Nurs 220 Exam 1-4 Review UPDATED ACTUAL Questions and
CORRECT Answers
To evaluate a client's personal identity, the nurse should -Personal identity can be evaluated from the standpoint of three aspects of
consider what three aspects of the client's self? self; the ideal self, the real self, and the public self.
Rationale: The ideal self reflects the qualities an individual believes he or she
should possess, as well as those he or she aspires to develop. The real self
represents an individual's perceived true self; it may include observations about
self or self perceived qualities that the individual hides from others or does not
readily share. The public self is formed on the basis of how the individual
wishes to be perceived by others.
Which hormone is one of the primary mediators of -The two primary stress mediators are glucocorticoids (e.g. cortisol) and
stress? catecholamines (e.g. epinephrine).
Rationale: Serotonin is a neurotransmitter that is involved in some mood and
anxiety disorders, but it is not a primary mediator of stress. Somatostatin is a
hormone released by the pituitary gland. It is not involved in the stress
response. Glucagon is secreted by the pancreas to increase blood glucose
levels.
The nurse is caring for a client who is hospitalized with A) The duration of the illness
pneumonia. Which of the following will the nurse assess B) The effect of the illness on future family functioning
when determining the impact of the illness on the D) The meaning of the illness to the family
family? Select all that apply E) The financial impact of the illness
A) The duration of the illness The impact on the family is assessed by the duration of the illness as well as its
B) The effect of the illness on future family functioning effect on the family finances and functioning. Other factors include residual
C) The cause of the illness effects of the illness, meaning of the illness to the family, and its significance to
D) The meaning of the illness to the family family systems. The cause of the illness is not a factor that determines the
E) The financial impact of the illness impact on the family.
What is the major effect of a health crisis on family -Serious illness or injury may result in changes in family roles, responsibilities,
structure? and functions.
Rationale: Illness may precipitate a health crisis in a family. Regardless of how
the family adapts to an illness, members of the family must constantly adjust
roles and responsibilities to manage the need of the ill family member.
The nurse is assessing his client's self concept. The A) Body image
client is status post-myocardial infarction and is due to C) Self-esteem
be discharged tomorrow. Which of the following E) Sexual orientation
focuses will give the nurse the most information about
the client's self concept? select all that apply. The nurse assessing self-concept focuses on the client's personal identity, body
A) Body image image, self-esteem, and role performance. Sexual orientation and gender
B) Gender identity identity do not always provide information about self-concept.
C) Self-esteem
D) Role performance
E) Sexual orientation
,It is a religious holy day. The hospitalized client is -Contact the chaplain to request to see the client today.
withdrawn, occasionally tearful, and requests a minister
to see him. Family is at the bedside. What action would Rationale: Even on a holy day, there is usually a spiritual caregiver on call for
the nurse take to address the client's spiritual distress the hospital. Encouraging the family to talk to the client ignores the client's
on this day? request. The other options may bring some relief to the client, but they still
ignore his request for a spiritual caregiver.
The nurse is caring for a woman who was involved in a -Family disorganization may occur.
car accident. The client's husband was killed in the
accident. The couple has two teenage children. Which Rationale: The death of a family member often has a profound effect on the
statement explains how this tragedy will be approached whole family-especially if the deceased, as in this situation, was the head of the
by the family? family. Family disorganization would be common, but as the family begins to
recover, a new sense of normalcy develops and the family reintegrates its roles
and functions. Families need support from extended family members, their
community, and spiritual advisers. The other options are not considered normal
patterns of family grieving, and the nurse should be alert for problems that may
develop if these are present.
Occupation-specific stressors that are ongoing and -Burnout
unmanaged can lead to what extreme form of stress?
Rationale: Eustress is good stress that leads to accomplishment and victory.
Distress is bad stress that is associated with inadequacy, insecurity, and loss.
Although occupation-specific stressors can be a type of distress, distress is not
the specific term for the extreme form of stress caused by ongoing and
unmanaged stress. The term used for that form of extreme stress us burnout.
Burnout in nurses can lead to reduced quality of care and decreased patient
satisfaction. Allostasis refers to changes necessary to achieve homeostasis
Which of the following most accurately describes the A) It is the overall level of distress experienced as a result of the mental illness
family burden associated with mental illness?
Family burden is the overall level of distress experienced as a result of the
A) It is the overall level of distress experienced as a mental illness.
result of the mental illness. Stigma is the pattern of negative attitudes that lead people to fear in
B) It is the pattern of negative attitudes that lead discriminate against individuals with mental illness and their families. Objective
people to fear individuals with mental illness. burdens are a type of family burden that is measurable or quantifiable. An echo
C) It is the measurable or quantifiable impacts of mental map is an assessment tool that helps nurses visualize how the family can
illness on the family. interacts with the external community environment.
D) It is the assessment that visualizes the way the family
interacts with the community.
The nurse is assessing a client's spirituality. Which of the B) The client reads spiritual material every morning.
following findings would suggest that the client E) The client tells the nurse she is convinced she will be punished in the
experiences of spirituality as a source of strength? afterlife.
A) The client uses the telephone to inform family Regularly reading spiritual material and asking to watch a religious service on
members of an unwanted diagnosis. Television are actions that suggest the client views spirituality as a source of
B) The client reads spiritual material every morning. strength in contrast, focusing on possible punishment in the after life would
C) The client asks to watch a religious service on suggest that the client is experiencing spiritual distress. Lack of interest in
television. meeting with a chaplain might indicate spiritual distress, or it might indicate that
D) The client says she has no desire to meet with a the diagnosis on the phone is unrelated to spirituality.
chaplain.
E) The client tells the nurse she is convinced she will be
punished in the afterlife.
, What is the term for the change that takes place in -The change that takes place in response to a stressor is adaptation
response to a stressor?
Rationale: When a person is in a threatening situation, immediate and often
involuntary responses occur.
A couple recently married. Both the husband and the -The blended family is one that is formed when parents bring unrelated
wife have previously been married and had two children from previous relationships together to form a new family.
children. What is given to this type of family?
Rationale: An extended family includes relatives; a nuclear family is the
traditional father/mother/children; a cohabiting family is composed of member
who live together but are not married.
Despite the presence of a large number of older adult -Cultural blindness.
residents of Asian heritage, a long term care facility has
not integrate the Asian concepts of hot and cold into Rationale: Not taking into consideration the importance of cultural practices
meal planning. The nurses at the facility should either aware or unaware of the actions.
recognize this as an example of:
What is the purpose of the affective and coping -The affective and coping function of the family is necessary to provide
function of the family? emotional comfort to family members and to help members establish an
identity to be maintained in times of stress.
Rationale: The physical function provides a safe environment for growth and
development, the economic function ensures financial assistance, and the
socialization function transmits values, attitudes, and beliefs.
What is the name given to the evaluative and affective -Self esteem is the evaluative and affective component of the self-concept.
component of the self-concept? Sometimes termed self-respect, self-approval, or self-worth.
A female client, from a male-dominated culture, is A) Assess who the decision maker is in the family.
being discharged after a lengthy hospitalization. Which
action by the nurse prior to providing discharge The nurse needs to identify who has the "authority" to make decisions in a
instructions is appropriate? client's family. If the decisionmaker is someone other than the client, the nurse
A) Assess who the decision maker is in the family. needs to include the individual in healthcare discussion. Nurses need
B) Ensure that the healthcare provider gives the awareness of cultural variations of gender because they will be caring for
instructions. diverse client needs. What might be considered sexism by one culture may not
C) Make sure instructions are understood by the client. be in another. Regardless of who is present during the teaching, it is always
D) Ask the client when the best time for teaching would necessary to make sure that the instructions are understood, but it is difficult to
be. do that before instructions are given. Asking the client when the best time for
teaching would be does not Address the need for the decision maker of the
family to be present. The nurse should not simply leave giving instructions to
the healthcare provider.
In which way can nurses develop cultural self -nurses can develop cultural self-awareness by becoming aware of the role of
awareness? the cultural influences in their own lives; objectively examining their own
beliefs, values, and practices; and identifying and reflecting on personal biases.
A nurse is caring for preschool age client who was -in some cultures and as people live longer, more than two generations May
admitted for dehydration. The child lives with the live together in an extended setting.
parents and maternal grandparents. In which of the
following types of family does this child reside? Rationale: A two-career family is one where both partners are employed. A
blended family occurs when existing family units join together to form new
families. A nuclear family is viewed as an autonomous unit in which both parents
reside in the home.
CORRECT Answers
To evaluate a client's personal identity, the nurse should -Personal identity can be evaluated from the standpoint of three aspects of
consider what three aspects of the client's self? self; the ideal self, the real self, and the public self.
Rationale: The ideal self reflects the qualities an individual believes he or she
should possess, as well as those he or she aspires to develop. The real self
represents an individual's perceived true self; it may include observations about
self or self perceived qualities that the individual hides from others or does not
readily share. The public self is formed on the basis of how the individual
wishes to be perceived by others.
Which hormone is one of the primary mediators of -The two primary stress mediators are glucocorticoids (e.g. cortisol) and
stress? catecholamines (e.g. epinephrine).
Rationale: Serotonin is a neurotransmitter that is involved in some mood and
anxiety disorders, but it is not a primary mediator of stress. Somatostatin is a
hormone released by the pituitary gland. It is not involved in the stress
response. Glucagon is secreted by the pancreas to increase blood glucose
levels.
The nurse is caring for a client who is hospitalized with A) The duration of the illness
pneumonia. Which of the following will the nurse assess B) The effect of the illness on future family functioning
when determining the impact of the illness on the D) The meaning of the illness to the family
family? Select all that apply E) The financial impact of the illness
A) The duration of the illness The impact on the family is assessed by the duration of the illness as well as its
B) The effect of the illness on future family functioning effect on the family finances and functioning. Other factors include residual
C) The cause of the illness effects of the illness, meaning of the illness to the family, and its significance to
D) The meaning of the illness to the family family systems. The cause of the illness is not a factor that determines the
E) The financial impact of the illness impact on the family.
What is the major effect of a health crisis on family -Serious illness or injury may result in changes in family roles, responsibilities,
structure? and functions.
Rationale: Illness may precipitate a health crisis in a family. Regardless of how
the family adapts to an illness, members of the family must constantly adjust
roles and responsibilities to manage the need of the ill family member.
The nurse is assessing his client's self concept. The A) Body image
client is status post-myocardial infarction and is due to C) Self-esteem
be discharged tomorrow. Which of the following E) Sexual orientation
focuses will give the nurse the most information about
the client's self concept? select all that apply. The nurse assessing self-concept focuses on the client's personal identity, body
A) Body image image, self-esteem, and role performance. Sexual orientation and gender
B) Gender identity identity do not always provide information about self-concept.
C) Self-esteem
D) Role performance
E) Sexual orientation
,It is a religious holy day. The hospitalized client is -Contact the chaplain to request to see the client today.
withdrawn, occasionally tearful, and requests a minister
to see him. Family is at the bedside. What action would Rationale: Even on a holy day, there is usually a spiritual caregiver on call for
the nurse take to address the client's spiritual distress the hospital. Encouraging the family to talk to the client ignores the client's
on this day? request. The other options may bring some relief to the client, but they still
ignore his request for a spiritual caregiver.
The nurse is caring for a woman who was involved in a -Family disorganization may occur.
car accident. The client's husband was killed in the
accident. The couple has two teenage children. Which Rationale: The death of a family member often has a profound effect on the
statement explains how this tragedy will be approached whole family-especially if the deceased, as in this situation, was the head of the
by the family? family. Family disorganization would be common, but as the family begins to
recover, a new sense of normalcy develops and the family reintegrates its roles
and functions. Families need support from extended family members, their
community, and spiritual advisers. The other options are not considered normal
patterns of family grieving, and the nurse should be alert for problems that may
develop if these are present.
Occupation-specific stressors that are ongoing and -Burnout
unmanaged can lead to what extreme form of stress?
Rationale: Eustress is good stress that leads to accomplishment and victory.
Distress is bad stress that is associated with inadequacy, insecurity, and loss.
Although occupation-specific stressors can be a type of distress, distress is not
the specific term for the extreme form of stress caused by ongoing and
unmanaged stress. The term used for that form of extreme stress us burnout.
Burnout in nurses can lead to reduced quality of care and decreased patient
satisfaction. Allostasis refers to changes necessary to achieve homeostasis
Which of the following most accurately describes the A) It is the overall level of distress experienced as a result of the mental illness
family burden associated with mental illness?
Family burden is the overall level of distress experienced as a result of the
A) It is the overall level of distress experienced as a mental illness.
result of the mental illness. Stigma is the pattern of negative attitudes that lead people to fear in
B) It is the pattern of negative attitudes that lead discriminate against individuals with mental illness and their families. Objective
people to fear individuals with mental illness. burdens are a type of family burden that is measurable or quantifiable. An echo
C) It is the measurable or quantifiable impacts of mental map is an assessment tool that helps nurses visualize how the family can
illness on the family. interacts with the external community environment.
D) It is the assessment that visualizes the way the family
interacts with the community.
The nurse is assessing a client's spirituality. Which of the B) The client reads spiritual material every morning.
following findings would suggest that the client E) The client tells the nurse she is convinced she will be punished in the
experiences of spirituality as a source of strength? afterlife.
A) The client uses the telephone to inform family Regularly reading spiritual material and asking to watch a religious service on
members of an unwanted diagnosis. Television are actions that suggest the client views spirituality as a source of
B) The client reads spiritual material every morning. strength in contrast, focusing on possible punishment in the after life would
C) The client asks to watch a religious service on suggest that the client is experiencing spiritual distress. Lack of interest in
television. meeting with a chaplain might indicate spiritual distress, or it might indicate that
D) The client says she has no desire to meet with a the diagnosis on the phone is unrelated to spirituality.
chaplain.
E) The client tells the nurse she is convinced she will be
punished in the afterlife.
, What is the term for the change that takes place in -The change that takes place in response to a stressor is adaptation
response to a stressor?
Rationale: When a person is in a threatening situation, immediate and often
involuntary responses occur.
A couple recently married. Both the husband and the -The blended family is one that is formed when parents bring unrelated
wife have previously been married and had two children from previous relationships together to form a new family.
children. What is given to this type of family?
Rationale: An extended family includes relatives; a nuclear family is the
traditional father/mother/children; a cohabiting family is composed of member
who live together but are not married.
Despite the presence of a large number of older adult -Cultural blindness.
residents of Asian heritage, a long term care facility has
not integrate the Asian concepts of hot and cold into Rationale: Not taking into consideration the importance of cultural practices
meal planning. The nurses at the facility should either aware or unaware of the actions.
recognize this as an example of:
What is the purpose of the affective and coping -The affective and coping function of the family is necessary to provide
function of the family? emotional comfort to family members and to help members establish an
identity to be maintained in times of stress.
Rationale: The physical function provides a safe environment for growth and
development, the economic function ensures financial assistance, and the
socialization function transmits values, attitudes, and beliefs.
What is the name given to the evaluative and affective -Self esteem is the evaluative and affective component of the self-concept.
component of the self-concept? Sometimes termed self-respect, self-approval, or self-worth.
A female client, from a male-dominated culture, is A) Assess who the decision maker is in the family.
being discharged after a lengthy hospitalization. Which
action by the nurse prior to providing discharge The nurse needs to identify who has the "authority" to make decisions in a
instructions is appropriate? client's family. If the decisionmaker is someone other than the client, the nurse
A) Assess who the decision maker is in the family. needs to include the individual in healthcare discussion. Nurses need
B) Ensure that the healthcare provider gives the awareness of cultural variations of gender because they will be caring for
instructions. diverse client needs. What might be considered sexism by one culture may not
C) Make sure instructions are understood by the client. be in another. Regardless of who is present during the teaching, it is always
D) Ask the client when the best time for teaching would necessary to make sure that the instructions are understood, but it is difficult to
be. do that before instructions are given. Asking the client when the best time for
teaching would be does not Address the need for the decision maker of the
family to be present. The nurse should not simply leave giving instructions to
the healthcare provider.
In which way can nurses develop cultural self -nurses can develop cultural self-awareness by becoming aware of the role of
awareness? the cultural influences in their own lives; objectively examining their own
beliefs, values, and practices; and identifying and reflecting on personal biases.
A nurse is caring for preschool age client who was -in some cultures and as people live longer, more than two generations May
admitted for dehydration. The child lives with the live together in an extended setting.
parents and maternal grandparents. In which of the
following types of family does this child reside? Rationale: A two-career family is one where both partners are employed. A
blended family occurs when existing family units join together to form new
families. A nuclear family is viewed as an autonomous unit in which both parents
reside in the home.
