Questions & Knowledge Review
Questions And Answers.
A married male client with three children has lost his job and states that he feels useless.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
He is tearful, upset, and embarrassed. What is an appropriate objective of care for this
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
client?
jl
1. Limiting tearfulness
jl jl
2. Increasing self-esteem
jl jl
3. Controlling feelings of sadness
jl jl jl jl
4. Promoting acceptance by others - Verified ANS ✔✔ - 2. Increasing self-esteem
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
The loss of a job can precipitate negative feelings about the self and decrease self-esteem.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
Feelings should be expressed, not limited; attempting to decrease a client's crying often
jl jl jl jl jl jl jl jl jl jl jl jl jl
ends up worsening it. Crying is not necessarily an expression of sadness; other feelings
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
are involved. The focus should be on the client's self-acceptance, not acceptance by
jl jl jl jl jl jl jl jl jl jl jl jl jl
others.
jl
A 44-year-old client has been unable to function since her husband asked for a divorce 2
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
this situation?
jl jl
1. Social jl
2. Situational
jl
3. Maturational
jl
4. Developmental - Verified ANS ✔✔ - 2. Situational
jl jl jl jl jl jl jl jl jl jl
Situational crises involve an unanticipated loss, such as a divorce, that is threatening to the
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
client. Social crises involve multiple losses such as those occurring during major disasters.
jl jl jl jl jl jl jl jl jl jl jl jl jl
Maturational crises occur in response to stress experienced as one struggles with
jl jl jl jl jl jl jl jl jl jl jl jl
developmental tasks. Developmental (maturational) crises are associated with
jl jl jl jl jl jl jl jl
developmental tasks; divorce is not a developmental task.
jl jl jl jl jl jl jl jl
A resident in a nursing home recently immigrated to the United States from Italy. How does
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
the nurse plan to provide emotional support?
jl jl jl jl jl jl jl
1. By offering choices consistent with the client's heritage
jl jl jl jl jl jl jl jl
2. By ensuring that the client understands American beliefs
jl jl jl jl jl jl jl jl
3. By assisting the client in adjusting to the American culture
jl jl jl jl jl jl jl jl jl jl
4. By correcting the client's misconceptions about appropriate health practices - Verified
jl jl jl jl jl jl jl jl jl jl jl
ANS ✔✔ - 1. By offering choices consistent with the client's heritage
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
,Adherence to a plan of care is enhanced by the nurse's providing choices consistent with
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and
jl jl jl jl jl jl jl jl jl jl jl jl jl
biases should not influence or interfere with the implementation of appropriate care.
jl jl jl jl jl jl jl jl jl jl jl jl
Helping the client adjust to the American culture is not the priority at this time; care should
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
be adapted to the client's needs and culture. The person's cultural practices should not be
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
addressed unless they are detrimental to the person's health.
jl jl jl jl jl jl jl jl jl
A nurse should reassess an older adult client's needs and current plan of care when the
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
client's behavior indicates the development of what symptom?
jl jl jl jl jl jl jl jl
1. Confusion
jl
2. Hypochondriasis
jl
3. Additional complaints
jl jl
4. Increased socialization - Verified ANS ✔✔ - 1. Confusion
jl jl jl jl jl jl jl jl jl jl jl
The development of confusion indicates that the client's ability to maintain equilibrium has
jl jl jl jl jl jl jl jl jl jl jl jl
not been achieved and that further disequilibrium is occurring. Hypochondriasis and
jl jl jl jl jl jl jl jl jl jl jl
additional complaints do not indicate that the plan needs to be changed unless the client's
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
history demonstrates no prior use of these defenses. Increased socialization is a positive
jl jl jl jl jl jl jl jl jl jl jl jl jl
response to the plan of care that does not require reassessment.
jl jl jl jl jl jl jl jl jl jl jl
An injured child is brought to the emergency department by the parents. While interviewing
jl jl jl jl jl jl jl jl jl jl jl jl jl
the parents, the nurse begins to suspect child abuse. Which parental behaviors might
jl jl jl jl jl jl jl jl jl jl jl jl jl
support this conclusion? Select all that apply.
jl jl jl jl jl jl jl
1. Demonstrating concern for the injured child
jl jl jl jl jl jl
2. Focusing on the child's role in sustaining the injury
jl jl jl jl jl jl jl jl jl
3. Changing the story of how the child sustained the injury
jl jl jl jl jl jl jl jl jl jl
4. Asking questions about the injury and the child's prognosis
jl jl jl jl jl jl jl jl jl
5. Giving an explanation of how the injury occurred that is not consistent with the injury -
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
Verified ANS ✔✔ - 2. Focusing on the child's role in sustaining the injury
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
3. Changing the story of how the child sustained the injury
jl jl jl jl jl jl jl jl jl jl
5. Giving an explanation of how the injury occurred that is not consistent with the injury
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
The child is often made the scapegoat in the situation; the parents blame the child because
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
they have unrealistic expectations of the child. Discrepancies or inconsistencies in the
jl jl jl jl jl jl jl jl jl jl jl jl
history result from attempts to present a story that is not based in fact. Discrepancies
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
between the parental explanation for the child's injuries and the physical findings or
jl jl jl jl jl jl jl jl jl jl jl jl jl
discrepancies in the history that each parent gives are common because the information
jl jl jl jl jl jl jl jl jl jl jl jl jl
that is being provided is not based in fact. Abusive parents usually do not ask questions
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
about the injury or prognosis and demonstrate little or no interest in their child's well-being.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
A nurse is planning to teach a client about self-care. What level of anxiety will best enhance
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
the client's learning abilities?
jl jl jl jl
1. Mild jl
2. Panic jl
3. Severe jl
4. Moderate - Verified ANS ✔✔ - 1. Mild
jl jl jl jl jl jl jl jl jl jl
,Mild anxiety motivates one to action, such as learning or making changes. Higher levels of
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is
jl jl jl jl jl jl jl jl jl jl jl jl jl
severely reduced by panic. The perceptual field is greatly reduced with severe anxiety and
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
narrowed with moderate anxiety.
jl jl jl jl
A nurse is caring for depressed older adults. What precipitating factors for depression are
jl jl jl jl jl jl jl jl jl jl jl jl jl
most common in the older adult without cognitive problems? Select all that apply.
jl jl jl jl jl jl jl jl jl jl jl jl jl
1. Dementia
jl
2. Multiple losses
jl jl
3. Declines in health
jl jl jl
4. A milestone birthday
jl jl jl
5. An injury requiring hospitalization - Verified ANS ✔✔ - 2. Multiple losses
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
3. Declines in health
jl jl jl
Depression in the older adult is most often associated with the loss of family members and jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
health, particularly when associated with a chronic illness, frequently precipitates
jl jl jl jl jl jl jl jl jl jl
depression in older adults. Dementia is a cognitive problem. Research does not correlate
jl jl jl jl jl jl jl jl jl jl jl jl jl
the onset of depression with a milestone birthday in older adults. A traumatic injury does
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
not precipitate the onset of depression in the older adult as often as does a chronic illness.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
The nurse observes biting, rocking, sucking, and lags in intellectual development in a child.
jl jl jl jl jl jl jl jl jl jl jl jl jl
She also concludes the child is suffering from sleep disorders. What could be the reason
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
for the child's condition?
jl jl jl jl
1. Physical neglect
jl jl
2. Sexual abuse
jl jl
3. Physical abuse
jl jl
4. Emotional abuse - Verified ANS ✔✔ - 4. Emotional abuse
jl jl jl jl jl jl jl jl jl jl jl jl
The child may be neglected if the parent is having a mental illness such as psychosis.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
Sleep disorders, feeding disorders, biting, rocking, sucking, and lags in intellectual
jl jl jl jl jl jl jl jl jl jl jl
development are behavioral findings associated with emotional abuse. Physical neglect,
jl jl jl jl jl jl jl jl jl jl
sexual abuse, and physical abuse manifest in different sets of signs and symptoms.
jl jl jl jl jl jl jl jl jl jl jl jl jl
Which emotional condition may be apparent in a client with an addiction?
jl jl jl jl jl jl jl jl jl jl jl
1. Insomnia
jl
2. Social isolation
jl jl
3. Acute confusion
jl jl
4. Functional urinary incontinence - Verified ANS ✔✔ - 2. Social isolation
jl jl jl jl jl jl jl jl jl jl jl jl jl
Social isolation is an emotional condition that may be apparent in a client with an addiction.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
Insomnia, acute confusion, and functional urinary incontinence are physical, not
jl jl jl jl jl jl jl jl jl jl
emotional, conditions that may be apparent in clients with addiction.
jl jl jl jl jl jl jl jl jl jl
A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
debilitated state. The healthcare provider tells the client that she is too frail for surgery or
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
further chemotherapy. When making rounds during the night, the nurse enters the client's
jl jl jl jl jl jl jl jl jl jl jl jl jl
room and finds her crying. Which is the most appropriate intervention by the nurse?
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
, 1. Sit down quietly next to the bed and allow her to cry.
jl jl jl jl jl jl jl jl jl jl jl jl
2. Pull the curtain and leave the room to provide privacy for the client.
jl jl jl jl jl jl jl jl jl jl jl jl jl
3. Explain to the client that her feelings are expected and they will pass with time.
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
4. Observe the length of time the client cries and document her difficulty accepting her
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
impending death. - Verified ANS ✔✔ - 1. Sit down quietly next to the bed and allow her to
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
cry.
jl
Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
client's behavior and provides an opportunity for the client to verbally express feelings if
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
desired. Pulling the curtain and leaving the room to provide privacy for the client may make
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
the client feel that the behavior is wrong or is annoying others. Also, it abandons the client
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
when support is needed. Explaining to the client that her feelings are expected and they
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
will pass with time closes off communication and does not provide an opportunity for the
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
client to talk about feelings. Also, it provides false reassurance. The length of time she
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
cries is unimportant at this time. Assuming that she is having difficulty accepting her
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
impending death is a conclusion without enough information.
jl jl jl jl jl jl jl jl
Which of these are symptoms of depression commonly observed in older adults? Select all
jl jl jl jl jl jl jl jl jl jl jl jl jl
that apply.
jl jl
1. Fatiguejl
2. Sadnessjl
3. Agitation
jl
4. Increased sleep
jl jl
5. Increased appetite - Verified ANS ✔✔ - 1. Fatigue
jl jl jl jl jl jl jl jl jl jl jl
2. Sadnessjl
3. Agitation
jl
Symptoms of depression that are often observed in older adults include fatigue, sadness,
jl jl jl jl jl jl jl jl jl jl jl jl
and agitation. Insomnia is more likely than increased sleep to occur in depressed older
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
adults. Anorexia, rather than increased appetite, is more likely to occur in depressed older
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
adults.
jl
A nurse is aware that after the administration of alprazolam (Xanax) is started, it is
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
important to observe the client for side effects. What is the nurse's initial action?
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
1. Measuring the client's urine output
jl jl jl jl jl
2. Examining the client's pupils daily
jl jl jl jl jl
3. Checking the client's blood pressure
jl jl jl jl jl
4. Monitoring the abdomen for distention - Verified ANS ✔✔ - 3. Checking the client's
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
blood pressure
jl jl
Orthostatic hypotension is a common side effect of alprazolam (Xanax) that occurs early in jl jl jl jl jl jl jl jl jl jl jl jl jl
therapy. Central nervous system depression is not an early side effect, but it may occur
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
after prolonged use. An alteration in urine output is not a common side effect, but it may
jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl
occur after prolonged use. Distention is not a common side effect, but distention from
jl jl jl jl jl jl jl jl jl jl jl jl jl jl
constipation may occur after prolonged use.
jl jl jl jl jl jl