NURS 232 Exam #3

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?

"This scale will give us some idea about your stress related to both positive and negative recent events in your life."

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?

2. A more bounding pulse: During this shock phase, the sympathetic nervous system is stimulated, resulting in increased myocardial contractility, which would be reflected in the client as a bounding pulse

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.

With mild anxiety, the student's perception and learning will be enhanced.

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?

The source of fear is identifiable, but anxiety may be vague.: The source of fear is identifiable, but anxiety is vague.

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?

Differentiate between "have to do" and "nice to do" at work.

This nurse should differentiate between what is essential care at work and what is nice to do but can be eliminated on days when stress is high and resources are limited.

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?

. Take the mother out of the room and comfort her.In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her.

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?

Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable.

the client that it is understandable that he is upset serves to show that the nurse accepts his right to be angry, but that the anger is the client's.

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?

2. "People generally find it easier to work through a crisis if someone is working with them."

: In general, people are more successful in working through a crisis if they have someone to help them.

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?

. Make certain that the nurses are well prepared for their responsibilities.

Rationale 2: In this situation, the best alternative is to be certain that the nurses are well prepared for the responsibilities of their jobs, as the frustration of being unprepared leads to burnout.

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?

4. Explore reasons why the outcome was not achieved.

Rationale 4: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

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?

severe

Rationale 3: At severe levels of anxiety, communication is difficult to understand.

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?

Anxiety can result from both positive and negative stimuli.

A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What defense mechanism is this client exhibiting?

. Denial

Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them.

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?

Minimization

Rationale 4: Minimization is not acknowledging the significance of a behavior.

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?

reaction formation

Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel

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?

sublimation

Rationale 2: Sublimation is displacement of sexual drives into more socially acceptable activities.

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?

4. The blood sugar

Rationale 4: The blood sugar generally increases because of the release of glucocorticoids and gluconeogenesis.

A newly hospitalized client is demonstrating anxiety and stress. What intervention can the nurse plan to help this client?

3. Control the environment of healing.

Rationale 3: The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable.

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?

3. There is an FDA warning regarding antidepressant use in teenagers and the increased risk of suicide.

Rationale 3: The major concern regarding use of antidepressants and teenagers is the increased risk for suicide.

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?

3. The child is reacting as a normal 2-year-old.

Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner

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 reaction to stress as being a

stimulusS

rationale:s tress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that can increase the individual's vulnerability to illness.

After hearing the diagnosis of cancer, a client becomes withdrawn and refuses to talk with friends or family. The nurse realizes this client is demonstrating which type of reaction to stress?

transaction

Stress that is a transaction refers to any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual, social system, or tissue system. The individual responds to perceived environmental changes with adaptive or coping responses such as being withdrawn.

The nurse identifies that a client is experiencing the resistance stage of the general adaption syndrome. What did the nurse assess to make this clinical decision?

3. There is localized swelling and inflammation of the client's leg wound

.Rationale 3: In the second stage in the general adaption syndrome, the stage of resistance is when the body's adaption takes place. The body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it, such as with localized swelling and inflammation of a leg wound.

A client is experiencing the shock phase within the general adaption syndrome. The nurse realizes that this phase affects which hormones?

epinephrine, norepinephrine and corticotropin-releasing

Rationale 1: In the alarm phase of the general adaption syndrome, epinephrine secretion is increased, which affects heart rate, breathing, and blood-clotting mechanisms

.Rationale 3: In the alarm phase of the general adaption syndrome, norepinephrine secretion is increased, which decreases blood flow to the kidney and increases renin release.

Rationale 4: The hypothalamus releases corticotropin-releasing hormone, which stimulates the anterior pituitary gland to release adrenocorticotropic hormone. This causes increased fat mobilization to make energy available and to synthesize other compounds needed by the body.

A client newly diagnosed with colon cancer finishes dinner and turns on the nightly news. The nurse suspects the client is experiencing which cognitive indicator of stress?

self control

Rationale 2: Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge. When self-control prevents panic and harmful or nonproductive actions in a threatening situation, it is a helpful response that conveys strength. Self-control carried to an extreme, however, can delay problem solving

A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress. What did the nurse assess to make this determination?

dilated pupils, diaphoretic and tachycardia

The nurse is concerned that a client diagnosed with a chronic illness is experiencing depression. What did the nurse assess in this client?

irritability, no appetite, constipation, complaints of headache and dizziness

While assessing a client's ability to cope after being diagnosed with a chronic illness, the client admits to an increase in drinking and smoking. The nurse recognizes the client is utilizing which type of coping strategy?

short term

coping strategies can reduce stress to a tolerable limit temporarily, but are ineffective ways to deal with reality permanently. They can even have a destructive or detrimental effect on the person. An example of short-term strategies is using alcoholic beverages or drugs.

The adult daughter of an older client, who provides and pays for the client's care and needs, tells the nurse that her time is limited because of work responsibilities. The client complains that all the daughter ever does is work. What basic need is being affected by the daughter's stress?

self esteem

The nurse asks a client what strategies he uses to cope with stress. The client does not respond. What should the nurse do?

ask the client whether crying occurs, suggest that the client use humor or exercise , question the use of anger.

During a health interview, the nurse decides to focus the assessment questions on the middle-aged client's amount of stress. What information did the nurse use to make this clinical decision?

caring for aging parents, needing to wear glasses to read, not having the same amount of stamina and energy

The nurse is preparing to assess a client's stress and coping patterns. What will be included in this assessment?

1. Client's perception of stressors

2. Manifestations of stress

4. Coping strategies

5. Weight changes

Self-concept

the collection of ideas, feelings, and beliefs one has about oneself

Self-awareness

the relationship between an individual's own and other's perception of self

Global self

refers to the collective beliefs and images one holds about oneself; the most complete description that individuals can give of themselves at any one time

Core self-concept

the belief and images that are most vital to an individual's identity

Ideal self

how we would prefer to be; the individual's perception of how one should behave based on certain personal standards, aspirations, goals, or values

Body image

how an individual perceives size, appearance, and functioning of his or her body and its parts

Role

the set of expectations about how an individual occupying a specific position behaves

Role performance

what a person does in a particular role in relation to the behaviors expected of that role

Role mastery

performance of role behaviors that meet social expectations

Role ambiguity

unclear role expectations; people do not know what to do or how to do it and are unable to predict the reactions of others to their behavior

Role strain

a generalized state of frustration or anxiety experienced with the stress of role conflict and ambiguity

Role conflicts

a clash between the beliefs or behaviors imposed by two or more roles fulfilled by one person

Self-esteem

the value one has for oneself; self-confidence

Global self-esteem

how much one likes one's perceived self as a whole

Specific self-esteem

how much one approves of a certain part of oneself

Factors that affect self-concept

1) Stage of Development

2) Family & Culture

3) Stressors

4) Resources

5) History of Success and Failure

6) Illness

Which statement, made by the client, would indicate a "me-centered" self-concept?

3. "My future is based on the decisions I make today."

Rationale & Pg. #: "me-centered" is when the individual values "how I perceive me" and try hard to live up to their expectations and compete only with themselves (pg. 987).

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses' self-concept along with information to use with clients. Why is the information for nurses important?

3. Nurses with positive self-concept are better able to help clients.

Rationale & Pg. #: nurses who are better able to understand the different dimensions of themselves can understand the needs, desires, feelings, and conflicts of their patients. Nurses who feel positive about themselves are more likely to help patients meet their needs (pg. 987).

The nurse with 25 years' experience is overheard saying, "I learn something new about nursing every day." What does this indicate about the nurse's self-awareness?

4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

Rationale & Pg. #: becoming self-ware is a process that requires time and energy and is never complete (pg. 987).

The nurse is determining a client's level of psychosocial development according to Erikson's stages. Place the developmental tasks in order according to Erikson's stages of psychosocial development.

1. Expressing one's own opinion

2. Guiding others

3. Asserting independence

4. Working well with others

Answer: 1, 4, 3, and 2

Rationale & Pg. #: expressing one's own opinion starts in toddlerhood, working well with others starts in early school years, asserting independence starts in adolescence, and finally guiding others starts when one gets to their middle age (pg. 988).

The adolescent male client who weighs 100 lbs. is considering taking "some herbal stuff" to increase muscle mass and strength. Which should the nurse realize this statement indicates about the client?

3. Incongruence between reality and ideal self

Rationale & Pg. #: identity stressors and body image stressors include unrealistic ideal self/body ideal like muscular configuration that cannot be achieved (pg. 991).

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? (Select all that apply.)

1. "I hate my hair."

3. "My hips are too big."

4. "I wish I had that nose job 2 years ago."

Rationale & Pg. #: specific self-esteem is how much one approves of a certain part of oneself (pg. 990).

The nurse is conducting a thorough psychosocial assessment of a client who reports fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment?

4. Investigate the client's culture prior to the interview.

Rationale & Pg. #: investigating the patient's culture prior to the interview can help to see how the patient's behavior is influenced by their culture (pg. 992).

A client had set the expected outcome: "At the next clinic visit, the client will report participation in three activities to increase self-esteem." Which action should the nurse take if the client is unable to meet the stated outcome?

1. Explore the possible reasons for not meeting the outcome.

Rationale & Pg. #: if outcomes are not achieved, the nurse should explore the reasons, considering questions like "Are there any new or additional roles causing increasing stress in adapting" or "have old situations recurred, triggered feelings or behaviors associated with low self-esteem" (pg. 994).

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included?

3. Respond to the baby's needs promptly and consistently.

Rationale & Pg. #: infants should learn that they can rely on their parents to meet their needs promptly and consistently (pg. 995).

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident?

1. Ask the resident for advice in setting up an activity in the dayroom.

Rationale & Pg. #: to enhance self-esteem in older adults, encourage creative activities to tap their resources and make sure that they are always shown respect and dignity (pg. 996).

During a home visit, an older male client tells the nurse that his wife died 3 years ago. What did the nurse observe as an indication that this client is experiencing complicated grief?

1. The client has an album of photographs of his wife open on the living room table.

2. He tells the nurse that his wife was an awful cook and that he has eaten better meals since she died.

3. He indicates that he sends his laundry out to be done because he had never figured out how the washer works.

4. He shows the nurse his wifes craft room that remains just as she left it before she died.

4. He shows the nurse his wifes craft room that remains just as she left it before she died.

The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family?

1. Anticipatory Grieving

2. Dysfunctional Grieving

3. Hopelessness

4. Caregiver Role Strain

1. Anticipatory Grieving

The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death?

1. Toddlers perceive death as irreversible and unnatural.

2. Preschool children view death as a spiritual release.

3. At about age 9, children begin to understand that death is inevitable.

4. Adolescents tend to have better outcomes than adults after a loss

3. At about age 9, children begin to understand that death is inevitable.

The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members. Which family would the nurse screen as at highest risk for complicated grief? The family of a client who

1. died after a long battle against cancer.

2. died after developing diabetes-induced renal failure.

3. was killed in the robbery of a bank.

4. died from chronic heart disease.

3. was killed in the robbery of a bank.

The nurse critically evaluates various models of grief used for terminally ill clients and their families. What should the nurse recognize when applying these models to individual cases?

1. The Kbler-Ross model is primarily used to describe anticipatory grief.

2. No clear timetables exist, nor are there clear-cut stages of grief.

3. The models serve as clear and definitive predictors of grief behaviors.

4. There is strong research proving that these models are not useful for many dying clients.

2. No clear timetables exist, nor are there clear-cut stages of grief.

A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death. What findings support this clients diagnosis?

Standard Text: Select all that apply.

1. Episodic coughing

2. No cephalic reflexes

3. Not breathing spontaneously

4. Inconsistent cardiac function on the heart monitor

5. Electroencephalogram showed no activity for 30 minutes

2. No cephalic reflexes

3. Not breathing spontaneously

5. Electroencephalogram showed no activity for 30 minutes

A client is diagnosed with a terminal illness and is demonstrating anxiety. What intervention can the nurse use to help the client at this time?

1. Explore the clients history with other stressful life events and how successful coping was at that time.

2. Teach the family that while talking with the client about death and dying is permissible, they should not allow the client to dwell on death.

3. Supply information about the clients disease process and the expected trajectory of death only on a need-to-know basis.

4. Encourage early pharmaceutical intervention with antianxiety and sedative medications.

1. Explore the clients history with other stressful life events and how successful coping was at that time.

A client who has AIDS tells the nurse, I dont know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too. The nurse recognizes this statement as being

1. an indication of hopelessness that should be further evaluated for treatment.

2. a simple statement of the facts regarding AIDS.

3. common and expected in those facing the end of life.

4. proof that the client is accepting the facts of the illness and impending death.

1. an indication of hopelessness that should be further evaluated for treatment.

The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago. She confides that she and the boss had been having a secret extramarital affair for years. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief?

1. Abbreviated

2. Chronic

3. Disenfranchised

4. External

3. Disenfranchised

The nurse is working with a father and his three children, ages 10, 14, and 17. The mother recently died after a long illness. The children are doing poorly in school, and the father is having a difficult time keeping up with household chores. He has recently taken on a second job to help pay his late wifes hospital bills. Which nursing diagnoses should the nurse consider in planning care for this family?

Standard Text: Select all that apply.

1. Anticipatory Grieving

2. Impaired Family Processes

3. Impaired Adjustment

4. Caregiver Role Strain

5. Hopelessness

2. Impaired Family Processes

3. Impaired Adjustment

4. Caregiver Role Strain

5. Hopelessness

During the bath, the client suddenly says, I am not going to get well. I think I am going to die. What response given by the nurse is most appropriate?

1. Lets think of something more cheerful.

2. You are doing so well; dont talk like that.

3. What makes you think you are dying?

4. Whatever is meant to be will happen.

3. What makes you think you are dying?

The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest. The client begins to exhibit severe dyspnea and air hunger and says, Please do something, I cant breathe. What action should be taken by the nurse?

1. Offer the client comfort measures until death occurs.

2. Call the clients physician for direction.

3. Initiate resuscitative measures.

4. Check the medical record to ascertain the terms of the directive.

3. Initiate resuscitative measures

A client with end-stage renal disease knows that he is dying but refuses to talk about it with his spouse. At times the spouse talks with the nursing staff about the clients condition but adamantly refuses to discuss death with the client. What will be the outcomes of this situation?

Standard Text: Select all that apply.

1. Client has dignity

2. Client has privacy

3. Client can finalize affairs

4. Client can plan own funeral

5. Client burdened with no one to confide in

1. Client has dignity

2. Client has privacy

5. Client burdened with no one to confide in

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse, This cannot be happening. There must be some mistake in the testing. What should be the nurses first step in assisting this family?

1. Provide structure and continuity to promote feelings of security.

2. Examine the nurses own feelings to ensure denial is not shared.

3. Offer spiritual support.

4. Allow the family to express sadness.

2. Examine the nurses own feelings to ensure denial is not shared.

A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services. What information should the nurse share with this client?

1. When clients are designated as terminally ill, they are automatically assigned to hospice care.

2. Hospice services are generally reserved for those who have a life expectancy of 6 months or less.

3. Only those clients with private insurance can receive hospice benefits.

4. Provision of hospice services is reserved only for those who refuse other palliative treatments.

2. Hospice services are generally reserved for those who have a life expectancy of 6 months or less.

The nurse is caring for a child who is dying. What is the most important communication strategy for the nurse to use at this time?

1. Talk to the child at the appropriate level of understanding.

2. Be totally open and honest with the child.

3. Avoid discussing death with the child.

4. Encourage the family to talk with the child about the impending death.

1. Talk to the child at the appropriate level of understanding.

The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurses best action according to these wishes?

1. Arrange an encounter with the client and tell him the truth.

2. Change the subject when the client asks about his impending death.

3. Tell the family that the patient has the right to know that he is dying.

4. Talk to the family about the situation and their concerns.

4. Talk to the family about the situation and their concerns.

The nurse who is providing postmortem care for a client sees that the client is wearing a ring. What is the most important action regarding this observation?

1. Remove the ring and give it to the family.

2. Call the presence of the ring to the attention of the funeral director.

3. Tape the ring to the clients finger.

4. Document fully whatever action is taken.

4. Document fully whatever action is taken.

A client recovering from back surgery is seen crying softly in bed. Upon assessment, the nurse learns that the client has been told of the future inability to perform certain sports, activities, and employment types because of the surgery. The nurse interprets this clients reaction as a response to which type of loss?

1. Situational loss

2. Anticipatory loss

3. Psychological loss

4. Developmental loss

1. Situational loss

An older client has just relocated from home to an assisted living facility. The nurse is concerned because the client has been withdrawn and is crying periodically throughout the day. What type of loss is this client demonstrating?

1. External objects

2. Familiar environment

3. Loved ones

4. Psychological

2. Familiar environment

A client with terminal cancer of the lung complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client?

Standard Text: Select all that apply.

1. Move the client to a room closer to the nurses desk for closer observation.

2. Help the client assume a position lying on the right side.

3. Place a fan in the room to move air around the client.

4. Change the clients oxygen therapy to a non-rebreathing mask.

5. Elevate the head of the clients bed to a Fowlers position.

6. Consider use of a p.r.n. morphine sulfate order.

3. Place a fan in the room to move air around the client

5. Elevate the head of the clients bed to a Fowlers position.

6. Consider use of a p.r.n. morphine sulfate order.

The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. What interventions are necessary for this preparation?

Standard Text: Select all that apply.

1. Provide a total bed bath.

2. Place absorbent pads beneath the body.

3. Remove dentures.

4. Dress the client in street clothes.

5. Place a pillow under the head.

6. Tape the eyelids closed.

2. Place absorbent pads beneath the body.

5. Place a pillow under the head.

The spouse of a deceased client is working through the stages of grief. If the nurse applies Martocchios five clusters of grief to this situation, the spouse would progress through the clusters in which order?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Reorganization and restitution

Choice 2. Yearning and protest

Choice 3. Identification in bereavement

Choice 4. Shock and disbelief

Choice 5. Anguish, disorganization, and despair

4, 2, 5, 3, 1

The nurse determines that a client, after learning of the death of a close family member, is demonstrating normal signs of grief. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Crying

2. Weakness

3. Inability to sleep

4. No appetite

5. Inability to concentrate on conversations

1. Crying

3. Inability to sleep

4. No appetite

5. Inability to concentrate on conversations

The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed

Standard Text: Select all that apply.

1. the clients denying the sons death.

2. depression.

3. sudden weight loss because of not eating.

4. crying.

5. verbalizing the desire to not live anymore.

1. the clients denying the sons death.

2. depression

3. sudden weight loss because of not eating.

5. verbalizing the desire to not live anymore.

When observing an older clients response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors

Standard Text: Select all that apply.

1. Importance of the person to the client

2. Amount of changes that will occur because of the loss

3. The clients beliefs

4. The clients values

5. The clients socioeconomic status

1. Importance of the person to the client

2. Amount of changes that will occur because of the loss

3. The clients beliefs

4. The clients values

The nurse is planning care to help a client work through the grieving process. What would be appropriate to include in this plan of care?

Standard Text: Select all that apply.

1. Listen to the client.

2. Clarify and reflect the clients feelings.

3. Reassure the client that all will be well.

4. Be silent.

5. Provide advice to the client.

1. Listen to the client.

2. Clarify and reflect the clients feelings.

4. Be silent.

The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time?

Standard Text: Select all that apply.

1. Encourage the client to resume normal activities on a schedule that promotes physical and psychological health.

2. Use therapeutic communication techniques.

3. Offer choices that promote client autonomy.

4. Provide information about community resources or support groups.

5. Acknowledge the grief of the client.

2. Use therapeutic communication techniques.

3. Offer choices that promote client autonomy.

4. Provide information about community resources or support groups.

5. Acknowledge the grief of the client.

A terminally ill client is demonstrating gurgling respirations. The nurse realizes that this client is

1. improving.

2. experiencing pain.

3. trying to talk.

4. nearing death.

4. nearing death.

The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

1. Diarrhea

2. Muscle spasms

3. Slow, weak pulse

4. Decreased blood pressure

5. Cyanosis of the extremities

3. Slow, weak pulse

4. Decreased blood pressure

5. Cyanosis of the extremities

While caring for a client who is approaching death, the nurse notices the clients facial expression of extreme sadness. What should the nurse do?

1. Leave the client alone.

2. Provide physical care to increase comfort.

3. Acknowledge the clients expression, and ask whether the client would like to talk about her feelings.

4. Offer to provide pain medication.

3. Acknowledge the clients expression, and ask whether the client would like to talk about her feelings.

The spouse of a dying client is sitting quietly in the clients room, looking at the floor. What can the nurse do to help the client and spouse during this time?

Standard Text: Select all that apply.

1. Encourage the spouse to move closer to the client, if desired.

2. Permit the spouse to sit alone.

3. Leave the spouse and client in the room alone together as much as possible.

4. Recommend that the spouse return home to get some rest.

5. Suggest the spouse read to the client, if desired.

1. Encourage the spouse to move closer to the client, if desired.

3. Leave the spouse and client in the room alone together as much as possible.

5. Suggest the spouse read to the client, if desired.

The family members of a client who has just died want to spend time with the client. What should the nurse do to prepare the client for the family?

Standard Text: Select all that apply.

1. Check the clients religion to make sure care is in compliance with religious expectations.

2. Remove equipment from the room.

3. Permit the family to view the client before postmortem care is done.

4. Change the linens.

5. Place the client in a natural body position.

1. Check the clients religion to make sure care is in compliance with religious expectations.

2. Remove equipment from the room.

4. Change the linens.

5. Place the client in a natural body position.

1) According to the National Council of State Boards of Nursing (NCSBN), which "rights" of delegation should the nurse follow? Select all that apply.

1. Supervision

2. Evaluation

3. Client

4. Time

5. Task

1. Supervision

2. Evaluation

5. Task

2) An unlicensed assistive person (UAP) is working on a rehabilitation unit. Which task would be appropriate for this person to delegate?

1. Taking and recording vital signs

2. Assisting with bathing

3. Making a bed

4. An unlicensed assistive person may not delegate tasks.

4. An unlicensed assistive person may not delegate tasks.

3) An RN delegates the task of taking a newly admitted client's vital signs to a nurse's aide. The client's blood pressure was 182/98, but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action?

1. Nurse manager

2. Aide

3. Client

4. RN

4. RN

4) A nurse manager has the reputation of being an autocratic leader. Which of the following statements by this manager would support that reputation?

1. "I'd like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit."

2. "I'm putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit."

3. "The new work schedule is posted for the next 6 weeks."

4. "I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front."

3. "The new work schedule is posted for the next 6 weeks."

5) During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: "When you all can come to a decision, let me know and we'll move on from there." This leader is best identified as which of the following?

1. Democratic leader

2. Permissive leader

3. Bureaucratic leader

4. Situational leader

2. Permissive leader

6) A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive

2. Democratic

3. Situational

4. Bureaucratic

3. Situational

7) A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership?

1. Charismatic

2. Shared

3. Transformational

4. Transactional

2. Shared

8) A charge nurse's responsibilities include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing?

1. Top level

2. Middle level

3. First level

4. Upper level

3. First level

9) The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement risk management?

1. Analyzing, classifying, and prioritizing risks

2. Evaluating and modifying risk reduction programs

3. Anticipating and seeking sources of risk

4. Developing a plan to avoid and manage risk

5. Gathering data that indicate success at avoiding or minimizing risk

3. Anticipating and seeking sources of risk

1. Analyzing, classifying, and prioritizing risks

4. Developing a plan to avoid and manage risk

5. Gathering data that indicate success at avoiding or minimizing risk

2. Evaluating and modifying risk reduction programs