Exam 5 Review

Question 1

A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye’s General Adaptation Syndrome (GAS) explains the possible cause for the adolescent’s manifestation?
A. Exhaustion Phase
B. Adaptive Phase
C. Resistance Phase
D. Alarm Phase

Answer 1

A. Exhaustion Phase

Question 2

A nurse is assessing a toddler whose parent has recently died. Which of the following findings should the nurse expect?
A. Depends on their friends for emotional support
B. Reports tightness in their chest
C. Cries frequently

Answer 2

C. Cries frequently - may cry, cling to caregivers, become irritable, or have difficulty sleeping in response to grief.

Question 3

A nurse is teaching about professional values in nursing with a newly licensed nurse. Which of the following information should the nurse include?
-Nonmaleficence
-Altruism
-Beneficence
-Social Justice
-Autonomy
-Integrity

Answer 3

Altruism, Social justice, autonomy, integrity

Question 4

A nurse is caring for a client who reports that they are experiencing grief following the loss of a pet and feel like they are grieving alone. The nurse should identify that the client has manifestations of which of the following types of grief?
A. Uncomplicated grief
B. Anticipatory grief
C. Disenfranchised grief
D. Prolonged grief

Answer 4

C. Disenfranchised grief - this is grief not considered accepted by society, such as the death of a pet.

Question 5

A nurse is assessing the respiratory pattern of an older client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
A. Breathing ranging from very deep to very shallow with periods of apnea.
B. Shallow to normal breaths alternating with periods of apnea
C. Rapid respirations that are unusually deep and regular.

Answer 5

A

Question 6

A nurse manager is preparing to discuss breach of confidentiality with their staff. Which of the following statements should the nurse manager plan to make? (select all that apply)
A. Your employer can terminate your employment if there is a breach of confidentiality
B. The State Board of Nursing can reprimand you for a breach of client confidentiality
C. Your institution can receive monetary fines for breach in confidentiality
D. The civil penalties for breach of confidentiality can include imprisonment
E. A breach in confidentiality is considered an act of professional negligence

Answer 6

A, B, C, D

Question 7

_____ is making an excuse or blaming someone else for a behavior rather than taking credit for the situation.

Answer 7

Rationalization

Question 8

A nurse is teaching a class about the general adaptive syndrome. The nurse should include that which of the following manifestations occurs during the exhaustion stage?
A. Dilation of pupils
B. Blood pressure increases
C. Blood glucose levels return to the expected reference range
D. Depression

Answer 8

D. Depression

Question 9

What does the NURSE mnemonic stand for?

Answer 9

Name, Understand, Respect, Support, Explore

Question 10

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the “R” in the NURSE mnemonic?
A. You have so much to deal with. How can I be of help?
B. It is impressive how you have managed to deal with this situation
C. It sounds like you are exhausted
D. Tell me more about how you are feeling

Answer 10

B.

Question 11

Which of the following phases of Selye’s General Adaptation Syndrome (GAS) reflects a nurse’s ability to successfully perform duties during a prolonged period of stress lasting weeks to months without any indication of observable impairment?
A. Resistance phase
B. Adaptive phase
C. Exhaustion phase
D. Alarm phase

Answer 11

A. resistance phases

Question 12

____ is the fulfillment of promises.

Answer 12

Fidelity

Question 13

_____ is the right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest.

Answer 13

Autonomy

Question 14

____ is a committment to do no harm.

Answer 14

Nonmaleficence

Question 15

_____ is a committment to tell the truth.

Answer 15

Veracity

Question 16

_______ is the action that promotes good for others, without any self-interest.

Answer 16

Beneficence

Question 17

When a nurse has problems connecting with others sympathetically, they are more than likely experiencing _____ _____.

Answer 17

Compassion fatigue

Question 18

A nurse is caring for a client who decides not to have surgery despite significant blockage of the coronary arteries. The nurse understands that this client’s choice is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence

Answer 18

B. Autonomy

Question 19

A nurse offers paint meds to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which ethical principle?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficence

Answer 19

D. Beneficence - this promotes good for the client.

Question 20

A nurse is instructing a group of newly licensed nurses about the responsibilities of organ donation and that all clients waiting for a new kidney transplant have to meet the same qualifications. This is an example of which ethical principal?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence

Answer 20

D. Nonmaleficence

Question 21

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma?
A. A nurse on a med-surg unit demonstrates signs of chemical impairment.
B. A nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints.
C. A family has conflicting feelings about the initiation of enteral tube feeding for their father who is terminally ill.
D. A client who terminally ill hesitates to name their partner on their durable power of attorney form.

Answer 21

C

Question 22

When a nurse releases a client’s medical diagnosis to a member of the press it is a _____ of ____________

Answer 22

Breach of confidentiality

Question 23

_____ is when one person makes another person fearful and apprehensive.

Answer 23

Assault

Question 24

______ is intentional and wrongful physical contact with a person that involves an injury or offensive contact

Answer 24

Battery

Question 25

When a person is confined or restrained against their will?

Answer 25

False imprisonment

Question 26

When a nurse fails to implement safety measures for a client at risk for falls it is an example of _____.

Answer 26

Negligence

Question 27

All states have some sort of _______________ that protects health care workers from liability when they intervene at a scene of an emergency.

Answer 27

Good Samaritan Law

Question 28

A legal document that expresses the client’s wishes regarding medical treatment in the even the client becomes incapacitated and is facing end-of-life issues.

Answer 28

Living will

Question 29

A nurse observes an assistive personnel reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy

Answer 29

A. The nurse should recognize that the AP is threatening the client.

Question 30

A nurse notes that an oncoming nurse smells of alcohol and seems unsteady. Which of the following actions should the nurse take?
A. Report the oncoming nurse to the board of nursing
B. Confront the oncoming nurse
C. Notify the oncoming supervisor
D. Ask assistive personnel (AP) if they smelled alcohol on the oncoming nurse’s breath

Answer 30

C

Question 31

Types of Loss:
A loss related to a change that is part of the cycle of life and is anticipated but still can be intensely felt. This type of loss ca be replaced by something different or better.
A. Actual Loss
B. Perceived Loss
C. Necessary Loss
D. Situational Loss

Answer 31

C. Necessary loss

Question 32

Types of Loss: Any loss of a valued person, item, or status (loss of job) that others can recognize.
A. Actual loss
B. Perceived loss
C. Necessary loss
D. Situational loss

Answer 32

A.

Question 33

Type of Loss: Any unanticipated loss caused by an external event (loss of home due to tornado)
A. Actual loss
B. Perceived loss
C. Necessary loss
D. Situational loss

Answer 33

D. Situational Loss

Question 34

Type of loss: Anything clients define as loss but that is not obvious or verifiable to others.
A. Actual loss
B. Perceived loss
C. Necessary loss
D. Situational loss

Answer 34

B. Perceived loss

Question 35

The 5 parts of grief according to the Kubler-Ross Model?

Answer 35

Denial, Anger, Bargaining, Depression, Acceptance (doesn’t have to be in this order)

Question 36

Which type of grief may be accompanied by suicidal ideation, intense feelings of guilt and lowered self-esteem?

Answer 36

Complicated grief

Question 37

Which type of grief starts before the actual loss?

Answer 37

Anticipated grief

Question 38

Which type of grief entails an experienced loss that cannot be publicly shared or is not culturally acceptable? (example: abortion or death of an incarcerated person)

Answer 38

Disenfranchised grief

Question 39

Irregular rate and depth of respirations that includes periods of apnea and periods of hyperventilation is an example of which type of respirations?

Answer 39

Cheyne-Stokes

Question 40

A nurse is caring for a client who has terminal lung cancer. Match the client statements to the Kubler-Ross model stage of grief the client is experiencing? (Match each letter to a number)
A. I am looking forward to our family reunion next year
B. This is so unfair. Why is this happening to me?
C. I promise to go to church every day, if I live through this.
D. I have nothing to live for anyway.
E. I have lived a good life.
1. Bargaining
2. Denial
3. Acceptance
4. Anger
5. Depression

Answer 40

A:2, B:4, C:1, D:5, E:3

Question 41

A nurse is caring for a client who is expected to die within 24 hours. The client’s family asks the nurse what physical changes to expect. Which manifestations should the nurse include? (Select all)
A. Increased urine output
B. Warm extremities
C. Decreased muscle tone
D. Periods of apnea
E. Bowel incontinence

Answer 41

C, D, E

Question 42

A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take? (select all)
A. Make sure the body is lying completely flat
B. Remove dentures from the client
C. Place a clean gown on the client’s body
D. Remove all equipment from the client’s bedside
E. Dim the lights on the client’s room

Answer 42

C, D, E

Question 43

_____ ______ is when a procedure if fully explained to the client and they sign and date their understanding.

Answer 43

Informed consent

Question 44

With mandatory reporting laws, which 3 groups of people must you report abuse or neglect on?

Answer 44

Elderly, children, mentally disabled

Question 45

Surgery at the wrong site is an example of?

Answer 45

malpractice

Question 46

Offensive, intimidating, malicious, condescending behavior is known as _____.

Answer 46

Bullying

Question 47

The lack of providing basic needs to a vulnerable person is _____.

Answer 47

Neglect

Question 48

What is the intergenerational violence theory?

Answer 48

When kids learn negative behavior by imitating caregivers.

Question 49

What is the psychodynamic theory?

Answer 49

Aggression and violence give individuals a dose of power and prestige0701

Question 50

Do or Don’t with Child Abuse Assessment: Pressure child to talk, lead or suggest answers to questions

Answer 50

Don’t

Question 51

What is the cycle of domestic abuse?

Answer 51

Honeymoon phase, tension-building phase, serious battering phase,

Question 52

What are signs of elder neglect?

Answer 52

Malnutrition, inappropriate clothing, poor hygiene, fear of caregiver

Question 53

When a patient is believed to have pass what does the nurse do to verify?

Answer 53

Two nurses listen for one full minute for absence of respirations and heart rate.

Question 54

What is the death rattle?

Answer 54

Secretion sounds in breathing right before death

Question 55

A 73-year-old patient who suffered a stroke is being transferred from the acute care
hospital to a nursing home for ongoing care because they are unable to care for themself at home.
Which type of loss is this patient most likely experiencing?
1. Environmental loss
2. Internal loss
3. Perceived loss
4. Psychological loss

Answer 55

1.

Question 56

For the majority of grief theories and models, which response typically occurs in the initial phase?
1. Awareness
2. Adjustment
3. Disbelief
4. Confrontation

Answer 56

3

Question 57

Which patient is at most risk for experiencing difficult grieving?
1. The middle-aged woman whose grandmother died of advanced Parkinson’s disease
2. A young adult with three small children whose wife died suddenly in an accident
3. The middle-aged person whose spouse suffered a chronic, painful death
4. An older adult whose spouse died of complications of chronic renal disease

Answer 57

2

Question 58

During a health history, a patient whose wife died unexpectedly 6 months ago in a
motor vehicle accident admits to drinking at least six alcoholic beverages every night before going
to bed. Which type of grief does this best illustrate?
1. Delayed
2. Uncomplicated
3. Disenfranchised
4. Masked

Answer 58

4

Question 59

The nurse is caring for a patient in a persistent vegetative state (PVS). Which
finding would the nurse expect to observe?
1. Is aware of family but can’t respond to them
2. Obeys the nurse’s commands
3. Has occasional grimaces and tears
4. Speaks intermittently

Answer 59

3

Question 60

Which intervention takes priority for the patient receiving hospice care?
1. Turning and repositioning the patient every 2 hours
2. Assisting the patient out of bed into a chair twice a day
3. Administering pain medication to keep the patient comfortable
4. Providing the patient with small, frequent, nutritious meals

Answer 60

3

Question 61

10. The nurse has been explaining advance directives to a patient. Which response by
    the patient would indicate successful teaching?
11. “It specifies your healthcare instructions should you become unable to make self-directed
    decisions.”
12. “It identifies the activities considered to be evidence of quality care.”
13. “It verifies your understanding of the risks and benefits associated with a procedure.”
14. “It allows you the autonomy to leave the hospital when you decide, even if it is against
    medical advice.”

Answer 61

1

Question 62

Which sign would the nurse observe in a client who is days to hours before death?
1. Absence of heart activity
2. Yellowish pallor
3. Excessive urine output
4. Dry mucous membranes

Answer 62

4

Question 63

Which intervention by the nurse is most appropriate when a patient who is dying
develops a “death rattle”?
1. Turn the patient to the prone position.
2. Raise the head of the bed.
3. Provide intravenous (IV) fluids.
4. Administer pain medication intravenously

Answer 63

2

Question 64

Which sign would the nurse observe in a client who is days to hours before death?

Answer 64

4

Question 65

A patient dying of heart failure has changed their choice of end-of-life treatment
measures several times. They say, “I just can’t make up my mind about it.” Which nursing
diagnosis is most appropriate for this patient?
1. Deficient knowledge
2. Spiritual distress
3. Decisional conflict
4. Complicated grieving

Answer 65

3

Question 66

Which patient goal is most appropriate when managing the patient dying of cancer?
1. The patient will request pain medication when needed.
2. The patient will report or demonstrate satisfactory pain control.
3. The patient will use only nonpharmacological measures to control pain.
4. The patient will verbalize understanding that it may not be possible to control the pain.

Answer 66

2

Question 67

When providing postmortem care, the nurse places dentures in the mouth and closes
the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so
important?
1. To prevent blood from settling in the head, neck, and shoulders
2. To perform these actions more easily before rigor mortis develops
3. To set the mouth in a natural position for viewing by the family
4. To avoid discoloration caused by blood settling in the facial area

Answer 67

2

Question 68

How should the nurse respond to a family immediately after a patient dies?
1. Ask the family to leave the patient’s room so postmortem care can be performed.
2. Leave tubes and IV lines in place until the family has the opportunity to view the body.
3. Express sympathy to the family by saying, “I am sorry for your loss.”
4. Tell the family that they will have limited time with their loved one.

Answer 68

3

Question 69

The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm.
What recommendation should the nurse make to the family regarding how to most therapeutically
care for the child?
1. Take the child to the funeral even if the child is frightened.
2. Notify the physician immediately if the child shows signs of regression.
3. Spend as much time as possible with the child.
4. Provide distraction whenever the child begins to express feelings of sadness

Answer 69

3

Question 70

A nursing student attending a conference on grief says to one of the presenters,
“The patient I cared for last week in clinicals told me they cried for 4 months after they lost their
cat. Isn’t that an excessive amount of time to cry over a cat?” What is the most appropriate
response by the presenter?
1. “Yes, 4 months is an excessive amount of time. Encourage them to obtain counseling.”
2. “No, when I lost my dog, I cried for 4 months. It was a difficult experience for me.”
3. “As long as the patient is able to get to other things in their life, then it is okay.”
4. “No, all people grieve differently, depending on how meaningful the loss was in their life.”

Answer 70

4

Question 71

A 16-year-old boy recently lost his father in a tragic motorcycle accident. In
assessing how well this teenager is managing and coping with the death of his father, the nurse
should be most alert for which high-priority behavior?
1. Exhibiting excessive crying
2. Engaging in health-risk behaviors
3. Not doing his homework
4. Distancing himself from friends

Answer 71

2

Question 72

Which interventions are appropriate for a client receiving palliative care? Select all
that apply.
1. Surgically inserting a device to decrease the workload of the heart in a client awaiting heart
transplantation
2. Infusing intravenous dopamine to raise the blood pressure of a client with end-stage lung
cancer
3. Providing moisturizing eye drops to an unconscious client whose eyes are dry
4. Administering a medication to relieve the nausea of a client with end-stage leukemia
5. Withholding pain medication from a terminally ill client with bone cancer

Answer 72

3, 4

Question 73

Which statements indicate the nurse has a good understanding of Dr. Elisabeth
Kübler-Ross’s theory? Select all that apply.
1. Patients must pass through each of the five stages of death and dying.
2. Kübler-Ross’s theory includes psychological responses from the terminal diagnosis to the
actual death.
3. The nurse’s role is to help patients move from one stage to the next, and finally to
acceptance.
4. Patients may experience two or three stages at the same time.
5. Kübler-Ross’s theory includes completing one stage and moving on to the next in sequence

Answer 73

2, 4

Question 74

Nurses frequently encounter death of patients in many healthcare settings. What are
some strategies nurses can use to better care for themselves when dealing with death and the
dying? Select all that apply.
1. Remain detached and unemotional when working with dying patients.
2. Talk with colleagues about feelings related to death and dying.
3. Use relaxation and focus on peaceful thoughts.
4. Understand own feelings about death and dying.
5. Suppress grieving when patients die.

Answer 74

2, 3, 4

Question 75

For a patient to be eligible for insurance benefits covering hospice care, a physician
must certify which conditions? Select all that apply.
1. Life expectancy is not more than 6 months.
2. Life expectancy is not more than 12 months.
3. The condition is expected to improve slightly.
4. The condition is not expected to improve.
5. The condition is severe and long-term

Answer 75

1, 4

Question 76

Which concept refers to conflicts that arise between two or more ethical principles
in patient care scenarios?
1. Nursing ethics
2. Bioethics
3. Ethical dilemma
4. Moral distress

Answer 76

4

Question 77

Confidentiality will be maintained by the nurse who believes in and values the
ethical principle of:
1. Fidelity.
2. Veracity.
3. Beneficence.
4. Autonomy

Answer 77

4

Question 78

The nurse provides care to an alert, oriented patient who is prescribed a blood
transfusion for treatment of severe anemia. The patient refuses the treatment. The primary care
provider explains to the patient that the blood transfusion is necessary for survival; however, the
patient continues to refuse the transfusion. Which action does the nurse anticipate implementing?
1. Document the patient’s confusion and administer the blood.
2. Request a psychological evaluation to ensure that the patient understands the risks.
3. Ask family members to persuade the patient to consent to receiving blood.
4. Follow the patient’s wishes and do not administer the blood

Answer 78

4

Question 79

The nurse provides care to a patient who is admitted to the hospital for management
of severe migraines. After administering a prescribed pain medication, the nurse states, “I will
return in 20 minutes to reassess your pain.” By following through on the commitment to return at
the specified time, which ethical principle does the nurse display?
1. Nonmaleficence
2. Autonomy
3. Beneficence
4. Fidelity

Answer 79

4

Question 80

An alert, oriented, competent 87-year-old patient requests a do not resuscitate/allow
natural death (DNR/AND) order. The patient’s family members oppose the patient’s decision and
ask the hospital’s ethics committee to intervene on their behalf. Which framework is the ethics
committee most likely to use as a guide for their decision-making process?
1. Social justice
2. Patient benefit
3. Autonomy
4. Consequentialist

Answer 80

3

Question 81

The nurse preceptor observes a novice nurse preparing to insert an intravenous (IV)
access device into a patient’s antecubital vein. Prior to inserting the IV, the novice nurse tells the
patient, “You won’t feel a thing.” The nurse preceptor recognizes the novice nurse’s violation of
which ethical principle?
1. Beneficence
2. Nonmaleficence
3. Veracity
4. Confidentiality

Answer 81

3

Question 82

The emergency department nurse provides care to a 17-year-old patient who is
diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment
and states, “I don’t want my parents to know I have been sexually active. If they find out about the
cancer, they’ll know I have been having sex.” When planning a course of action, the nurse
recognizes a conflict between which two ethical principles?
1. Nonmaleficence and autonomy
2. Nonmaleficence and veracity
3. Nonmaleficence and fidelity
4. Nonmaleficence and justice

Answer 82

1

Question 83

The nurse witnesses the patient’s signature on a consent form to participate in a
physician’s research study. After the physician leaves the room, the patient tells the nurse, “I don’t
really want to participate, but I’m afraid my doctor will be upset with me if I say no.” To advocate
for the patient, which nursing action is most appropriate?
1. Tell the patient the physician will not be upset if they decline to participate.
2. Inform the physician about why the patient agreed to participate.
3. Explain the importance of the research study to the patient.
4. Ask the patient to tell the nurse whether or not any action should be taken

Answer 83

2

Question 85

This medication gives rapid relief from anxiety and short term use is recommended due to its potential for dependence?

Answer 85

Alprazolam (Xanax)

Question 86

True or false: avoid activities that require alertness (driving, operating heavy equipment and machinery) after taking alprazolam.

Answer 86

True