Online Practice Test 42

1.		The client most likely to be experiencing a negative situational stress response is:  Your Answer: An 80-year-old victimized by a telephone scam
		Objective: Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. Rationale: An 18-year-old beginning college in a new state is experiencing a situational stress response. The other answers are examples of developmental stressors. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		A parent is waiting outside of the recovery room during a tonsillectomy. The parent who exhibits mild anxiety is the one who:  Your Answer: Swears at a passing nurse, wondering why no one has been out of surgery yet Correct Answer: Asks a passing nurse if the surgery is over
		Objective: Differentiate four levels of anxiety. Rationale: Asks a passing nurse if the surgery is over is an indicator of mild anxiety. All other answers represent behaviors associated with higher levels of anxiety. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		A client in a violent marriage must decide whether to continue in her marriage. The most appropriate nursing diagnosis for this client is:  Your Answer: Decisional conflict
		Objective: Identify essential aspects of assessing a client's stress and coping patterns. Rationale: The client is uncertain what the next action should be. The client is not struggling with care giving, denying reality, or projecting a falsely positive self-evaluation. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		A client recovering from a spinal cord injury becomes angry with the nurse and uses obscenity. The nurse's best response is:  Your Answer: "What did I do to make you so angry?" Correct Answer: "I'm listening. Tell me what this is about."
		Objective: Identify essential aspects of assessing a client's stress and coping patterns. Rationale: Clients with trauma have a need to express anger and have it acknowledged. Laughing does not acknowledge the client's need to express strong displeasure with a severe injury. The client's anger is best acknowledged in such a manner that the client does not suppress future attempts to express emotion. The client owns the anger, and needs to assume responsibility for the anger and deal with it. Nursing Process: Intervention Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		A bystander at an automobile accident is excited and alarmed. He feels nauseated and dizzy, has difficulty focusing, and the pulse is elevated. What level of anxiety is the bystander feeling? Your Answer: Panic Correct Answer: Severe
		Objective: Differentiate four levels of anxiety. Rationale: Mild anxiety symptoms include increased arousal, few if any gastric symptoms, and minor if any respiratory or circulatory changes. Moderate anxiety symptoms include a narrowed focus of attention; selectively inattentive, slightly increased heart and respiratory rate; and "butterflies in the stomach." Panic symptoms include agitation, unpredictable responses, distorted perception, dyspnea, palpitations, and feelings of impending doom. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
6.		Which of the following are considered defense mechanisms? (Select all that apply.) Your Answer: Projection Minimization Compensation
		Objective: Identify behaviors related to specific ego defense mechanisms. Rationale: Defense mechanisms may be adaptive or maladaptive. Compensation, denial, displacement, identification, intellectualization, introjection, minimization, projection, rationalization, reaction formation, regression, repression, sublimation, substitution, and undoing are considered defense mechanisms. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge of stress and coping.
7.		A nurse feels vulnerable after a child dies following a lengthy resuscitation effort. A positive coping strategy for the nurse is to: Your Answer: Accept it as part of a day's work Correct Answer: Meet with others who participated in the resuscitation to grieve together
		Objective: Discuss types of coping and coping strategies. Rationale: Nurses must learn positive coping strategies to deal with stress and prevent burnout. The nurse needs to tune into feelings rather than suppress and numb them with sedatives. A child's death is always extraordinary. It is important for the nurse to deal with the grief. The nurse makes the assumption that a mistake caused the child's death, rather than recognizing that people do the best they can in desperate circumstances and that even children cannot always be resuscitated. Reviewing resuscitations can be useful if done to improve overall care. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
8.		When discussing their father's behavior during a family counseling session, a brother says to his sister, "Sure, Dad was rough, but not as bad as Grandma. Don't you remember Grandma? She was much worse. If it weren't for her, he would have been OK." The defense mechanism the brother is using is: Your Answer: Projection
		Objective: Identify behaviors related to specific ego defense mechanisms. Rationale: He is not justifying his father's behaviors by faulty logic or ascribing motives. He is not minimizing by not acknowledging his father's behavior. He is not compensating by emphasizing a more desirable trait of his father. He is projecting the behavior being discussed to his grandmother. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		While performing discharge planning for a client recovering from a stroke, the nurse may use which factor as an indication of a client's potential for effective coping?  Your Answer: How the client and family understand stressors, and their ability to provide a supportive environment
		Objective: Identify essential aspects of assessing a client's stress and coping patterns. Rationale: Effective coping is not dependent upon one's education level. Confidence is an important element of coping, but may not be based on the reality of the client's current condition. This may help the client afford community resources not covered by Medicare, but this alone does not indicate a client's or family's ability to cope. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		__________ is a short-term helping process of assisting clients to work through a crisis to resolution and restore their pre-crisis level of functioning.  Your Answer: Rehabilitation Correct Answer: Crisis Intervention
		Objective: Describe interventions to help clients minimize and manage stress. Rationale: The goal of crisis intervention is to provide immediate relief for the client. Crisis intervention goes beyond kindness. It involves deliberate acts to benefit the client. The client does not see the police’s presence being for her benefit and relief. Sexual assault is a traumatic event with short- and long-term psychological effects. Crisis intervention is not intended to be a cure. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.