a new sterile dressing. 14. The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected? 1. Clean areas of granulation tissue 2. Exudate in the bottom of the wound 3. A pus-coated area on the side of the wound 4. Intact skin at the edge of the wound 15. The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury16. The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used. 17. The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears. 18. The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? 1. Keep the head of the client's bed at 30 degrees. 2. Coat the client's back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement. 19. Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three 20. The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The client's serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change.4. Unlicensed assistive personnel (UAP) followed a right side–back–left side–back turning schedule. 21. The nurse has applied an aquathermia pad to a client's back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this request? 1. Because this client's thermal tolerance is higher than normal, increasing the temperature is necessary. 2. This client may be experiencing a rebound effect from the application of moist heat. 3. Adaptation of the thermal receptors often results in the decreased sensation of warmth. 4. The aquathermia pad should be replaced with a standard hot pack. 22. The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Poor skin turgor. 2. Elevated body temperature. 3. Diminished pain sensation. 4. Thin epidermis. 5. Dry skin. 23. A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? Standard Text: Select all that apply. 1. Minimal tissue loss. 2. Closure of the wound will occur within 5 days. 3. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater. 24. A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase? 1. Inflammatory 2. Proliferative 3. Maturation 4. Remodeling25. A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing? 1. Exudative 2. Proliferative 3. Inflammatory 4. Maturation 26. While changing a client’s dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wound’s drainage? 1. Purulent 2. Serous 3. Sanguineous 4. Serosanguinous 27. The nurse documents that a client’s postoperative wound is purosanguinous. What did the nurse assess in this client’s wound? 1. Water and red blood cells 2. Pus and red blood cells 3. Watery drainage 4. Pus 28. The nurse is assessing a client’s pressure ulcer. To determine the depth of the ulcer, the nurse should take which action? 1. Measure the width. 2. Measure the length. 3. Insert a sterile swab into the deepest part of the wound. 4. Identify where on the face of a clock the ulcer is located. 29. A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate? 1. Impaired Skin Integrity 2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection 30. A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client’s wound? Standard Text: Select all that apply.1. Cover it with transparent film. 2. Apply a damp-to-damp normal saline dressing. 3. Cover it with a dry dressing. 4. Irrigate the wound. 5. Apply impregnated hydrogel. 31. The nurse is preparing to irrigate a client’s abdominal wound. In which order should the nurse perform this irrigation? Standard Text: Click and drag the options below to move them up or down. Choice 1. Dry the area around the wound. Choice 2. Insert the catheter into the wound until resistance is met. Choice 3. Remove and discard clean gloves. Choice 4. Apply clean gloves. Choice 5. Irrigate until the solution flows clear. Choice 6. Select a syringe with a catheter attached or with an irrigating tip. 32. A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? Standard Text: Select all that apply. 1. The application of cold dilates blood vessels. 2. The application of cold constricts blood vessels. 3. The application of cold decreases inflammation. 4. The application of cold reduces localized pain. 5. The application of cold provides a calming, sedative effect. 33. During morning care, unlicensed assistive personnel observe a client’s abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do? 1. Reinforce the wound with supplies on the client’s bedside table. 2. Document that the bath was completed, and the condition of the dressing. 3. Complete the bath, then report the change to the nurse. 4. Report the dressing changes to the nurse immediately. 34. The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging? Standard Text: Select all that apply. 1. Finger 2. Forearm 3. Upper leg4. Lower leg 5. Upper arm 35. The nurse is preparing to apply a moist aquathermia pack to a client’s left upper leg. In which order should the nurse prepare and apply this treatment? Standard Text: Select all that apply. 1. Use tape or gauze ties to hold the pad in place. 2. Set the desired temperature according to the manufacturer’s instructions. 3. Apply the pad to the body part. The treatment is usually continued for 30 minutes. 4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. 5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use. Chapter 37 1. The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase 2. The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively. 3. The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment5. Maintain NPO status 4. The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery 5. The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls 6. The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have. 7. The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation 8. The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head 9. The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first?1. Level of consciousness 2. Dressing 3. Drains 4. Skin color 10. The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls 11. A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. "These exercises help prevent pneumonia." 2. "The doctor ordered the exercises." 3. "All surgical clients must do these exercises." 4. "These exercises prevent thrombophlebitis." 12. The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place 13. The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests 14. The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client’s risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours.3. Monitor intake and output every 2 hours. 4. Provide for early ambulation. 15. A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive. 16. The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother’s maiden name 17. The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask 18. The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the client's blood pressure. 4. Clean the stockings. 19. The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube.3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents. 20. The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes 21. The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment. 22. The nurse is planning a perioperative client’s needs upon discharge. What should be included when determining these needs? Standard Text: Select all that apply. 1. Client’s abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home health care services 23. The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Standard Text: Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation. 24. A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Standard Text: Select all that apply.1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group. 25. During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest. 26. The nurse is preparing to change the dressing on a client’s postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing. Standard Text: Click and drag the options below to move them up or down. Choice 1. Assess the location, type, and odor of wound drainage. Choice 2. Remove the outer dressing. Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. Choice 4. Remove the under dressing. Choice 5. Apply clean gloves. Choice 6. Place the soiled dressing in a moisture-proof bag. 27. The nurse is planning to remove the sutures from a client’s surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision. 28. The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.29. The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet. 30. The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Standard Text: Select all that apply. 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose. 31. The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? Standard Text: Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon 32. The nurse has removed the sutures from a client’s surgical wound. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon. 33. A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Standard Text: Select all that apply.1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage 34. The nurse is completing a preoperative assessment with a client. What should this assessment include? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate 35. A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this client’s degree of risk for this major surgical procedure? Standard Text: Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status Chapter 38 1. During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? 1. Use the clock face as a format for describing the position of food on meal trays. 2. Provide all teaching materials in very large font. 3. Ensure that the client has assistance when ambulating. 4. Use only nonirritating soaps for bathing. 2. A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss4. Loss of ability to smell 3. A client has been treated for diabetes mellitus since childhood. Currently, the client’s blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell 4. The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? 1. Schedule a Weber and Rinne test. 2. Observe the client's interaction with significant others. 3. Use an otoscope to visualize the inner ear. 4. Confront the client with the nurse's suspicion. 5. The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide? 1. Expect that the child will be enrolled in a special hearing intervention program immediately. 2. Keep your child in a quiet environment until additional testing is done. 3. Interventions to support hearing are not useful until the child is at least 9 months old. 4. Hearing loss is not serious until 1 year of age. 6. The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room. 7. The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention? 1. Walk slightly behind the client. 2. Walk 1 foot in front of the client. 3. Walk on the right side of the client. 4. Walk on the left side of the client.8. An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state? 1. As reversible confusion 2. As sundown syndrome 3. As delirium 4. As dementia 9. The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client? Standard Text: Select all that apply. 1. Speech 2. Stimuli 3. Receptor 4. Perception 5. Impulse conduction 10. A client can be aroused only with extreme or repeated stimuli. How should the nurse document this client’s behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose 11. The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning? 1. Background noise such as music will keep this client calm. 2. Activities should be scheduled at the same time each day. 3. Pain mediation will increase dementia. 4. It is important to talk with the client throughout procedures. 12. The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes13. The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement? 1. Use short phrases. 2. Overarticulate words. 3. Vary the volume of the voice. 4. Face the client during conversation. 14. A client is experiencing changes in taste. What can the nurse do to improve this client’s gustatory sense? Standard Text: Select all that apply. 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures. 15. The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners 16. The nurse documents that a client is fully conscious. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Client responded to verbal stimuli. 2. Client responded to written words. 3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert. 17. A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this client’s response to sensory stimuli as being due to which factor? 1. Lifestyle2. Developmental stage 3. Culture 4. Illness 18. The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Excessive sleeping 2. Confusion at night 3. Anger over minor issues 4. Easily distracted 5. Sitting quietly reading a book 19. The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Standard Text: Select all that apply. 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tests 20. A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the client’s sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment 21. The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Standard Text: Select all that apply. 1. Client has severe pain. 2. Client has impaired vision. 3. Client is unable to ambulate. 4. Client is on medication that alters sensory perception. 5. Client has no family in the immediate area.22. The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client? 1. Social Isolation 2. Risk for Impaired Skin Integrity 3. Disturbed Sensory Perception 4. Risk for Injury 23. The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on beside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and care of hearing aid. 4. Client demonstrates difficulty with problem solving. 24. A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Standard Text: Select all that apply. 1. Eliminate unnecessary noise. 2. Keep eyeglasses within reach. 3. Place a calendar in the room, and identify each day. 4. Keep the room well lit during waking hours. 5. Provide dark glasses. 25. Which recent change, reported by a client’s family, would indicate that the client’s hearing ability is decreasing? Standard Text: Select all that apply. 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly 26. The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Sleeplessness 2. Anxiety 3. Apathy4. Racing thoughts 5. Somatic complaints Chapter 42 1. The nurse elects to use a scale of stressful life events to assess the level of a newly admitted client's stress. How should the nurse explain the use of this scale to the client? 1. "We will consider only the negative life events that have happened to you recently." 2. "You should try to remember any stressful event that has occurred to you in the last 10 years to include in the scale." 3. "This scale will give us a definite stress level number that can be used to compare your stress to that of others your age." 4. "This scale will give us some idea about your stress related to both positive and negative recent events in your life." 2. The client has just received news of the death of a relative. Over the next few hours, what physiologic response should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event? 1. Drop in blood pressure from 130/80 to 120/75 2. A more bounding pulse 3. Slight increase in urine output 4. Some decrease in oxygen saturation 3. The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety? 1. The student's perception and learning is enhanced. 2. The student's attention is focused solely on studying for the examination. 3. The student's only topic of conversation is the examination. 4. The student cannot talk about the examination without crying. 4. While attempting to choose a nursing diagnosis, the nurse must decide whether the client is experiencing anxiety or fear. What key point would help the nurse make this decision? 1. Anxiety is a milder form of fear. 2. Fear results in a physiologic response, whereas anxiety is psychologic. 3. The source of fear is identifiable, but anxiety may be vague. 4. Anxiety is generally based in reality, fear is not.5. The new nurse feels overwhelmed by the demands of working on a busy acute care unit and maintaining a growing family. What strategy should this nurse employ to lessen this stress? 1. Spend the lunch hour completing documentation while eating a sandwich. 2. Set the alarm earlier in order to get to work early. 3. Focus on work instead of on family until more familiar with the environment. 4. Differentiate between "have to do" and "nice to do" at work. 6. The nurse is caring for a critically ill child. While the nurse is preparing to administer a treatment to the child, the child's mother becomes distraught and begins to cry loudly while stroking the child's face. What is the nurse's best response to this occurrence? 1. Tell the mother that she needs to control herself for the benefit of her child. 2. Distract the mother by having her straighten the linens on the bed. 3. Explain the procedure that will occur with the treatment. 4. Take the mother out of the room and comfort her. 7. A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the nurse do in response to this outburst? 1. Call the charge nurse and refuse to take care of this client until he is under control. 2. Apologize to the client for the unit rules, but tell him the rules must be followed. 3. Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable. 4. Tell the client that he is acting like a child and that such behavior will not be tolerated. 8. A client tells the nurse about being laid off from work, the spouse wanting a divorce, and being ill with a chest cold for a month. What statement should the nurse make that reflects understanding of a client in crisis? 1. "Once you reach the crisis state, you may remain there for several months until you recover." 2. "People generally find it easier to work through a crisis if someone is working with them." 3. "Men often handle crisis better individually, whereas women do better with a counselor." 4. "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible." 9. The nurse manager suspects the nursing staff is experiencing burnout because of complaints and an increase in absenteeism. The nurses also appear tired and anxious. What can the manager do to help reduce this burnout?1. Ask the physician staff to take over some of the tasks they routinely ask the nurses to do. 2. Make certain that the nurses are well prepared for their responsibilities. 3. Assign each nurse to spend 30 minutes with the hospital psychologist daily. 4. Ask administration to require 30 minutes of exercise at the end of each shift. 10. The nurse identifies that a client has not met the expected outcome established for the nursing diagnosis Ineffective Individual Coping. What should the nurse do first? 1. Revise the nursing diagnosis. 2. Reassess the patient, looking for previously unknown stressors. 3. Rewrite the interventions used to address the problem. 4. Explore reasons why the outcome was not achieved. 11. The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for the nurse to understand the client's needs. The nurse suspects the client has progressed to which anxiety level? 1. Mild 2. Moderate 3. Severe 4. Panic 12. The physician has just told the client that the results of a biopsy performed yesterday reveal no malignancy. During discharge teaching, the nurse finds the client to be easily distractible and unable to focus. What is the nurse's best interpretation of this situation? 1. The client did not understand that there is no malignancy. 2. Anxiety can result from both positive and negative stimuli. 3. Because there is no malignancy present, the client feels there is no need for teaching. 4. These findings reflect mild anxiety, but the client should retain information taught despite this distractibility. 13. A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What defense mechanism is this client exhibiting? 1. Compensation 2. Denial 3. Displacement 4. Identification 14. The victim of domestic abuse tells the nurse, "I know my spouse didn't mean to hurt me. The situation just got out of hand." The nurse recognizes that the client is exhibiting which defense mechanism?1. Intellectualization 2. Introjection 3. Projection 4. Minimization 15. The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the client's husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism? 1. Reaction formation 2. Rationalization 3. Regression 4. Reparation 16. The parents of a school-age client who was sexually abused by a minister want to know why someone who is sexually attracted to children would choose to go into the ministry. The nurse explains that the displacement of sexual drives into socially acceptable activities is which type of defense mechanism? 1. Repression 2. Sublimation 3. Substitution 4. Undoing 17. The assessment of a client undergoing testing for an anxiety disorder reveals an increased heart rate, an increased respiratory rate, a low-normal hematocrit, and a low blood sugar. Which finding is contrary to what could be explained by a normal response to anxiety? 1. The heart rate 2. The respiratory rate 3. The hematocrit 4. The blood sugar 18. A newly hospitalized client is demonstrating anxiety and stress. What intervention can the nurse plan to help this client? 1. Explain all procedures in detail before performing them. 2. Let the client make the majority of decisions about the plan of care. 3. Control the environment of healing. 4. Demonstrate staff competence by using multiple nurses for care.19. The parents of an adolescent who has a history of depression are concerned because the physician has prescribed an SSRI antidepressant for their child. What information should the nurse use to formulate a response to these parents' concerns? 1. These medications are addictive and difficult to discontinue when the depressive incident is past. 2. It is difficult for teenagers to manage the dosage regimen for many of these drugs because they must be taken with a full meal. 3. There is an FDA warning regarding antidepressant use in teenagers and the increased risk of suicide. 4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3 to 4 days of the first dose. 20. A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this client’s behavior? 1. The parents may have been abusing this child. 2. The child is probably developmentally delayed secondary to multiple hospitalizations. 3. The child is reacting as a normal 2-year-old. 4. The child could be suffering from a clinical depression. 21. During an assessment, the nurse learns that a client has been having periodic upper respiratory infections since experiencing the death of a close family member. The nurse identifies this client’s rea