Exam 3 102

Question 1

Theory of nursing that views the person, family, and community as constantly changing in response to environment and stressors is known as?

Answer 1

Neuman’s system model

Question 2

A clients effort to manage psychological stress?

Answer 2

Coping

Question 3

When teaching client about negative feedback response to stress, nurse includes what to describe the benefits of this stress response?

Answer 3

Results in neurophysiological response.

Question 4

Nurse observes client whose home life is chaotic with intermittent homelessness, their child has spina bifida, and an abusive spouse appear to be experiencing allostatic load. As a result nurse expects to detect which of the following?

Answer 4

Chronic illness

Question 5

DM client comes in with high blood sugar and states “That test is wrong my DM has been controlled for the last 6 months.” This client is experiencing what defense mechanism?

Answer 5

Denial

Question 6

Young woman was in automobile accident 6 months ago and is experiencing vivid images of the crash when she hears loud, sudden noises. She is experiencing?

Answer 6

PTSD

Question 7

Grandfather living in Japan worries about his young grandsons who disappeared after a tsunami. This is an example of?

Answer 7

An adventitious crisis.

Question 8

During assessment interview of older woman experiencing a developmental crisis, nurse asks what question?

Answer 8

Since your husband has died, how have you been doing in the evening when you feel lonely?

Question 9

Nurse planning care for 16 yr old male taking in stressors that are experienced most commonly by adolescents which include?

Answer 9

Search for identity with peer groups, separating from family.

Question 10

Child that has been in house fire comes to ED with parents, child and parents are upset and tearful. During nurse’s assessment for stress the nurse says?

Answer 10

Tell me what bothers you most about this experience?

Question 11

Increased blood volume, HR, blood glucose level, and mental alertness level occur during which part of general adaptation syndrome (GAS)?

Answer 11

Alarm reaction

Question 12

While assessing a person for effects of the GAS nurse should be aware that?

Answer 12

Glucose increases the alarm reaction stage.

Question 13

A newly diagnosed type 2 diabetes client exhibits denial when she says: my blood sugar was just a little high, I don’t have diabetes. The nurse responds with?

Answer 13

Silence. Nurse understands denial is a defense mechanism that assists in coping with shock.

Question 14

Vital functions associated with survival, including HR, BP and respirations are controlled by?

Answer 14

Medulla oblongata

Question 15

The substance secreted by pituitary gland?

Answer 15

Adrenocorticotropic hormone (ACTH)

Question 16

Physiological signs of stress that occur during the early stage of GAS do NOT include?

Answer 16

Impaired mentation

Question 17

Man adjusting to chronic illness this is example of?

Answer 17

Response to situational factor.

Question 18

The nurse assists a client in connecting a stressful event with the clients reaction to the event. This approach is?

Answer 18

Crisis intervention

Question 19

A depressed client is crying and verbalizes feeling low self esteem and self worth, best nursing response?

Answer 19

Review recent behaviors or accomplishments and demonstrate skill or ability.

Question 20

Self concept is linked to job performance and satisfaction in what developmental stage?

Answer 20

Young adulthood

Question 21

Client had mastectomy and refuses to eat, discourages visitors, and pays little attention to appearance. One morning she has done makeup and combed hair, nurse response?

Answer 21

I see you have combed your hair and put makeup on.

Question 22

When individual internalizes beliefs, behavior, and values of role models into a personal, unique expression of self, this documented as?

Answer 22

Identification

Question 23

Outcome criteria for evaluating achievement of the client’s goal, the client will express increased interest in sexual intimacy, should come from?

Answer 23

What the client identifies as the desired outcome.

Question 24

What is most accurate description of sexual development in the school aged child?

Answer 24

The child asks specific questions about sexuality.

Question 25

Nurse educating new mother about infants sexual development, nurse understands teaching was effective when mother states?

Answer 25

My infant is beginning to tell the difference between men and women.

Question 26

What nursing measure promotes sleep in school aged children?

Answer 26

Encourage quiet activities before bedtime.

Question 27

What medication is safest to administer to adults needing assistance in falling asleep?

Answer 27

Benzodiazepines

Question 28

Client reports vivid dreams to nurse. What sleep phase is this?

Answer 28

REM sleep

Question 29

To validate suspicion of married man with sleep apnea nurse does what?

Answer 29

Questions spouse to see if she has been awoken by husbands snoring.

Question 30

What intervention is appropriate for care plan to improve older adult’s sleeping?

Answer 30

Decrease fluids 2-4 hours before sleep.

Question 31

Client with obstructive sleep apnea will most likely report what symptom?

Answer 31

Excessive daytime sleepiness.

Question 32

Phenytoin (Dilantin), an anticonvulsant causes what type of sleep problem?

Answer 32

Increased daytime sleepiness.

Question 33

Nurse developing plan of care for narcolepsy client. What intervention is appropriate to include?

Answer 33

Encourage client to take one or two 20 minute naps during the day.

Question 34

Client being discharged on around the clock opioids what should the nurse request an order for?

Answer 34

Stimulant laxative

Question 35

When setting goals for a client with chronic back pain nurse should begin by doing what?

Answer 35

Asking what does your pain prevent you from doing that you used to do?

Question 36

What sign or symptom in an opioid naive client is of greatest concern when assessing the client 1 hour after administering?

Answer 36

Difficulty arousing the client because sedation always occurs before respiratory depression.

Question 37

After returning from vacation nurse notices client has been receiving Percocet, 2 tablets by mouth every 3 hours for past 3 days, nurse most concerned about?

Answer 37

Amount of acetaminophen received daily. Maximum amount is 4g every 24 hours.

Question 38

Crisis intervention nurse working with mother whose Down syndrome child is hospitalized with pneumonia and lost her entitlement check, when can client be expected to regain stability?

Answer 38

After 6 weeks when she adjusts to the child’s respiratory status and reestablishes entitlement checks.

Question 39

Several staff members are complaining that a client has constant questions. What interpretation of this behavior helps the nurse provide care?

Answer 39

Inability of decision making reflects a self concept issue.

Question 40

20 yr old client has eating disorder with nursing diagnosis of low self esteem, what intervention would be best to address this?

Answer 40

Offer independent decision making opportunities.

Question 41

When developing outcome for 15 yr old girl, nurse considers primary developmental task of adolescence?

Answer 41

Form sense of identity.

Question 42

In planning care for 85 yr old male most important basic need to be met is?

Answer 42

Preservation of self esteem.

Question 43

Eriksons stage of development for old age?

Answer 43

Ego integrity vs. Despair

Question 44

Nurse suspects woman is being sexually abused, what should nurse do?

Answer 44

Tell client about the safe house for women.

Question 45

What question represents a nonjudgmental approach when gathering sexual health history?

Answer 45

Do you have sex with men, women, or both?

Question 46

54 year old male being treated for depression comes into clinic complaining he cannot get an erection, intervention?

Answer 46

Antidepressants may be affecting his sexual functioning.

Question 47

Older adult cautioned about long term use of sedatives and hypnotics because these medications can?

Answer 47

Lead to sleep deprivation.

Question 48

Nurse teaching client about using compounds such as melatonin for sleep?

Answer 48

Should not be used indefinitely, may interfere with prescription meds, not regulated by FDA.

Question 49

Nurse teaching client about taking benzos and that this med causes?

Answer 49

Grogginess and feeling hung over.

Question 50

What indicates further need for teaching on sleep hygiene?

Answer 50

I will have a glass of wine before bed to relax.

Question 51

To improve sleep in adolescence?

Answer 51

Do not study in bed, turn off cell phone at night, avoid coffee and soda before bed.

Question 52

Nurse taking sleep history, what statement needs further follow up?

Answer 52

I always feel tired when I wake up in the morning.

Question 53

Client returns after knee surgery and is complaining of pain, nurse response?

Answer 53

Assess characteristics of pain.

Question 54

Client states he has 6/10 pain and wife says he does not, who is the most accurate resource for assessing pain?

Answer 54

The clients report of pain is the best method for assessing pain.

Question 55

When using ice massage for pain relief?

Answer 55

Apply ice using firm pressure over skin, apply until numbness occurs and remove for 5-10 mins.

Question 56

Educating client about transcutaneous electrical nerve stimulation (TENS) what info should you include?

Answer 56

TENS electrodes are applied near or directly on the site of pain.

Question 57

While caring for cancer client, nurse knows WHO analgesic ladder recommends?

Answer 57

Transitioning use of adjuvants with NSAID drugs to opioids.

Question 58

Carpenter is primary wage earner in family and has recently become a hemiplegic what role problem is he experiencing?

Answer 58

Role conflict