NSG 3130/ NSG 3130 Exam 3 | 2026/2027 Update | Fundamentals of Nursing Practice II | Verified Q&A Pack | Grade A

NSG 3130/ NSG 3130 Exam 3 | 2026/2027 Update | Fundamentals of Nursing Practice II | Verified Q&A Pack | Grade A A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after6:00 pm when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? a. Gently explain the policy to the family and then implement it. b. Inquire of the nursing supervisor how an exception to the policy could be made. c. Call the client's primary care provider for advice. d. Move the deceased to an empty room and assign an aide to stay with the body. b. Inquire of the nursing supervisor how an exception to the policy could be made. Rationale: a. When possible, modifications of policy that demonstrate respect for individual differences should be explored. b. Correct. When possible, modifications of policy that demonstrate respect for individual differences should be explored. c. The primary care provider is in no position to modify the implementation of hospital policy. d. Utilizing an empty room and a staff member for a deceased client is an inappropriate use of resources. The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate? a. "I'm very sorry for your loss." b. "I'll take you in to view the body." c. "I didn't know your father but I am sure he was a wonderful person." d. "How long will you want to stay with your father?" a. "I'm very sorry for your loss." Rationale: a. Correct. This statement acknowledges the family's grief simply. b. Avoid statements that may be interpreted as overly impersonal. c. Avoid statements that may be interpreted as false support. d. Avoid statements that may be interpreted as harsh. An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss? a. "I told the doctor I would stop driving, but I am not going to yet." b. "I always knew this day would come, but I hoped it wouldn't be now." c. "What does he know? I'm a better driver than he will ever be." d. "Well, at least I have friends and family who can take me places." d. "Well, at least I have friends and family who can take me places." Rationale: a. This option does not demonstrate movement toward a goal of adaptation nor problem solving. b. This option does not demonstrate movement toward a goal of adaptation nor problem solving. c. This option does not demonstrate movement toward a goal of adaptation nor problem solving. d. Correct. Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss. When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response? a. "Tell me what it means to you to have this surgery." b. "You must be very glad to be having this lesion removed." c. "I cry when I am happy or relieved sometimes, too." d. "Isn't it wonderful that the lesion is not cancer?" a. "Tell me what it means to you to have this surgery." Rationale: a. Correct. The nurse needs to assess and explore the meaning of the client's crying. b. Option 2 leaps to assumptions about the meaning of the tears and ignores the possibility of the client's distress. c. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct. d. Option 4 leaps to assumptions about the meaning of the tears and ignores the possibility of the client's distress. A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? a. The client demonstrates having adequate financial resources to pay for health care for many more years. b. The client spends the majority of his or her time in spiritual reflection. c. The client has no signs or symptoms of preventative complications of the illness. d. The client verbalizes satisfaction with current relationships with other persons. d. The client verbalizes satisfaction with current relationships with other persons. Rationale: a. Although being able to pay for care may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal. b. Although apparent spiritual peace may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal c. Although the absence of physiological complications may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal. d. Correct. Quality of life is determined by the client and expressed in terms of his or her satisfaction with a variety of aspects of life. After the death of several long-term clients, which action indicates the nurse is demonstrating ineffective coping? a. The nurse talks at length to her partner about the deaths. b. The nurse keeps busy with other actions and doesn't think about the deaths for several days. c. The nurse offers to work extra shifts for several weeks. d. Several nurses schedule a group session with the agency clergy to discuss the deaths. c. The nurse offers to work extra shifts for several weeks. Rationale: a. Effective coping may include verbalizing feelings one-on-one. Of course, the nurse may not disclose confidential information to her partner or others who would not already have this information .b. Effective coping may include initiating nued on next slide c. Correct. Taking on additional work would only serve as an additional stressor. In addition, a nurse who has not begun resolution of feelings is unlikely to be able to meet clients' emotional needs. d. Effective coping may include verbalizing feelings in a group setting. Of course, the nurse may not disclose confidential information to others who would not already have this information. The nurse helps a 50-year-old client with diabetes who is to begin giving insulin injections identify previously successful coping strategies that maybe useful in the current situation. Which stressor is closely related to the new stressor? a. Interviewing for a new job b. Death of a pet while the person was a teenager c. The person's partner filing for a divorce d. Starting to wear eyeglasses at age 30 d. Starting to wear eyeglasses at age 30 Rationale: a. Interviewing for a job is a very short-lived situational stressor. b. Coping strategies effective while a teenager may not be relevant at age 50. c. Experiencing the stress of a divorce is asocial/role stressor quite unlike that of a health problem. d. Correct. Wearing glasses is another example of beginning a new strategy to assist with what will be a lifelong health need even though it is not necessarily a desired change. Two people have been in a motor vehicle crash and have similar injuries. According to the transaction-based model, their degree of stress from the incident would be: a. Based on previous experience and personal characteristics. b. Extremely similar since they had the same stimulus. c. The identical physiologic alarm reaction. d. Different depending on their external resources and support levels. a. Based on previous experience and personal characteristics. Raionale: a. Correct. In the transaction model, stress is a very personal experience and varies widely among individuals. b. Option 2 represents the stimulus model. c. Option 3 represents the response model of stress. d. Option 4, external resources and support are a factor in determining stress levels but omit the key aspects of internal/personal influences. A client informed of a cancer diagnosis assures the nurse he is fine. Which of the following is the most indicative physical evidence to the nurse of the client's stress? a. Constricted pupils b. Dilated peripheral blood vessels (flush) c. Hyperventilation d. Decreased heart rate c. Hyperventilation Rationale: a. With stress, pupils dilate. b. With stress, peripheral blood vessels constrict. c. Correct. With stress, respirations increase. d. With stress the heart rate increases. A middle-aged male client is experiencing job-related stress associated with the fear of being laid off, resulting in his accepting projects that require a great deal of travel. Which of the following would be the most important health promotion strategy for this client? a. Exercise b. Sleep c. Nutrition d. Time management b. Sleep Rationale: a. It is easier for clients to adapt to modifying exercise during travel than it is to control sleep. b. Correct. All of the four areas of health promotion strategies may be important but for this client sleep is likely to be the most adversely affected by travel in which changing time zones and unfamiliar sleeping quarters are common. c. It is easier for clients to adapt to modifying nutrition during travel than it is to control sleep. d. Although time management is important when work demands such as traveling significantly increase, but the basic need for sleep is a higher health concern. When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? a.Pain tolerance b.Pain intensity c.Location of pain d.Pain history b.Pain intensity Rationale: a.Pain tolerance is important, but you need to know the client's pain intensity first. b.Correct. Option B is the best answer because it specifically addresses pain intensity. In a postoperative client it is important to assess pain intensity frequently to manage the acute pain experience. c.Location of pain is important, but you need to know the client's pain intensity first for effective pain management. d.This information is important but not for a client in acute pain. The priority would be to assess the pain intensity. Clients in acute pain may not want to answer pain history questions.You can ask when they are more comfortable. A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely? a.Drowsy; drifts off to sleep before completing a sentence b.Respirations = 18/minute c.Drowsy; easily aroused d.Pain rating 1-2/10 a.Drowsy; drifts off to sleep before completing a sentence Rationale: a.Correct. This indicates an increasing level of sedation, which can be an early sign of impending respiratory depression. b.Option B is normal .c.Option C can indicate increasing sedation; however, option A describes a higher level of sedation and an intervention such as notifying the primary care provider. d.Option D indicates pain management that maybe tolerable for the client. The client has an order of morphine 2.5to 5.0 mg intravenous (IV) every 4hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0to 10. He is now watching television and visiting with family members.When you ask about his pain, he rates it as a 5. His vital signs are stable.What nursing intervention is the most appropriate? a.Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain. b.Give 2.5 mg of morphine IV to avoid the client becoming addicted. c.Give nothing at this time because he is not exhibiting any signs of pain. d.Give morphine 5.0 mg IV and reassess in 20minutes d.Give morphine 5.0 mg IV and reassess in 20minutes Rationale: a.With option A, you would be under medicating the client based on the most important data when assessing a client's pain, his perception or rating of the pain. b.Research shows that few clients become addicted, plus there is no information to indicate signs of addiction. This answer, based on the data, would be under medicating the client. c.Option C does not address the intensity as well as D. d.Correct. The client's perception/intensity rating of his pain is the most important even though other signs may suggest he is not having pain.His pain rating warrants a higher dose of the as needed (prn) morphine. During an admission nursing assessment, a client with diabetes describes his leg pain as a"dull, burning sensation." The nurse recognizes this description to be characteristic of which type of pain? a.Physiological b.Somatic c.Visceral d.Neuropathic d.Neuropathic Rationale: a.Incorrect. b.Incorrect. c.Incorrect. d.Correct. A clue to the answer is that the client has diabetes which often leads to diabetic peripheral neuropathy A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he doesn't move." Which nursing diagnoses should be a priority? a.Deficient Knowledge (pain control measures) b.Ineffective Health Maintenance c.Risk for Ineffective Airway Clearance d.Impaired Physical Mobility a.Deficient Knowledge (pain control measures) Rationale: a.Correct. Based on the information provided, the nurse needs to gather more information about the client's understanding about the effects of pain on recovery and if the client has misconceptions about pain. b.Option B usually pertains more to chronic pain and fatigue. c.Option C could be true but the priority is option A. d.Option D could be true but the priority is option A. A client asks the nurse the differences between traditional therapies and alternative therapies.What is the best response? a.Alternative therapies cost less than traditional therapies .b.Alternative therapies are used if traditional therapies are ineffective. c.Alternative therapies can be as effective as traditional therapies for some conditions. d.Alternative therapies utilize products from nature but traditional therapies do not. c.Alternative therapies can be as effective as traditional therapies for some conditions. Rationale: a.Alternative therapies often cost less, but this is not a primary consideration. b.Clients often seek alternative therapies because traditional therapies are ineffective, but this is not the primary difference. c.Correct. Although the effectiveness of alternative therapies is sometimes not scientifically established, many people report significant benefit from them for a wide variety of conditions. d.Both traditional and alternative therapies utilize products from nature. Before meeting with a client with a terminal illness, a new graduate nurse reviews information on spirituality. Which is the best explanation of spirituality? a.That which gives people purpose and meaning in their lives b.A formalized religious dogma c.A nondenominational community service d.People being responsible for their life patterns a.That which gives people purpose and meaning in their lives Rationale: a.Correct. Spirituality gives us purpose and meaning in life; involves a relationship with oneself, others, and a higher power; and involves finding significant meaning in the entirety of life. b.Spirituality is a much broader concept than religion and religious services. c.Spirituality is a much broader concept than religion and religious services. d.Responsibility to life patterns is a concept of humanism Which nursing action is most likely to create a healing environment? a.Use technology to prevent health care-associated infections .b.Empower clients to make healthy decisions for themselves .c.Assist clients to obtain a safe and comfortable place to live. d.Ensure that primary care providers' orders are carried out. .b.Empower clients to make healthy decisions for themselves Rationale: a.Healing environments are not dependent on technology .b.Correct. Healing environments help empower clients to make healthy decisions. c.Assist clients to obtain a safe and comfortable place to live are environmental interventions, not a general approach to clients. d.Healing environments are not dependent on primary care providers' orders. A client asks the nurse to state one of the primary principles associated with naturopathy.Which of the following is the best response? a.A higher being guides the learning needed to treat disease. b.It focuses on environmental causes when treating illnesses. c.It focuses on early detection and treatment of disease. d.It is a way of life to maintain health and prevent disease. d.It is a way of life to maintain health and prevent disease. Raionale: a.Belief in a higher being is not a core principle. b.The primary focus is disease prevention. c.The primary focus is disease prevention. d.Correct. Naturopathy focuses on the total person. Naturopathy may be the best choice in decreasing disease rates by empowering and educating people about ways to stay healthy From the perspective of traditional Chinese medicine, which is the best definition of disease? a.Imbalance or disruption in food digestion b.Imbalance or interruption in the flow of qi c.Imbalance or disruption in key social relationships d.Imbalance or disruption in thoughts or emotions b.Imbalance or interruption in the flow of qi Rationale: a.Incorrect. b.Correct. Qi is the flow of energy in the body that must be uninterrupted for a person to be in a healthy state. All the other imbalances may result from an imbalance in the flow of qi or flow of vital energy through specific anatomical points along the surface of the body. c.Incorrect. d.Incorrect. 9. A client is on complete bed rest and complains of back pain from lying "in the bed all the time." What is a nursing intervention that uses a nonpharmacologic method to ease the discomfort? (Select all that apply.) 1. Administering a dose of morphine for pain 2. Assisting the client to a bedside chair 3. Giving the client a back massage 4. Instructing the client that the health care provider will see him tomorrow night 5. Using music that contains no words 6. Instructing the client in guided imagery 3. Giving the client a back massage 5. Using music that contains no words 6. Instructing the client in guided imagery A patient recently got pregnant and tells the nurse, "I don't understand, I have been on oral contraceptive pills for years." The nurse reviews medical history with the patient and realizes that what herbal substance could be to blame for the unintended pregnancy? A. Milk Thistle B. Echinacea C. Ginseng D. Valerian A. Milk Thistle A patient with a terminal illness tells the nurse, "I have lived a long life. I am ready to go." What is the nurse's best response? a. Offer the patient a back rub b. Sit quietly by the patient's bedside c. Tell the family about the patient's statement d. Discuss with the patient how dying is part of the life cycle b. Sit quietly by the patient's bedside A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse? a. "Everyone will remember her because she was so cute. She was one of our favorites." b. "As hard as this is, it is probably for the best because she was in a lot of pain." c. "She put up the good fight but now she is out of pain and in heaven." d. "It must be hard to deal with such a precious loss." d. "It must be hard to deal with such a precious loss." he nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic technique should the nurse use when communicating with the family? Select all that apply. a. Discourage reminiscing. b. Make the decisions for the family. c. Encourage expression of feelings, concerns, and fears. d. Explain everything that is happening to all family members. e. Touch and hold the client's or family member's hand if appropriate. f. Be honest and let the client and family know they will not be abandoned by the nurse. c. Encourage expression of feelings, concerns, and fears. e. Touch and hold the client's or family member's hand if appropriate. f. Be honest and let the client and family know they will not be abandoned by the nurse. A client is close to death and the family asks how the nurse will know when their father has died. What is the best response the nurse can state to the family? a. Your loved one will quit breathing and the machine will alarm. b. Your father's blood pressure will drop. c. Your father will quit breathing, his heart will quit pumping and he will have no blood pressure when I take it. d. It should be shortly as his blood pressure has already dropped. I am just waiting for him to stop breathing. c. Your father will quit breathing, his heart will quit pumping and he will have no blood pressure when I take it. The nurse's patient has just died and the nurse is preparing him for viewing by the family. What preparations should the nurse make first for the viewing? a. Give the patient a bath, change the bed, and put on a fresh gown. b. Position the patient with his arms to his side, close his eyes, close his mouth, and remove all the jewelry. c. Check the patient's religious beliefs and discuss with the family member how they would like to have the body prepared. d. Tape all tubes per protocol, clean the room, remove supplies from the bedside, and lower the lights. c. Check the patient's religious beliefs and discuss with the family member how they would like to have the body prepared. nurse is guiding her patient's family through the death of their grandmother. She asks what religion the family is and they reply that they are Hindu. What is a Hindu's belief on cremation? a. Cremation is opposed as is autopsies. b. Cremation is preferred. c. All parts of the body need to be buried, not cremated. d. The patient needs to be dressed in their "temple clothes" before cremation. b. Cremation is preferred. Which is an important concept to consider about anxiety to provide appropriate nursing care? a. Panic attacks generally have a slower onset that can be prevented if identified early. b. One can conceptualize anxiety as being similar to the health-illness continuum. c. People who lead healthy lifestyles rarely experience anxiety. d. Anxiety is an abnormal reaction to realistic danger. b. One can conceptualize anxiety as being similar to the health-illness continuum. A patient is told that surgery is necessary, and the patient begins to experience elevations in pulse, respirations, and blood pressure. Which stage of anxiety is indicated by these nursing assessments? a. Mild-the vital signs remain the same as at resting stage b. Moderate-the pulse, respirations, and blood pressure are slightly elevated c. Severe-pulse and respirations are rapid, blood pressure is high d. Panic-pulse and respirations are very rapid, blood pressure is high, pt may hyperventilate b. Moderate-the pulse, respirations, and blood pressure are slightly elevated A nurse is teaching a patient about the positive effects of exercise to reduce anxiety. Which patient comment about how exercise reduces anxiety indicates that the patient understand the nurse's teaching? a. "It stimulates the production of endorphins." b. "It interferes with the ability to concentrate." c. "It reduces the metabolism of epinephrine." d. "It decreases the acidity of blood." a. "It stimulates the production of endorphins." nurse identifies that a patient is mildly anxious. Which assessment of the patient supports this conclusion? a. Preoccupied-this is moderate anxiety b. Forgetful-this is moderate anxiety c. Fearful-this has nothing to do with anxiety d. Alert-Increased alertness occurs when one is mildly anxious. Alertness and vigilance are the result of an increase in one's perceptual field and state of arousal in response to the stimulation of the autonomic system when one feels threatened. d. Alert-Increased alertness occurs when one is mildly anxious. Alertness and vigilance are the result of an increase in one's perceptual field and state of arousal in response to the stimulation of the autonomic system when one feels threatened. When assessing a patient for anxiety, which characteristic about anxiety should the nurse consider? a. It is triggered by a known stressor. (It is triggered by an unknown stressor.) b. It occurs simultaneously with fear. c. It is a response that is avoidable. d. It is a universal experience. (Anxiety is a common and universal response to a threat. Anxiety is a psychosocial response to an unknown stress; it may be a vague sense of apprehension at one extreme to impending doom at the other extreme). d. It is a universal experience. (Anxiety is a common and universal response to a threat. Anxiety is a psychosocial response to an unknown stress; it may be a vague sense of apprehension at one extreme to impending doom at the other extreme). Anxiety can progress through levels of severity from mild to panic. The patient's level of anxiety will influence how the nurse approaches the patient situation. Place these patient statements in order as anxiety progresses from mild, to moderate, to severe, to panic. a. "I want to know more about the surgery I am having tomorrow." (1)-mild b. "I don't think I am going to make it through the surgery tomorrow." (4)-panic c. "I can't concentrate and all I think about is the pain I may have tomorrow." (3)-severe d. " I get butterflies in my stomach when I think about the surgery tomorrow." (2)-moderate a. "I want to know more about the surgery I am having tomorrow." (1)-mild b. "I don't think I am going to make it through the surgery tomorrow." (4)-panic c. "I can't concentrate and all I think about is the pain I may have tomorrow." (3)-severe d. " I get butterflies in my stomach when I think about the surgery tomorrow." (2)-moderate A stressor is a condition in which the person experiences changes in the normal balanced state. a. True b. False True In stimulus-based stress models, stress is defined as a stimulus, a life event, or a set of circumstances that physiological and/or psychological reactions that may increase the individual's vulnerability to illness. a. True b. False True Problem solving involves thinking through a threatening situation, using specific steps to arrive at a solution. a. True b. False True Structuring (discipline) is assuming a manner and facial expression that convey a sense of being in control or charge. a. True b. False (It is self-control) False Self-control is the arrangement or manipulation of a situation so that threatening events do not occur. a. True b. False (It is structuring) False Blank* is consciously and willfully putting a thought or feeling out of mind: “I won’t deal with that today. I’ll do it tomorrow.” Suppression Blank*, or daydreaming, is likened to make-believe. Fantasy Blank* may be described as dealing with change—successfully or unsuccessfully. Coping Crisis Blank* is a short-term process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning. intervention A coping Blank* (coping mechanism) is a natural or learned way of responding to a changing environment or specific problem or situation. strategy What concept refers to efforts to improve a situation by making changes or taking action? a. Problem-focused coping b. Emotion-focused coping c. Long-term coping d. Short-term coping a. Problem-focused coping __________Focuses on solving immediate problems and involves individuals, groups, or families. a. Crisis intervention b. Caregiver burden c. Crisis counseling d. Burnout c. Crisis counseling __________ is resorting to an earlier, more comfortable level of functioning that is characteristically less demanding and responsible. a. Reaction formation b. Projection c. Minimization d. Regression d. Regression _____________is displacement of energy associated with more primitive sexual or aggressive drives into acceptable activities. a. Sublimation b. Substitution c. Undoing d. Repression a. Sublimation Which of the following is NOT a cognitive indicator or thinking response to stress? a. Structuring b. Suppression c. Anxiety d. Problem solving c. Anxiety A client comes into the clinic with tremors and pitch changes in her voice. She also has facial twitches -and her respiratory and heart rates are slightly elevated. At the end of her assessment, she tells you, "I feel like I have butterflies in my stomach." Which level of anxiety is this client experiencing? 1. Mild 2. Moderate 3. Severe 4. Panic 2. Moderate Rationale: Client is experiencing moderate anxiety as evidenced by voice tremors and pitch changes, facial twitches, shakiness, and slightly elevated respiratory and heart rates, and she told you "I feel like I have butterflies in my stomach." Mild anxiety would be characterized by mild restlessness, sleeplessness, increased verbalization, feelings of increased arousal and alertness, and no changes in respiratory and heartrates, Severe anxiety is characterized by communication difficulties; increased motor activity; inability to relax, focus, and concentrate; ease of distractibility; tachycardia; and hyperventilation. Panic anxiety is characterized by increased motor activity, agitation, unpredictable responses, distorted or exaggerated perception, dyspnea, palpitations, choking, chest pain, and a feeling of impending doom. The spouse of a client is discussing the difference between anxiety and fear. Which of the following statements indicates a need for further teaching? 1. "The source of anxiety is identifiable and the source of fear may not be identifiable." 2. "Anxiety is related to the future, that is, to an anticipated event. Fear is related to the present." 3. "Anxiety is vague, whereas fear is definite." 4. "Anxiety is the result of psychological or emotional conflict; fear is the result of a discrete physical or psychological entity." 1. "The source of anxiety is identifiable and the source of fear may not be identifiable." Rationale: The source of anxiety may not be identifiable; the source of fear is identifiable. Anxiety is related to the future, that is, to an anticipated event. Fear is related to the present. Anxiety is vague, whereas fear is definite. Anxiety the result of psychological or emotional conflict; fear is the result of a discrete physical or psychological entity. Which of the following is an appropriate strategy for dealing with a client's anger? Which of the following is an appropriate strategy for dealing with a client's anger?1. Try to understand the meaning of the client's anger.2. Do not let clients talk about to anger until you are ready.3. After the interaction is completed, avoid processing your feelings and responses to the client withyour colleagues.4. Listen to the client, and act just like the client. 2. Do not let clients talk about to anger until you are ready. 3. After the interaction is completed, avoid processing your feelings and responses to the client with your colleagues. 4. Listen to the client, and act just like the client. 1. Try to understand the meaning of the client's anger. Rationale: Try to understand the meaning of the client's anger. After the interaction is completed, take process your feelings and your responses to the client with your colleagues. Let clients talk about their anger. Listen to the client and act as calmly as possible. Which of the following techniques prevents burnout for nurses? 1. Avoid collegial support groups. 2, Avoid involvement in constructive change efforts. 3. Learn to say "No". 4. Engage in exercise when you can to direct energy inward. 3. Learn to say "No". Rationale: Nurses can prevent bum out by using the techniques to manage stress discussed for clients. Nurses must first recognize their stress and become attuned to such responses as feelings of being overwhelmed, fatigue, angry outbursts, physical illness, and increases in coffee drinking, smoking, or substance abuse. Once attuned to stress and personal reactions, it is necessary to identify which situations produce the most pronounced reactions so that steps may be taken to reduce the stress. Suggestions include: Develop collegial support groups to deal with feelings and anxieties generated in the work setting. Get involved in constructive change efforts if organizational policies and procedures cause stress. Learn to say no. Establish a regular exercise program to direct energy ward. At which developmental stage would a client experience getting married, leaving home, managing a home, getting started in an occupation, continue one's education, and having children? 1. Adolescent 2. Young adult 3. Middle adult 4. Older adult 2. Young adult Rationale: The adolescent is characterized by changing physique, relationships involving sexual attraction, exploring independence, choosing a career. The young adult is characterized by getting married, leaving home, managing a home, getting started in an occupation, continuing one's education, having children. The middle adult is characterized by physical changes of aging, maintaining social status and standard of living, helping teenage children to become independent, aging parents. The older adult is characterized by decreasing physical abilities and health, changes in residence, retirement and reduced income, death of spouse and friends. Which of the following is an example of the defense mechanism of displacement? 1. A husband and wife have an argument, and the husband becomes so angry he hits a door instead of his wife. 2. A woman who was told her father has metastatic cancer, continues to plan a family reunion 18months in advance. 3. A mother is told her child must repeat a grade in school and the mother blames this on the teacher's poor instruction. 4. A woman wants to marry a man exactly like her deceased father, and settles for someone whose appearance resembles her father. 1. A husband and wife have an argument, and the husband becomes so angry he hits a door instead of his wife. Rationale: Displacement is the transferring or discharging of emotional reactions from fine one object or person to another object or person. An example would be when a husband and wife have an argument, the husband becomes so angry he hits a door instead of his wife. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. An example would be a woman who, though told her father has metastatic cancer, continues to plan a family reunion 18 months in advance. Projection is a process in which blame is attached to others or the environment for unacceptable desires, thoughts, shortcomings, and mistakes. An example would be a mother who is told that her child must repeat a grade in school, and the mother blames this on the teacher's poor instruction. Substitution is the replacement of a highly valued; unacceptable, or unavailable object by a less valuable, acceptable, or available object. An example would be a woman who wants to marry a man exactly like her deceased father, and settles for someone whose appearance resembles her father's. A nurse is taking care of an adult client when he throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying? 1. Repression 2. Regression 3. Reaction formation 4. Rationalization 2. Regression Rationale: Regression is resorting to an earlier, more comfortable level of functioning that is characteristically less demanding and responsible. An example would be an adult who throws a temper tantrum when he does not get his own way. Repression is an unconscious mechanism by which threatening thoughts, feelings, and desires are kept from becoming conscious; the repressed material is denied entry into consciousness. An example would be a teenager who, having seen is best friend killed in a car crash, becomes amnesic about the circumstances surrounding the accident. Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel. An example would be an executive who resents his bosses for calling in a consulting firm to make recommendations for change in his department, but verbalizes complete support of the idea and is exceedingly polite and cooperative. Rationalization is justification of certain behaviors by faulty logic and ascribing motives that are socially acceptable but did not in inspire the behavior. An example would be a mother who spanks her toddler too hard and says it was all right because he couldn't feel it through the diaper anyway. A nurse is planning a seminar on minimizing stress and anxiety. Which of the following statements is NOT correct? 1. Provide an atmosphere of warmth and trust; convey a sense of caring and empathy. 2. Listen attentively; try to understand the client's perspective on the situation. 3. Control the environment to minimize additional stressors, such as by reducing noise, limiting the number of individuals in the room, and providing care by the same nurse as much as possible. 4. Communicate in long, detailed sentences. 4. Communicate in long, detailed sentences. Rationale: To minimize stress and anxiety the nurse should communicate in short, clear sentences; provide an atmosphere of warmth and trust; convey a sense of caring and empathy; listen attentively; try to understand the client's perspective on the situation; and control the environment to minimize additional stressors such as by reducing noise, limiting the number of individuals in the room, and providing care by the same nurse as much as possible. During discharge planning, the nurse is teaching the client common characteristics of crises. Which of the following statements is NOT correct? 1. The person is not aware of a warning signal and does not "see it coming." 2. The crisis is often experienced as ultimately life threatening, whether this perception is realistic or not. 3. Communication with significant others is often increased. 4. There may be a perceived or real displacement from familiar surroundings or loved ones. 3. Communication with significant others is often increased. Rationale: Common characteristics of crises include: All crises are experienced as sudden. The person is usually not aware of a warning signal, even if others could "see it coming." The individual or family may feel that they had little or no preparation for the event or trauma. The crisis is often experienced as ultimately life threatening, whether this perception is realistic or not. Communication with significant others is often decreased or cut off. There may be perceived or real displacement from familiar surroundings or loved ones. All crises have an aspect of loss, whether actual or perceived. The losses can include an object, a person, a hope, a dream, or any significant factor for that individual. A nurse is evaluating a nursing student's understanding of the clinical manifestations of stress. Which of the following statements by the nursing student demonstrates a need for further teaching? 1. "Pupils constrict to decrease visual perception when serious threats to the body arise." 2. "Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism." 3. "Heart rate and cardiac output increase to transport nutrients and by-products of metabolism more efficiently " 4. "Skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine." 1. "Pupils constrict to decrease visual perception when serious threats to the body arise." Rationale: The clinical manifestations of stress include: Pupils dilate to increase visual perception when serious threats to the body arise. Sweat production (diaphoresis) increases to control body heat due to increased metabolism. Heart rate and cardiac output increase to transport nutrients and by-products of metabolism more efficiently. Skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine. Bereavement is: a. The total response to the emotional experience relate to loss. b. The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship. c. The behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and custom. d. An actual or potential situation in which something that is valued is changed or no longer available. b. The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship. Rationale: Bereavement is the subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship. Grief is the total response to the emotional experience related to loss. Grief manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow. Mourning is the behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and custom. Loss is an actual or potential situation in which something that is valued is changed or no longer available. A nurse's client just passed away. The nurse understands that rigor mortis is the stiffening of the body that occurs about ______ hours after death. a) 2 to 4 b) 5 to 7 c) 8 to 10 d) 11 to 13 a) 2 to 4 Rationale: Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death. It results from a lack of adenosine triphosphate (ATP), which causes the muscles to contract, which in turn immobilizes the joints. Rigor mortis starts in the involuntary muscles (heart, bladder, and so on), then progresses to the head, neck and trunk, and finally reaches the extremities. All other times are incorrect. A nurse is taking care of a client who just lost her husband to a terminal illness. The client is refusing tobelieve that loss is happening. Which of Kubler-Ross's stages of grieving is the client experiencing? a) Denial b) Anger c) Bargaining d) Depression a) Denial Rationale: Denial occurs when an individual refuses to believe that loss is happening, or is unready to dealwith practical problems, such as prosthesis after loss of leg. A client in denial may assume artificialcheerfulness to prolong denial. Anger is when a client or family is hostile toward a staff member about matters that normally would not bother them. Bargaining occurs when one seeks to bargain to avoid loss. The bargaining client may express feelings of guilt or fear of punishment for past sins, real or imagined. Depression occurs when one grieves over what has happened and what cannot be. The depressed client may talk freely (e.g., reviewing past losses such as money or job) or may withdraw A nurse is evaluating a nursing student who is caring for a dying client's physiological needs. Which of the following actions demonstrates a need for further teaching? a) For an unconscious client with an airway clearance problem, the nursing student places him in Fowler's position. b) The client is diaphoretic; the nursing student gives the client frequent baths and changes the linen. c) The nursing student regularly changes client's position. d) The nursing student provides the client with skin care in response to incontinence of urine or feces. a) For an unconscious client with an airway clearance problem, the nursing student places him in Fowler's position. Rationale: For an unconscious client experiencing airway clearance problems, the nursing student would put the client in a lateral position. For a conscious client with an airway clearance problem, the nursing student would place him in Fowler's position. If the client is diaphoretic, the nursing student would give the client frequent baths, change the linen, and regularly change the client's position. The nursing student would provide skin care to the client in response to incontinence of urine or feces. A nurse is planning a seminar on the dying person's bill of rights. Which of the following statements is NOT part of the dying person's bill of rights? a) I have the right to express my feelings and emotions about my approaching death in my own way. b) I have the right to expect continuing medical nursing attention even though cure goals must be changed to comfort goals. c) I have the right to be free from pain. d) I have the right to die alone. d) I have the right to die alone. Rationale: The dying person's bill of rights includes: I have the right not to die alone. I have the right to express my feelings and emotions about my approaching death in my own way. I have the right to expect continuing medical and nursing attention even though cure goals must be changed to comfort goals. I have the right to be free from pain. The nurse is providing care to an unconscious client who is dying. Which of the following is NOT a clinical manifestation of impending clinical death? a) Difficulty swallowing and gradual loss of the gag reflex b) Mottling and cyanosis of the extremists c) Rapid, shallow, irregular, or abnormally slow respirations d) Faster and weaker pulse d) Faster and weaker pulse Rationale: Clinical manifestations of impending clinical death include: Slower and weaker pulse Difficulty swallowing and gradual loss of the gag reflex Mottling and cyanosis of the extremities Rapid, shallow, irregular, or abnormally slow respirations At what age does a client typically believe his or her own death can be reversible? a) Infancy to 5 years b) 5 to 9 years c) 9 to 12 years d) 12 to 18 years a) Infancy to 5 years Rationale: Infancy to 5 years—Does not understand concept of death, Infant's sense of separation forms basis for later understanding of loss and death. Believes death is reversible, a temporary departure, or sleep. Emphasizes immobility and inactivity as attributes of death. 5 to 9 years—Understands that death is final. Believes own death can be avoided. Associates death with aggression or violence. Believes wishes or unrelated actions can be responsible for death. 9 to 12 years—Understands death as the inevitable end of life. Begins to understand own mortality, expressed as interest in afterlife or as fear of death. 12 to 18 years-Fears a lingering death. Which of the following actions is NOT appropriate for the nurse providing postmortem care? a) One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it. b) The eyelids are closed and held in place for a few seconds so they remain closed. c) Dentures are always removed and placed with the client's personal belongings. d) All jewelry is removed, except a wedding band in some instances, which is taped to the finger. c) Dentures are always removed and placed with the client's personal belongings. Rationale: Nursing personnel may be responsible for care of a body after death. Normally the body is placed in a supine position with the arms either at the sides, palms down, or across the abdomen. Dentures are usually inserted to help give the face a natural appearance. The mouth is then closed. One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it. The eyelids are closed and held in place for a few seconds so-they remain closed. All jewelry is removed, except a wedding band in some instances, which is taped to the finger. A patient requests pain medication for severe pain. Which should the nurse do first when responding to this patient's request? a. Use distraction to minimize the patient's perception of pain. b. Place the patient in the most comfortable position possible. c. Administer pain medication to the patient quickly. d. Assess the various aspects of the patient's pain. All the factors that affect the pain should be assessed including location, intensity, quality, duration, pattern, aggravating and alleviating factors. Assessment must precede intervention. d. Assess the various aspects of the patient's pain. All the factors that affect the pain should be assessed including location, intensity, quality, duration, pattern, aggravating and alleviating factors. Assessment must precede intervention. patient has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this patient? a. Asking what is an acceptable level of pain. b. Providing interventions that do not precipitate pain. c. Focusing on pain management interventions before pain is excessive. d. Determining the level of function that can be performed without pain. c. Focusing on pain management interventions before pain is excessive. Which concept should the nurse consider when assessing a patient's pain? a. The expression of pain is not always congruent with the pain experienced. b. Pain medication can significantly increase a patient's pain tolerance. c. The majority of cultures value the concept of suffering in silence. d. Most people experience approximately the same pain tolerance. a. The expression of pain is not always congruent with the pain experienced. A nurse is assessing a patient in pain. Which word might the nurse use when documenting the pattern of a patient's pain? a. Tenderness b. Moderate c. Episodic d. Phantom c. Episodic A nurse is assessing a patient experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? a. Self-focusing b. Sleep disturbances c. Guarding behaviors d. Variations in vital signs d. Variations in vital signs Acute pain stimulates the sympathetic nervous system, which responds by increasing pulse, respirations, and blood pressure. Chronic pain stimulates the parasympathetic nervous system which results in lowered pulse and blood pressure. nurse is caring for patients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action? a. Patient-controlled analgesia b. Intramuscular sedatives c. Intravenous narcotics d. Regional anesthesia c. Intravenous narcotics When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? a. Pain tolerance b. Pain intensity c. Location of pain d. Pain history b. Pain intensity A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely? a. Drowsy; drifts off to sleep before completing a sentence b. Respirations = 18/minute c. Drowsy; easily aroused d. Pain rating 1-2/10 a. Drowsy; drifts off to sleep before completing a sentence The client has an order of morphine 2.5to 5.0 mg intravenous (IV) every 4hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0to 10. He is now watching television and visiting with family members. When you ask about his pain, he rates it as a 5. His vital signs are stable. What nursing intervention is the most appropriate? a. Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain. b. Give 2.5 mg of morphine IV to avoid the client becoming addicted. c. Give nothing at this time because he is not exhibiting any signs of pain. d. Give morphine 5.0 mg IV and reassess in 20minutes. d. Give morphine 5.0 mg IV and reassess in 20minutes. During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse recognizes this description to be characteristic of which type of pain? a. Physiological b. Somatic c. Visceral a.Physiologicalb.Somaticc.Viscerald.Neuropathic d. Neuropathic A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he doesn't move." Which nursing diagnoses should be a priority? a. Deficient Knowledge (pain control measures) b. Ineffective Health Maintenance c. Risk for Ineffective Airway Clearance d. Impaired Physical Mobility a. Deficient Knowledge (pain control measures) Prevents migraines, arthritis, and stimulates digestion. May increase the anticoagulant effects of aspirin and anticoagulant medications. Feverfew Helps with digestion, relieves motion sickness, dizziness, and nausea. May increase the anticoagulant effects of aspirin and anticoagulant medications. Ginger Boosts immune system, promotes wound healing. Reduces effectiveness of immunosuppressants. Echinacea Enhances flow in gallbladder, liver, spleen, and stomach. Reduces the effectiveness of oral contraceptives. Milk Thistle Reduces BP & Cholesterol, antibiotic/antifungal, anticlotting. May increase the anticoagulant effects of aspirin and anticoagulant medications. Garlic May improve memory function, relieve stress, treat dizziness. May increase the anticoagulant effects of aspirin and anticoagulant medications. Ginkgo Acts as an antidepressant, anti-inflammatory, antiviral. May potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems. St. John's Wort Sedative, tranquilizer, lowers BP, helps with menstrual cramps. May increase the sedative effects of antianxiety medication. Valerian Treats prostate hypertrophy, anti-inflammatory. May give false low prostate-specific antigen (PSA) levels, thereby delaying diagnosis of prostate cancer. Saw Palmetto Stimulates mental activity, enhances immune system, improves appetite. May interact with caffeine and cause irritability. May decrease the effectiveness of glaucoma medications. Ginseng A client asks the nurse the differences between traditional therapies and alternative therapies. What is the best response? a. Alternative therapies cost less than traditional therapies. b. Alternative therapies are used if traditional therapies are ineffective. c. Alternative therapies can be as effective as traditional therapies for some conditions. d. Alternative therapies utilize products from nature but traditional therapies do not. c. Alternative therapies can be as effective as traditional therapies for some conditions. Before meeting with a client with a terminal illness, a new graduate nurse reviews information on spirituality. Which is the best explanation of spirituality? a. That which gives people purpose and meaning in their lives b. A formalized religious dogma c. A nondenominational community service d. People being responsible for their life patterns a. That which gives people purpose and meaning in their lives Which nursing action is most likely to create a healing environment? a. Use technology to prevent health care-associated infections. b. Empower clients to make healthy decisions for themselves. c. Assist clients to obtain a safe and comfortable place to live. d. Ensure that primary care providers' orders are carried out. b. Empower clients to make healthy decisions for themselves. A client asks the nurse to state one of the primary principles associated with naturopathy. Which of the following is the best response? a. A higher being guides the learning needed to treat disease. b. It focuses on environmental causes when treating illnesses. c. It focuses on early detection and treatment of disease. d. It is a way of life to maintain health and prevent disease. d. It is a way of life to maintain health and prevent disease. From the perspective of traditional Chinese medicine, which is the best definition of disease? a. Imbalance or disruption in food digestion b. Imbalance or interruption in the flow of qi c. Imbalance or disruption in key social relationships d. Imbalance or disruption in thoughts or emotions b. Imbalance or interruption in the flow of qi A nurse preceptor is educating a new nurse regarding cultural health practices. The nurses describes medicine men and women that act as channels to help others achieve wellness. Medicine objects, ceremonial treatments, healing touch, acupressure, and herbs are frequently used. The new nurse would correctly identify this as which culture? A. Chinese B. Indian C. Native American D. Latin American C. Native American A nurse is assessing her patients' use of complementary therapies. The patient states that she has been using aromatherapy on and off for the last several years. When looking at the patient's history, what would warrant further education regarding the use of aromatherapy? A. Diabetes B. Asthma C. Insomnia D. Osteoporosis B. Asthma Which of the following therapies focuses on the client's way of life, using mixtures of several different CAM therapies and tailoring it to the individual client? Some examples include dietetics, herbs, spinal manipulation, exercise therapy, and hydrotherapy. A. Homeopathy B. Curanderismo C. Naturopathy D. Biofeedback C. Naturopathy A patient asks the nurse about homeopathy as an option to help supplement their current medication regimen. The nurse explains homeopathy to the patient. What statement, if made by the patient, indicates a need for additional teaching? A. Homeopathy uses the law of similar B. Substances are diluted with the belief that the more diluted, the more potent it becomes C. Remedies are diluted beyond the point at which any molecules of the substance can theoretically still be found in the solution. D. These are regulated by the FDA and are evaluated for safety and effectiveness D. These are regulated by the FDA and are evaluated for safety and effectiveness Which of the following is a type of hand-mediated biofield therapy that uses the hands to alter the energy field of the person being treated? A. Hypnotherapy B. Reflexology C. Reiki D. Chiropractic C. Reiki A nurse is caring for a client that has been taking fish oils for the last year. Which of the following statements, if made by the client, indicates a need for further education? A. There is no guarantee that each dose contains a consistent amount of the intended substance B. Companies are required to test for safety and report those findings to the FDA C. There are multiple manufactures of the same product D. There are possible contamination risks including mold, bacteria, pesticides, and metals B. Companies are required to test for safety and report those findings to the FDA A male patient was recently diagnoses with Prostate Cancer. His doctor informs him that one of his herbal supplements likely impaired the ability of them to detect the cancer early because it caused falsely low PSA levels. The nurse recognizes that which herb was likely responsible for this? A. Garlic B. Feverfew C. Valerian D. Saw Palmetto D. Saw Palmetto A nurse is evaluating her patients to see who may benefit from massage therapy. Which of the following patients has a contraindication to this type of therapy? A. A person with chronic lower back pain B. An athlete with a recent sports related muscle strain C. A pregnant female in her first trimester D. An elderly person with osteoporosis of the spine C. A pregnant female in her first trimester A nurse is reviewing herbal supplements for her patient with Alzheimer's disease. What herbal supplements would the nurse expect to see her patient on to help improve cognitive abilities and memory? (Select all that apply). A. Ginkgo B. Ginseng C. Valerian D. St. John's Wort E. Milk Thistle A. Ginkgo B. Ginseng A nurse is discussing botanical healing with her patient suffering from depression. The nurse understands that which of the following herbs is frequently used as an antidepressant? A. Valerian B. Ginkgo C. St. John's Wort D. Saw Palmetto C. St. John's Wort A patient admitted to the hospital was recently started on a blood thinner for chronic atrial fibrillation. The patient is wanting to take herbal therapy. Based on his current medication regimen, the nurse knows that which of the following herbal therapies is safest for this patient to take? A. Echinacea B. Garlic C. Ginger D. Feverfew A. Echinacea A patient is discussing with his provider the possibility of adding bio electromagnetic therapy as a complementary practice to his current medication regimen. The nurse knows that which of the following conditions would be a contraindication to this type of therapy? A. Chronic stress B. History of GI complaints C. Alzheimer's D. Implanted Pacemaker D. Implanted Pacemaker A nurse is providing education to her patient about meditation. Which of the following statements, if made by the client, indicates a need for further teaching? A. I will lay in my bed comfortably and allow my spouse to lead me through the exercises. B. I should chose a time either first thing in the morning or in the evening C. I should make sure I wait at least 2 hours