chapter 42 posttest

8/3/2019 Chapter 42 Posttest

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1. A client comes into the clinic with vocal tremors and pitch changes. The client is also experiencingfacial twitches, shakiness, and slightly elevated respiratory and heart rates. At the end of theassessment, the client tells the nurse, “I feel like I have butterflies in my stomach.” The nurseassesses the client’s anxiety level as:a. Moderate.b. Severe.c. Mild.

d. Panic.

Grade: 1

User Responses: a.Moderate.

Feedback: a.Rationale: The client is experiencing moderate anxiety as evidenced byvoice tremors and pitch changes, facial twitches, shakiness, and slightlyelevated respiratory and heart rates. An additional symptom may bedescribed as having “butterflies” in the stomach.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Physiological Integrity

2. A client complains of difficulty concentrating and a headache. The nurse observes that the client has afrightened facial expression and is easily distracted. The nurse assesses the client’s anxiety level as:a. Mild.b. Moderate.c. Panic.d. Severe.

Grade: 1

User Responses: d.Severe.

Feedback: a.Rationale: A severely anxious person has concentration difficulties,distractibility, headache or dizziness, and a fearful facial expression.

Cognitive Level: ApplyingNursing Process: Assessment

Client Need: Physiological Integrity 3. Click the thumbnail below to see a larger view of the image.

While being prepared for a surgical procedure, a client is talking a lot and asking the nurse severalquestions about the procedure. Using the table shown, the nurse assesses the client’s anxiety level asa. Severe.b. Panic.

c. Mild.d. Moderate.



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Grade: 1

User Responses: c.Mild.

Feedback: a.Rationale: Click the thumbnail below to see a larger view of the image.

The client is using learning to adapt to the anxiety. Mild anxiety manifestsas asking questions in order to cope. Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychosocial Integrity

4. The nurse, who is caring for an 8-year-old child who has been in a chronic vegetative state since anaccident 6 years ago, is gathering a social history from the parents. The mother reports losing weightbecause she has little time to cook. Her 12-year-old child has been having difficulty with school, and

she recently separated from her husband who told her he wanted a “normal” life. The nurse plans careusing the nursing diagnosis of:a. Disabled Family Coping.b. Ineffective Coping.c. Caregiver Role Strain.d. Post-Trauma Syndrome.

Grade: 1

User Responses: a.Disabled Family Coping.

Feedback: a.Rationale: This family is demonstrating disabled family coping becausecaring for the child is impacting more than just the primary caregiver. Whilethe mother demonstrates caregiver role strain, this is also impacting thesibling’s ability to perform in school. The husband’s self-removal from the

family also supports this diagnosis. Cognitive Level: AnalyzingNursing Process: DiagnosisClient Need: Psychosocial Integrity

5. The nurse who is familiar with the stimulus-based model is caring for a young adult who presents inthe clinic with reports of chest pain. The nurse assesses for stressor(s) that could contribute to the cliens physical pain, including:(Select all that apply.) Note: Credit will be given only of all correct choices and no incorrect choices are selected.a. Establishing peer relationships.b. Leaving home.

c. Getting married.d. Accepting changes in residence.e. Continuing education.



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Grade: 1

User Responses: b.Leaving home.,c.Getting married.,e.Continuing education.

Feedback: a.Rationale:Cognitive Level: UnderstandingNursing Process: AssessmentClient Need: Psychosocial Integrity

·

Accepting a change in residence is a stress stimulus normallyfound in the older adult group.· Leaving home is a common stress stimulus for the young adult.· Continuing education is a common stimulus for stress in young

adults.· Marriage is a developmental stress stimulus for young adults.· Establishment of peer relationships is a developmental stressor

for children. 6. The nurse is caring for two clients who have been in a motor vehicle crash and have similar injuries.

According to the transaction-based model, their degree of stress from the crash is:a. Extremely similar, because they had the same stimulus.b. Identical, with the same physiologic alarm reactions.c. Different, depending on their external resources and support levels.d. Based on previous experience and personal characteristics.

Grade: 1

User Responses: d.Based on previous experience and personal characteristics.

Feedback: a.Rationale: In the transaction model, stress is a very personal experienceand varies widely among individuals, depending on their previousexperiences and personal characteristics.

Cognitive Level: UnderstandingNursing Process: AssessmentClient Need: Psychosocial Integrity

7. Click the thumbnail below to see a larger view of the image.

The nurse is caring for a client when he hears of the tragic death of a relative. Using the figure shownand according to Selye, the body’s response when a client receives disturbing or happy news is:a. The stage of resistance.b. The alarm reaction.c. The shock phase.

d. The countershock phase.



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Grade: 1

User Responses: b.The alarm reaction.


The body’s initial response is the alarm reaction, which alerts the body'sdefenses. Cognitive Level: RememberingNursing Process: AssessmentClient Need: Physiological Integrity

8. After the death of several long-term clients, the nurse demonstrates ineffective coping when:a. The nurse investigates transfer opportunities to a short-stay unit.b. The nurse talks at length to a friend about the deaths.c. The nurse keeps busy by working extra shifts for several weeks and does not think about the

deaths for several days.d. The nurse schedules a group session that includes other nurses and the agency’s clergy to

discuss the deaths.

Grade: 1

User Responses: c.The nurse keeps busy by working extra shifts for several weeks and doesnot think about the deaths for several days.

Feedback: a.Rationale: Taking on additional work would only serve as an additionalstressor. In addition, a nurse who has not begun resolution of feelings isunlikely to be able to meet clients' emotional needs.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial Integrity

9. The client is upset after the primary care provider tells him that the lump on his knee is cancer and theleg will need to be amputated. The client responds by getting drunk so he will not have to think aboutthe future. The nurse recognizes the client’s action as an example of a:a. Emotion-focused coping strategy.b. Short-term coping strategy.c. Long-term coping strategy.d. Problem-focused coping strategy.

Grade: 1

User Responses: b.Short-term coping strategy.



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Feedback: a.Rationale: Short-term coping strategies can reduce stress to a tolerablelimit temporarily, but are ineffective ways to permanently deal with reality.They may even have a destructive or detrimental effect on the person.Examples of short-term strategies are using alcoholic beverages or drugs,daydreaming and fantasizing, relying on the belief that everything will workout, and giving in to others to avoid anger.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychosocial Integrity

10. The client's husband died suddenly this week. She has two young children and is trying to stay strongfor them emotionally. After the funeral is over and the family has gone home, the nurse anticipatesthat the client is most likely in the stage of:a. Shock.b. Exhaustion.c. Resistance.d. Alarm reaction.

Grade: 1

User Responses: c.Resistance.Feedback: a.Rationale: The stage of resistance is when the body's adaptation takesplace. In other words, the body attempts to cope with the stressor and tolimit the stressor to the smallest area of the body that can deal with it. Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Physiological Integrity

11. A middle-aged male client is experiencing job-related stress associated with the fear of layoff, whichresults in his accepting projects that require a great deal of travel. The most important health promotionstrategy for the nurse to teach this client is:a. Sleep.b. Nutrition.

c. Time management.d. Exercise.

Grade: 1

User Responses: a.Sleep.

Feedback: a.Rationale: All of the four areas of health promotion strategies may beimportant, but for this client, sleep is likely to be the most adversely affectedby travel, in which changing time zones and unfamiliar sleeping quartersare common. Thus, it becomes the most important area that requiresintervention to avoid worsening the existing stress. Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and Maintenance

12. While conducting discharge planning for a client recovering from a stroke, the nurse expects the client’s ability to cope effectively will be improved by:a. The family providing a supportive environment.b. The client’s college education.c. The client expressing confidence in receiving good care at home.d. The client having insurance in addition to Medicare.



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Grade: 1

User Responses: a.The family providing a supportive environment.

Feedback: a.Rationale: How the client and family understand stressors, and thefamily's ability to provide a supportive environment, are important factorsthat will contribute to the client’s ability to cope effectively.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial Integrity

13. A client who was raised in an abusive family resented the mother for not being protective. Since thedeath of the abusive father, the client has been taking care of the mother and devoting time tocounseling abused women. The nurse determines that the client is using the defense mechanism of:a. Denial.b. Sublimation.c. Projection.d. Reaction formation.

Grade: 1

User Responses: d.Reaction formation.Feedback: a.Rationale: Reaction formation causes persons to act exactly the opposite

of the way they feel.


14. The nurse recognizes an example of displacement when observing that:a. A mother is told her child must repeat a grade in school, and she blames the child’s failure on the

teacher’s lack of skill.b. A woman, though told her father has metastatic cancer, continues to plan a family reunion 18

months in advance.c. A husband and wife are fighting, and the husband becomes so angry he hits a door.d. A school-aged child begins to wet the bed after a parent becomes ill.

Grade: 1

User Responses: c.A husband and wife are fighting, and the husband becomes so angry hehits a door.

Feedback: a.Rationale: The angry husband hitting the door is a demonstration of thedefense mechanism of displacement, which is the transferring ordischarging of emotional reactions from one object or person to anotherobject or person.


15. While performing a physical assessment of the client, the nurse assesses stress and coping by:(Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.a. Assessing the client for physical or stress-related health problems.b. Questioning the client about perceived stressors or stressful incidents.c. Observing the client for verbal, motor, cognitive, or other physical manifestations of stress.d. Examining the client for nail biting, nervousness, or weight changes.e. Assessing the client’s education.



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Grade: 1

User Responses: a.Assessing the client for physical or stress-related health problems.,b.Questioning the client about perceived stressors or stressful incidents.,c.Observing the client for verbal, motor, cognitive, or other physicalmanifestations of stress.,d.Examining the client for nail biting,nervousness, or weight changes.

Feedback: a.Rationale: Cognitive Level: UnderstandingNursing Process: AssessmentClient Need: Psychosocial Integrity

· Assessing the client for physical indicators of stress such as nailbiting, nervousness, or unplanned weight changes contributes tothe nurse’s assessment of stress.

· The presence of stress-related health problems such ashypertension or headaches can contribute to the nurse’sassessment of the client’s stress.

· Asking clients about situations that they perceive as stressful is animportant assessment component.

· Observing the client’s behavior for outward manifestations of stress, which may present with verbal, motor, cognitive, or other

physical manifestations.· Educational level is not a component of the stress assessment.

16. Click the thumbnail below to see a larger view of the image.

A postoperative client has a blood glucose level of 285 mg/dL. The client is concerned and tells thenurse, “I have never been told I had diabetes.” Using the box shown, the nurse’s best response is:a. “It is probably a mistake, and I’ll check it again.”b. “The high glucose is a normal response to the stress of surgery."c. “The earlier we diagnose diabetes, the better your prognosis will be.”d. “I’ll notify your doctor immediately.”



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Grade: 1

User Responses: b.“The high glucose is a normal response to the stress of surgery."


Glucocorticoids released in response to the stress of surgery cause anelevation of blood glucose. This is a normal response and, while it shouldbe monitored, will subside as the stressor is withdrawn or accommodated. Cognitive Level: UnderstandingNursing Process: Implementation

Client Need: Physiological Integrity 17. An older adult man was able to climb up to the roof to rescue his grandson, who was about to fall.

When discussing the incident with the client’s family, the nurse explains that a physiologic responseto stress may have given the client the ability to perform a far more strenuous physical activity thannormal. This nurse knows this response is the result of:a. Stimulation of the parasympathetic nervous system.b. Bronchial dilation.c. Release of adrenal hormones.d. Increased blood clotting.

Grade: 1

User Responses: c.Release of adrenal hormones.

Feedback: a.Rationale: Adrenal hormonal release, specifically epinephrine, allowsthe person faced with a stressor to perform more strenuous activities thannormal. This is often called the “fight-or-flight” response. Cognitive Level: UnderstandingNursing Process: ImplementationClient Need: Physiological Integrity

chapter 42 posttest

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