Chapter 27: Self-ConceptMULTIPLE CHOICE 1. The client has just learned that his motorcycle accident has resulted in his left leg being amputated. When helping this client form goals and strategies for realistic goals, the nurse needs to assess the client’s: 1. Ideal and perceived self-concept 2. Intellectual and spiritual strengths 3. Involvement with significant others 4. Interests and past accomplishments ANS: 1 What individuals think and how they feel about themselves affects the way in which they care for themselves. A physical change in the body, such as an amputation, can lead to an altered body image affecting identity and self-esteem. The nurse should assess the client’s ideal and perceived self-concept in order to help the client establish realistic goals and implementation strategies. Intellectual and spiritual strengths may be important when determining a client’s ability to cope. However, when developing goals and implementation strategies, the process is going to begin with the client’s perception of self-concept, because this will greatly impact his response to the amputation. When assessing coping behaviors of an individual, involvement with significant others may be an indication of available resources as well as a source of strength for a client. Assessing a client’s interests and past accomplishments may provide information regarding a client’s identity. Identity is only one component of self-concept. The nurse needs to determine the client’s ideal and perceived self-concept in order to get “the big picture” as this will greatly impact his response to the amputation. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 2. A client is manifesting behaviors that are consistent with a negative self-concept. The nurse that is working with him has observed that the client maintains: 1. Frequent eye contact 2. Independence in self-care 3. A passive personal attitude 4. An interest in the surroundings ANS: 3 A passive attitude is a behavioral characteristic suggestive of a negative self-concept. Avoidance of eye contact would be a behavior suggestive of a negative self-concept. Being excessively dependent is characteristic of a negative self-concept. A lack of interest in what is happening in one’s surroundings is characteristic of a negative selfconcept. DIF: A REF: 412-413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 3. A 76-year-old client who recently lost his wife is admitted for surgery. The nurse is using Erikson as a psychosocial framework for client assessment. Which of the following behaviors would alert the nurse that the client has an alteration in the integrity stage of his psychosocial development? 1. Accepting his own limitations 2. Verbalizing fear about the surgery 3. Expressing his thoughts about his care 4. Demanding excessive assistance from his daughter ANS: 4 Being angry, being excessively dependent, and having a passive attitude are all behaviors suggestive of an altered self-concept. The older client, who has lost a spouse and is now demanding excessive assistance from a child, is demonstrating an alteration in the integrity stage of his psychosocial development. Accepting one’s limitations is not consistent with a disturbance in the integrity stage of psychosocial development. Verbalizing fear about the surgery is not consistent with a disturbance in the integrity stage of psychosocial development. Expressing thoughts about one’s care is not consistent with a disturbance in the integrity stage of psychosocial development. DIF: A REF: 418 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 4. A client, while receiving therapies for lung cancer, has been hospitalized for an extended period of time. She has become very depressed, refuses visitors, and does not participate in personal grooming. In order for the nurse to assist in achieving resolution of the client’s problem, he should have the client: 1. Get washed and dressed independently 2. Think positively instead of negatively 3. Contact a support group and explore a psychological consultation 4. Become more physically independent and return to prior activities ANS: 3 Consultation with significant others, mental health clinicians, and community resources can result in a more comprehensive and workable plan. Clients who are experiencing threats to or alterations in self-concept often benefit from collaboration with mental health and community resources to promote increased awareness. The client’s problem of a negative self-concept must be addressed first. As a result, the client may begin to bathe and dress independently. The client needs to express his negative feelings. This would be one step in addressing his self-concept problem. Stating the client should think positively instead of negatively, at this point, is unrealistic. A long-term goal may be that the client will become more independent and return to prior activities. It is not realistic at this time. DIF: A REF: 420 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 5. The client is on the orthopedic unit following back surgery. He states, “I feel like I can’t do anything anymore—and I won’t be able to continue my landscaping business.” This is predominantly an example of a problem in which of the following components of self-concept? 1. Body image 2. Self-esteem 3. Identity 4. Role ANS: 4 A physical health deficit that prevents role assumption can create a problem in the role performance component of self-concept. A client who is verbalizing concern about continuing a previous occupation is not demonstrating a problem in body image, but rather in the role performance component of self-concept. Self-esteem is closely related to self-concept, but is not a component of self-concept. Identity involves the internal sense of individuality, wholeness, and consistency of a person over time and in various circumstances. The client is verbalizing concern about role performance, not necessarily identity. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 6. A recently divorced client, who is a lawyer, comes to the clinic. She has gotten custody of her two teenagers and states, “It is going to impossible for me to raise my children the way I’d like and keep working as hard as I do.” This is an example of: 1. Role strain 2. Role conflict 3. Role ambiguity 4. Gender role stereotype ANS: 2 Role conflict results when a person is required to simultaneously assume two or more roles that are inconsistent, contradictory, or mutually exclusive. The single mother who is having difficulty managing working long hours and trying to raise her children as she perceives she would like to, is experiencing role conflict. Role strain is a feeling of frustration when a person feels inadequate or feels unsuited to a role, such as with gender role stereotypes. Role ambiguity involves unclear role expectations. The client is not expressing doubt as to what her roles are. A gender role stereotype is where there is an expectation that something is a “man’s role” or a “woman’s role” because the position has been typically held by a man or woman. The client is not expressing concern about a gender role stereotype, but rather in managing two contradictory roles. DIF: A REF: 415 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 7. A prostitute with HIV and severe complications is being cared for on a medical unit. The nurse is seeking to develop a therapeutic relationship with the client. Which of the following statements best reflects the nurse’s attempt to support the client’s selfexploration? 1. “What type of support do you feel you need?” 2. “Don’t be embarrassed by your former occupation.” 3. “What type of schedule could allow you to eat without being nauseated?” 4. “The people who work here are professionals; we’ll not judge your past actions.” ANS: 1 Encouraging the client’s self-exploration by asking about the type of support needed is achieved by accepting the client’s thoughts and feelings, by helping the client to clarify interactions with others, and by being empathetic. Telling the client not to be embarrassed does not encourage self-exploration. It also assumes that the client is embarrassed, which may not be the case. Asking about the type of schedule involves the client in a decision-making process related to the client’s care, but does not support the client’s self-exploration. Self-exploration expands self-awareness. Telling the client that staff will not try to judge the client’s past is not therapeutic and implies judgment is due and does not encourage open communication and self-exploration. DIF: A REF: 418 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 8. A school-age client has just been diagnosed with juvenile diabetes. The client is very angry about the new disease. Which of the following statements is most appropriate for the nurse counselor working with this client? 1. “Try not to be angry. You are receiving the best care possible.” 2. “You appear upset about the diagnosis. Let’s talk about your feelings.” 3. “You learn quickly and will probably handle the difficult treatments very well.” 4. “It is all right to be angry with your friends, but try not be angry with your parents.” ANS: 2 Stating that the client appears to be upset and then suggesting a discussion clarifies the meaning of verbal and nonverbal communication. This response also demonstrates acceptance of the client’s thoughts and feelings and encourages open communication. Telling the client to try not to be angry and that he is receiving the best care possible is not therapeutic. It does not address the client’s feelings of anger and conveys a message that feeling angry is not acceptable. Saying that the client is a quick learner and will probably handle the treatment well is not therapeutic. It does not encourage the client to communicate his or her feelings. Explaining that it is all right to be angry with friends but to try to not be so with parents is not therapeutic. It is not addressing the cause of the anger but is putting limits on how the anger may be expressed. DIF: A REF: 417 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 9. A client’s biggest concern is about the interactions that she has with her family, and she is in the process of establishing a positive view of herself. Which group is the client meeting the developmental needs of: 1. 12- to 20-year-old age-group 2. Early 20s to mid-40s age-group 3. Mid-40s to mid-60s age-group 4. Late 60s and older age-group ANS: 2 The developmental needs of the early 20s to mid-40s age-group include the establishment of intimate relationships with family and significant others; having stable, positive feelings about self; and experiencing successful role transitions and increased responsibilities. The self-concept developmental needs of the 12- to 20-year-old agegroup include accepting body changes, examining attitudes and beliefs, establishing goals for the future, and interacting with those whom he or she finds sexually attractive or intellectually stimulating. The self-concept developmental tasks of the mid-40s to mid60s age-group include accepting changes in appearance and endurance, reassessing life goals, and showing contentment with aging. The self-concept developmental needs of the late 60s and older age-group include feeling positive about one’s life and its meaning, and being interested in providing a legacy for the next generation. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 10. In developing role behavior, the child learns which of the following through substitution? 1. Internalizing beliefs and values of role models 2. Refraining from behavior even though tempted 3. Avoiding unacceptable behavior because it is punished 4. Engaging in an acceptable behavior instead of another unacceptable one ANS: 4 In the process of substitution, an individual replaces one behavior with another that provides the same personal gratification. The child has learned to substitute one behavior for another for a positive outcome. In the process of identification, an individual internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self. In the process of inhibition, an individual learns to refrain from behaviors, even when tempted to engage in them. Avoiding unacceptable behavior because it is punished is seen in the process of reinforcement-extinction. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 11. The nurse recognizes that self-concept develops throughout an individual’s lifetime. Which developmental task associated with self-concept is expected in an assessment of an individual from the 12- to 20-year-old age-group? 1. Identifying with a gender 2. Exploring goals for the future 3. Distinguishing oneself from the environment 4. Feeling positive about one’s life achievements ANS: 2 The developmental tasks associated with self-concept in the 12- to 20-year-old age-group include accepting body changes; examining attitudes, values, and beliefs; and establishing goals for the future. Identifying with a gender is an expected developmental task associated with self-concept in the 3- to 6-year-old age-group. Distinguishing oneself from the environment is an expected developmental task associated with self-concept in the newborn to 1-year-old age-group. Feeling positive about one’s life achievements is an expected developmental task associated with self-concept for the late 60s and older agegroup. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 12. The nurse is working with a client and wants to learn about the individual’s perception of identity. What question should the nurse use to assess this? 1. “What changes would you make in your appearance?” 2. “What activities do you enjoy doing?” 3. “How would you describe yourself?” 4. “What is your usual day like?” ANS: 3 Asking, “How would you describe yourself?” is an example of a question a nurse could use to assess a client’s perception of identity. Asking, “What changes would you make in your appearance?” is an example of a question a nurse could use to assess a client’s perception of body image. Asking, “What activities do you enjoy doing?” is an example of a question a nurse could use to assess a client’s perception of self-esteem. Asking, “What is your usual day like?” is an example of a question a nurse could use to assess a client’s role performance. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 13. The client has very recently been let go from his place of employment and is very upset about the loss. The nurse is establishing a plan of care for the client, she determines that an appropriate outcome for this client with situational low self-esteem is: 1. Client will recognize his inability to make decisions 2. Client will respond to anxiety with decreased amounts of stress 3. Client will use therapeutic communication skills to discuss his needs 4. Client will discuss a minimum of two areas where he is functioning well ANS: 4 An appropriate outcome for the client with situational low self-esteem would be for the client to discuss a minimum of two areas where he is functioning well. Having the client recognize his inability to make decisions would not be an appropriate outcome for the client with low self-esteem. The focus should be on his abilities, not inability. Client responding to the anxiety with decreased amounts of stress does not address the issue of low self-esteem. Being able to use therapeutic communication is always an asset, but the focus should be on improving his self-esteem by determining his strengths, recognizing his worth as a person, realizing what he is able to control, and providing support from others who are having, or had, the same experience. DIF: A REF: 423 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 14. Which of the following statements best reflects an understanding of the definition of negative client self-concept? 1. “Acne is very difficult to deal with, especially for a youngster.” 2. “Managing type 2 diabetes can be very challenging for the client.” 3. “An above the knee amputation requires extensive physical therapy.” 4. “Clinical depression can make things like going to work quite difficult.” ANS: 1 Self-concept is an individual’s conceptualization of himself or herself. It is a subjective sense of self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions. Self-concept directly affects one’s self-esteem, or how one feels about himself or herself. Adolescence is a particularly critical time when many variables affect self-concept and self-esteem. The remaining options are not necessarily directly reflective of self-concept issues. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 15. The nurse recognizes which of the following clients is at greatest risk of developing negative self-esteem? 1. A 35-year-old woman who has been diagnosed morbidly obese 2. A 53-year-old male avid golfer who has lost two fingers on his right hand 3. A 63-year-old man experiencing erectile dysfunction post prostatectomy 4. A 14-year-old girl with a facial scar resulting from an automobile accident ANS: 4 Adolescence is a particularly critical time when many variables affect self-concept and self-esteem. The adolescent experience appears to adversely affect self-esteem, more strongly for girls than for boys. The remaining options, while depicting issues that can affect self-esteem, all relate to the older, more developmentally advanced individual. DIF: A REF: 411 OBJ: Analysis TOP: Nursing Process: Analysis MSC: NCLEX® test plan designation: Safe, Effective Care Environment 16. A 73-year-old client who is no longer working as a cabinetmaker begins to make statements that suggest negative self-concept. This is most likely related to: 1. The prospect of limited financial and health care resources 2. The loss of family members and friends to death and illness 3. The physical changes the aging process has had on his health and body 4. The perceived loss of respect others once had for his woodworking abilities ANS: 3 Evidence suggests that sense of self is often negatively affected in older adulthood because of the intensity of emotional and physical changes associated with aging. The remaining options can be factors in the self-concept of the older client but are not as predictable as the effect of physical aging. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 17. A client is seen in a walk-in clinic for a sinus infection. Which of the following statements made by the client shows the most positive attitude regarding personal health? 1. 2. 3. 4. “I haven’t missed work due to illness in over 15 years.” “When do I need to return to the clinic for a follow-up?” “I don’t like taking medications unless I really need them.” “Should I be concerned about giving this infection to someone else?” ANS: 1 How individuals view themselves and their perception of their health are closely related. A client’s belief in personal health often enhances his or her self-concept. Statements such as “I can get through anything” or “I’ve never been sick a day in my life” indicate that a person’s thoughts about personal health are positive. The remaining options may reflect the client’s personal opinion regarding aspects of health and health care but not as directly as pride in past good health. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 18. The nurse expects which of the following healthy clients to present with the best view of self-esteem? 1. 8-year-old boy 2. 18-year-old male adolescent 3. 38-year-old woman 4. 58-year-old woman ANS: 1 Self-esteem is usually highest in childhood, drops during adolescence, rises gradually throughout adulthood, and declines again in old age. Although variability exists, in general this pattern holds true across gender, socioeconomic status, and ethnicity. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 19. The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted disease (STD). The nurse realizes that such risk-taking behavior (e.g., unprotected sex) is most often a result of: 1. Peer pressure 2. Poor self-esteem 3. Social expectation 4. Lack of information ANS: 2 For some adolescents, a decline in self-esteem results in increased risk-taking behavior. This is demonstrated in unsafe behaviors such as premature sexual activity, unprotected sex, risky driving, or substance abuse. The remaining options represent factors that may affect decision making but they do not have as big an impact on this age-group as is poor self-esteem. DIF: C REF: 412 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 20. The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted disease (STD). The nurse realizes that such risk-taking behavior is often a predictor of even more serious self-destructive behaviors, and so this client should be: 1. Screened for illegal drug use 2. Assessed for suicidal ideations 3. Interviewed regarding alcohol consumption 4. Provided information regarding birth control ANS: 2 Low self-esteem and stressful life events significantly predict suicidal ideations in adolescents. Nurses in all health care settings need to initiate suicide screening and implement nursing interventions directed toward suicide prevention and early detection. Although the remaining options are areas that should be addressed, suicidal ideations are the most serious possible risk-taking behavior. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 21. A 73-year-old client shares with the nurse that she feels so useless, especially now that arthritis makes her life-long hobby of hand sewing so painful as to make it almost impossible. Which of the following nursing responses is most therapeutic given the client’s current poor self-esteem image? 1. “What is it about sewing that makes it so enjoyable for you?” 2. “I’m sure your sewing is beautiful; have you ever considered teaching others to sew?” 3. “Maybe you can find something else that will give you as much satisfaction about yourself.” 4. “We can attempt to find the proper pain management plan to minimize the discomfort so you can sew again.” ANS: 2 Researchers have reported a sharp decline in self-esteem around age 70. Based on Erikson’s stages of development, a decline in self-concept at this advanced age reflects a diminished need for self-promotion and a shift in self-concept to a more modest and balanced view of the self. The nurse is acknowledging the client’s talent as well as providing a possible alternate avenue to improve self-esteem. The remaining options all deal with the issue but either do not provide guidance or may propose unrealistic alternatives. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 22. Which of the following statements best reflects the client’s perception of the female role? 1. “My wife bakes the best bread.” 2. “All of my daughters are stay-at-home moms.” 3. “I don’t understand why a woman would want to be a coal miner.” 4. “We are so proud; our granddaughter got accepted into law school.” ANS: 4 Gender identity is a person’s private view of maleness or femaleness. This option reflects a sense of pride in a female accomplishment that may be typically viewed as being maleoriented, thus showing the client’s atypical perception of the female role. The remaining options are either general statements or examples of less predominant perceptions of traditional roles. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 23. Research has shown that Caucasian girls and women appear to experience more pressure to be physically thin than do African American girls and women. The most likely reason for this variation in attitude is the: 1. Caucasian culture values physical thinness 2. African American culture does not value physical thinness 3. Caucasian girls and women are genetically programmed for physical thinness 4. African American girls and women are not genetically programmed for physical thinness ANS: 2 Culture and society dictate the accepted norms of body image and influence one’s attitudes (Figure 27-2). Racial and ethnic background plays an integral role in body satisfaction in adolescent girls as reflected in the higher incidence of body satisfaction among African American girls compared to Caucasian girls (Kelly and others, 2005). Further, African American girls described more favorable views about physical appearance, reported less social pressure for thinness, and exhibited less tendency to base self-esteem on body image than did Caucasian girls (White and others, 2003). The value placed on thinness by the African American culture would not influence the Caucasian girl or woman, and the options related to genetics are not proven. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 24. A 12-year-old girl’s expressed goal to be “super thin” is a body image issue influenced primarily by: 1. Peer pressure 2. Societal values 3. Teenage role modeling 4. Normal developmental changes ANS: 2 Cultural and societal attitudes and values influence body image. Culture and society dictate the accepted norms of body image and influence one’s attitudes. Peer pressure and role modeling are influenced by the perceived social preference. Normal physical developmental changes resulting from puberty do not typically result in “super thin” body types. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 25. Which of the following statements best reflects a client’s healthy sense of identity? 1. “My name is Susan.” 2. “My children are my world.” 3. “I’m looking for my perfect job.” 4. “I’m happiest when I get to exercise regularly.” ANS: 4 Identity involves the internal sense of individuality, wholeness, and consistency of a person over time and in different situations. Identity implies being distinct and separate from others. Being “oneself” or living an authentic life is the basis of true identity. Knowing what makes oneself happy is a sign of identify. While looking for the perfect job infers some self-awareness, it is as of yet unfulfilled. Identifying so closely with one’s child is not an indicator of a healthy sense of identity nor is simply stating one’s name. DIF: C REF: 412 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 26. Which of the following physical changes that are commonly seen during puberty would be most likely to cause body image problems for a 12-year-old girl? 1. Having her first menstrual period 2. Growing 3 inches over the summer 3. Experiencing a substantial increase in breast size 4. Experiencing hair growth on legs and underarms ANS: 3 The development of secondary sex characteristics and changes in body fat distribution have a tremendous impact on the self-concept of an adolescent. The visible changes to the body would likely have more impact than the more covert event of a menstrual period. Although the remaining options might affect the client’s body image, the effect is likely to have less of an impact. DIF: C REF: 415 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 27. Which of the following statements, regarding the physical changes that are associated with the normal aging process, made by a 63-year-old female client best reflects a negative sense of body image? 1. “I felt old when I had to by bifocal glasses.” 2. “My aging joints just don’t allow me to hike like I used to.” 3. “In order to be successful at my work, I need to dye away the gray hair.” 4. “It’s much more difficult to socialize with friends now that I can’t hear as well.” ANS: 3 Changes associated with aging (e.g., wrinkles; graying hair; and decrease in visual acuity, hearing, and mobility) also affect body image in an older adult. Expressing the concern that gray hair would negatively affect her career is the most negative statement regarding body image. The remaining options suggest limitations and personal attitudes about adapting to the changes of aging, but they do not suggest such strong negative personal feelings as does the correct answer. DIF: C REF: 415 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 28. Which of the following statements best reflects a client’s healthy sense of selfesteem? 1. “I always try to do the best I can” 2. “I’ll keep trying till I get it right.” 3. “I’m not good at it but I enjoy playing guitar ” 4. “If I can’t build it, it isn’t worth being built.” ANS: 1 Self-esteem is positive when one feels capable, worthwhile, and competent. Recognizing that one does the best one can is the best reflection of self-esteem. The other options either state a sense of perseverance, an expression of a lack of talent, or an unrealistic view of self-worth and esteem. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 29. The best indication that a client will regain a good sense of self esteem after experiencing a second below the knee (BTK) amputation is: 1. The client stating, “I’ll get over this setback” 2. A solid, caring relationship with family and friends 3. A healthy sense of self esteem after the first amputation 4. The client telling his wife, “I’ll still be able to work from a wheelchair.” ANS: 3 Once established, basic feelings about the self tend to be constant, even though a situational crisis temporarily affects self-esteem. While the remaining options reflect positive behaviors or situations, they are dependent to a large degree on the client’s previously established sense of self-esteem. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 30. Which of the following nursing actions will have the most therapeutic impact on the self-esteem of a client with HIV? 1. Dealing with the client’s needs in a nonjudgmental manner 2. Being aware of how the client will react based on the client’s culture 3. Providing care that will meet the client’s emotional and physical needs 4. Being careful to avoid nonverbal communication that could be misinterpreted ANS: 1 A nurse’s acceptance of a client with an altered self-concept helps promote positive change. The nurse must have the ability to convey a nonjudgmental attitude toward clients so as to convey an accepting attitude. The remaining options are therapeutic but they are all outcomes of a nonjudgmental attitude on the part of the nurse. DIF: C REF: 417 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment Potter & Perry: Fundamentals of Nursing, 7 Edition th Test Bank Chapter 29: Spiritual Health MULTIPLE CHOICE 1. A nurse should be aware that adolescent clients who are discussing spirituality often: 1. Have a good concept of a supreme being 2. Question religious practices and/or values 3. Fully accept the higher meaning of their faith 4. Often give themselves over to spiritual tasks ANS: 2 Adolescents often reconsider their childlike concept of a spiritual power, and in the search for an identity, they may either question practices and values or find the spiritual power as the motivation to seek a clearer meaning to life. Adolescents do not necessarily have a good concept of a supreme being. Adolescents do not necessarily fully accept the higher meaning of their faith. Older adults, not adolescents, often turn to important relationships and the giving of themselves to others as spiritual tasks. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 2. 1. 2. 3. 4. A nurse’s knowledge about spirituality begins with him or her: Researching all popular religions Looking at his or her own beliefs Sharing his or her faith with the clients Providing prayers and religious articles for clients ANS: 2 Knowledge about spirituality begins with nurses’ insight about their own spirituality. This self-exploration may occur through reading, religious involvement, or activities such as meditation to understand their own beliefs and values. Researching popular religions may add to the nurse’s knowledge, but knowledge of spirituality begins with the nurse examining his or her own beliefs. It is essential for the nurse to be aware of his or her own beliefs so as to not impose them on others, and to be able to recognize and understand a client’s spiritual needs. The nurse’s knowledge about spirituality does not begin with the nurse sharing his or her faith with clients. Providing prayers and religious articles for clients may be an intervention to meet a client’s spiritual needs; however, it is not how the nurse’s knowledge about spirituality begins. DIF: A REF: 444 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 3. The client experienced a near-death experience and was successfully resuscitated. The nurse wants to provide the opportunity for the client to discuss the near-death experience. The most appropriate response by the nurse is: 1. “This is a common experience that is easily explained.” 2. “That must have been a very awful experience for you.” 3. “Have you ever heard of other persons having a near-death experience?” 4. “What was your experience like, and how did it make you feel?” ANS: 4 After a client has experienced a near-death experience, it is important for the nurse to remain open, such as asking about the experience and how it made the client feel, and give the client a chance to explore what happened. This is not a common experience that can be easily explained. The client should be encouraged to discuss it as he or she may find meaning from this powerful experience. The nurse should not assume this was an awful experience for the client. Many people who have had a near-death experience report positive aftereffects, including a positive attitude and spiritual development. Asking if the client had ever heard of other persons having a near-death experience would not be the most appropriate response. It does not help the client explore his or her own experience. DIF: A REF: 447 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 4. A 76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the client’s spiritual needs and responds best by saying: 1. “I notice you have a Bible; is that a source of spiritual strength to you?” 2. “What do you believe will happen to your personal spirit when you die?” 3. “We would allow members of your church to visit you whenever you desire.” 4. “Has hearing about your terminal condition made you lose your faith or beliefs?” ANS: 1 Stating the observation of a client having a Bible opens communication regarding the client’s source of strength. Assessing a client’s source of strength and faith can direct interaction with the client, including medical treatment plans. Asking what the belief about the spirit upon death is not the best response. It does not provide information that would assist the nurse in meeting the client’s spiritual needs. Allowing fellow church members is not the best response. It implies the client goes to church or should go to church, and assumes that church members are a source of strength for the client. It does not provide assessment information to determine the client’s spiritual needs. Asking if this has caused a loss in faith or beliefs is not the best response. It has a negative connotation, and does not assess the client’s source of strength or the beliefs of the client. DIF: A REF: 447 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 5. A client with diabetes is being cared for in the home, with the assistance of a home health nurse and a family member. The client asks you if eating a vegetarian diet will conflict with the disease. The nurse anticipates that the client will follow a vegetarian diet because he is a member of which of the following religions? 1. Hinduism 2. Judaism 3. Islam 4. Sikhism ANS: 1 Some sects of Hindus are vegetarians. The belief is not to kill any living creature. Followers of Judaism may observe the kosher dietary restriction of avoiding pork and shellfish and not preparing and eating milk and meat at the same time. People of Islamic faith do not consume pork and alcohol. Fasting is done during the month of Ramadan. Members of the Sikhism religion do not necessarily follow a vegetarian diet. DIF: A REF: 450 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 6. A tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a: 1. Relationship with a divinity 2. System of organized beliefs 3. Cultural connectedness 4. Meaning and purpose ANS: 4 Hope provides a sense of meaning and purpose. When a person has hope, he or she has an attitude of something to live for and look forward to. Faith is a relationship with a divinity. Religion is a system of organized beliefs. Spirituality provides a cultural connectedness. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 7. The nurse, while working with a client to support and assess spirituality should first: 1. Refer the client to the agency chaplain 2. Assist the client to use faith to get well 3. Provide a variety of religious literature 4. Determine the client’s personal belief system ANS: 4 While working with a client to assess and support spirituality, the nurse should first determine the client’s perceptions and belief system. Exploring the client’s spirituality may reveal responses to health problems that require nursing intervention, or it may reveal the existence of a strong set of resources that enable the client to cope effectively. Although the agency chaplain may be a source for referral, it is not the first action the nurse should take in assessing and supporting a client’s spirituality. The nurse needs to first assess a client’s spirituality to determine the client’s perceptions and belief system before attempting to assist the client to use faith to get well. Providing a variety of religious literature may be ineffective as it does not address the client as an individual and does not assess the client’s personal spiritual needs. The nurse should first assess the client’s perception and belief system before implementing any intervention. DIF: A REF: 444-445 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 8. If a client is identified as following the traditional health care beliefs of Judaism, the nurse should prepare to incorporate the following into care: 1. Faith healing 2. Regular fasting 3. Ongoing group prayer 4. Observance of the Sabbath ANS: 4 Observance of the Sabbath is important to a client who follows the traditional health care beliefs of Judaism. This client my refuse treatments scheduled on the Sabbath. Followers of the Islamic or Christian faith may use faith healing in response to illness. Regular fasting may be seen with some Roman Catholics or with followers of the Russian Orthodox Church. Ongoing group prayer may be seen with the Islamic faith. Christians also use prayer. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 9. The nurse is conferring with the nutritionist about the needs of a Native American. The nurse anticipates that the client will: 1. Follow a strict vegetarian diet 2. Avoid the use of alcohol and tobacco 3. Expect to avoid pork-related products 4. Follow a diet according to individual tribal beliefs ANS: 4 Food practices of Native Americans are influenced by individual tribal beliefs. Some Hindus and Buddhists are vegetarians. Buddhists, Mormons, and some Baptists, Evangelicals, and Pentecostals avoid the use of alcohol and tobacco. Members of Hinduism, Islam, and Judaism may avoid pork products. DIF: A REF: 457 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 10. The nurse has identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the client’s spiritual needs? 1. Altered health maintenance 2. Ineffective individual coping 3. Impaired long-term memory 4. Decreased adaptive capacity ANS: 2 Ineffective individual coping is a nursing diagnosis that may apply to clients in need of spiritual care. The nursing diagnosis of altered health maintenance does not indicate the greatest potential need for spiritual care. The nursing diagnosis of impaired long-term memory does not imply the need for spiritual care. The nursing diagnosis of decreased adaptive capacity does not indicate the greatest potential need for spiritual care. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 11. The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child: 1. Baptism will be performed immediately 2. Special prayers will be said over the child 3. Special preparations will be made for the umbilical cord and placenta 4. No particular rituals will usually be performed in the postpartum period ANS: 4 No special rituals are usually performed in the immediate postpartum period with members of the Shinto, Buddhist, or Hindu religions. Many Christians will baptize their infants. Followers of Islam will say special prayers after birth over the child. Navajos make special preparations for the umbilical cord and placenta after the birth of a child. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 12. The nurse may incorporate similarities of nutritional needs into the plan of care for clients who are Mormon and Buddhist. Members of these religions both: 1. Fast on Fridays 2. Follow vegetarian diets 3. Avoid alcohol and tobacco 4. Avoid mixing dairy and meat products ANS: 3 Both Mormons and Buddhists avoid alcohol and tobacco. Some Roman Catholics and Russian Orthodox members may fast on Fridays. Both Hindus and Buddhists may follow vegetarian diets. Followers of Judaism may avoid eating milk and meat at the same time. DIF: A REF: 457 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 13. The nurse anticipates the gender-related needs of the clients and tries to accommodate those needs whenever possible. A female nurse is arranged for the female client who practices: 1. Sikhism 2. Judaism 3. Hinduism 4. Buddhism ANS: 1 Females are to be examined by females according to the Sikhism religion. Followers of Judaism view visiting the sick as an obligation. They have no restrictions on genderrelated care. Followers of Hinduism view illness as being caused by past sins. Prolonging life is discouraged. There are no restrictions on care related to gender. Buddhists believe in Dharma, which teaches that life is impermanent and all persons have to age and die. There are no restrictions on care related to gender. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 14. The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the child’s birth for the clients who are: 1. Catholic 2. Navajo 3. Shinto 4. Hindu ANS: 2 After a Navajo child’s delivery, the umbilical cord is taken from the newborn, dried, and buried near a place that symbolizes what parents want for the child’s future. Catholics do not have special care of the umbilical cord after delivery. They may want their newborn baptized if there is any chance of the newborn not surviving. Shintos have no special rituals related to birth, including the umbilical cord. Hindus have no special rituals related to birth, including the umbilical cord. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 15. A client diagnosed with an autoimmune disorder uses guided imagery to help control anxiety. Which of the following assessment data supports the effectiveness of the intervention on the actual management of the disease? 1. A noticeable increase in the client’s appetite 2. A decrease in the client’s HDL cholesterol level 3. A white blood cell count at the low-normal range 4. A blood glucose level at the low end of the normal range ANS: 3 Current evidence has shown that relaxation exercises and guided imagery improve immune function. So a normal white cell count in a client diagnosed with an autoimmune disorder would be considered evidence of the therapeutic nature of the guided imagery. There is no known connection to these other options. DIF: C REF: 444 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 16. Which of the following statements made by a client diagnosed with terminal renal failure best expresses the client’s sense of hope? 1. “My father lived for years with this disease.” 2. “I’ve had a good life, and I’ll live each day as it comes.” 3. “Research is always coming up with new treatments and cures.” 4. “My daughter is getting married in 4 months, and I’m going to walk her down the aisle.” ANS: 4 When a person has the attitude of something to live for and look forward to, hope is present. The plan to attend and participate in the daughter’s wedding provides the focus for living. The other options are lacking that component of focus. DIF: C REF: 446 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 17. The wife of a client diagnosed with Alzheimer’s disease shares with the home health nurse that, “We always went to church on Wednesday evenings. I miss that a lot.” Which of the following statements made by the nurse has the greatest therapeutic value at this time? 1. “Was religion as important to your husband as well?” 2. “Please tell me more about the role religion plays in your lives.” 3. “May I help arrange for a sitter so you can attend church services again?’ 4. “Attending church services has always been very important to me as well.” ANS: 3 Encourage caregivers to participate in spiritual behaviors or practices (e.g., prayer, attending religious services) to enhance spiritual well-being when appropriate. Since the client has introduced the wish to attend services, it is appropriate for the nurse to make a suggestion to help that happen. Some of the remaining options do encourage the caregiver to discuss the couple’s spiritual needs but do not directly deal with the verbalized need. The final option is merely the nurse’s statement of religious practice. DIF: C REF: 445-446 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 18. A client who recently required advanced cardiac life support after experiencing a myocardial infarction shares with the nurse that, “I could hear voices talking about me dying and then there was this brightly lighted tunnel.” Which of the following statements made by the nurse shows the best understanding of therapeutic communication regarding a client’s near-death experience? 1. “Tell me more about what you saw and heard.” 2. “What you are describing is called a near-death experience.” 3. “Many clients who have been clinically dead have those types of memories.” 4. “What you are describing is most likely a result of the drugs you were given.” ANS: 1 Clients who have a near-death experience are often reluctant to discuss it, thinking family or caregivers will not understand. However, individuals experiencing a near-death experience who discuss it with family or caregivers find acceptance and meaning from this powerful experience. By encouraging the client to discuss the experience, the nurse is providing therapeutic care in an accepting manner. The remaining options close the communication opportunity by providing a reason for the event. DIF: C REF: 13 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 19. Which of the following statements made by a nurse regarding spiritual support provided displays an inappropriate intervention or attitude? 1. “I offer to pray with my clients as I prepare them for transport to surgery.” 2. “I always try to tell my Catholic clients when Mass is being held in the chapel.” 3. “When caring for a client for the first time, I always check to see their religious affiliation.” 4. “I’m not very comfortable interviewing a client concerning their religious beliefs or practices.” ANS: 1 It is essential to promote an environment that respects clients’ values, customs, and spiritual beliefs. Routinely implementing nursing interventions such as prayer or meditation is coercive and/or unethical. Therefore determine which interventions are compatible with the clients’ beliefs and values before selecting nursing interventions. To routinely offer to pray with a client without first establishing the appropriateness of that intervention is unethical and so requires immediate instruction of that to the nurse. Two options are not inappropriate and so require no intervention while the third reflects the nurse’s discomfort with a task but does not indicate any failure to provide effective, appropriate nursing care. DIF: C REF: 448 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 20. When asked about his or her religious affiliation, a client responds, “That’s personal; why do you want to know?” The most appropriate nursing response is: 1. “You need not answer my question if you prefer not to share that information.” 2. “All information you provide will be kept in strict confidence.” 3. “By knowing your religious preferences, I can best meet your spiritual needs.” 4. “I did not mean to offend you; we ask that question of all our new admissions.” ANS: 3 The Joint Commission requires health care organizations to acknowledge clients’ rights to spiritual care and provide for clients’ spiritual needs through pastoral care or others who are certified, ordained, or lay individuals. The Joint Commission requires nurses to assess their clients’ denomination, beliefs, and spiritual practices. Informing the client of this requirement and the purpose for which the information will be used is the most appropriate response. The remaining options fail to fully answer the client’s question. DIF: C REF: 448 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 21. Which of the following interview questions will best determine a client’s readiness for enhanced spiritual well-being? 1. “Are you a religious person?” 2. “Are you satisfied with your life?” 3. “To whom do you turn when you have a problem to deal with?” 4. “Do you tend to rely on prayer during times of personal stress?” ANS: 3 Readiness for enhanced spiritual well-being is based on defining characteristics that show a person’s ability to experience and integrate meaning and purpose in life through connectedness with self and others. A client with this nursing diagnosis has potential resources to draw on when faced with illness or a threat to well-being. By asking the client to identify his or her coping strategy for times of stress, the nurse can begin to assess the client’s spiritual well-being. The remaining options are more directed towards assessing faith, or life satisfaction. DIF: C REF: 452 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 22. The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to: 1. Move the family into the unit’s sunroom for the ritual 2. Ask the client and her family to be allowed to pray with the group 3. Offer to arrange for the facility’s chaplain to attend the prayer session 4. Schedule the client’s physical therapy treatments to avoid being an interruption ANS: 4 Spiritual priorities do not need to be sacrificed for physical care priorities. For example, when a client is in acute distress, focus care to provide the client a sense of control, but when a client is terminally ill, spiritual care is possibly the most important nursing intervention. By arranging for the PT treatment at a time that will not interrupt the client’s prayers, the nurse is showing attention to the client’s spiritual needs most therapeutically. While the other options may be appropriate, they do not address the facilitation of the client’s expressed need regarding prayer. DIF: C REF: 444 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 23. A client who has been severely burned has been taught meditation techniques to help manage the stress of his recovery period. The nurse recognizes which of the following assessment findings as most conclusive of the effectiveness of the intervention? 1. The client stating, “I like to meditate” 2. Observing the client in a meditative pose 3. The client heard telling his son that he has learned to meditate 4. A 10-point drop in the client’s systolic blood pressure after meditation ANS: 1 The most conclusive evidence of the effectiveness of the intervention is the client’s verbalization of its worth. The client stating his positive feelings regarding meditation is the best option. The remaining options may indicate effectiveness but not as personally as the client’s statement. DIF: C REF: 457 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Effective Care Environment Potter & Perry: Fundamentals of Nursing, 7 Edition th Test Bank Chapter 31: Stress and Coping MULTIPLE CHOICE 1. For a lifestyle stress indicator and reduction in the incidence of heart disease a recommended intervention would be: 1. Regular physical exercise 2. Attendance at a support group 3. Self-awareness skill development 4. Effective time management techniques ANS: 1 A regular exercise program reduces tension, promotes relaxation, increases one’s resistance to stress, and reduces the risk of cardiovascular disease. Support systems may benefit a person experiencing stress but do not reduce the incidence of heart disease. Selfawareness skill development may enable a person to recognize when they are experiencing stress and need to implement stress-reducing strategies, but they will not reduce the incidence of heart disease. Time management, including setting priorities, helps individuals identify tasks that are not necessary or can be delegated to someone else. Effective time management will help lower one’s level of stress, but does not reduce the incidence of heart disease. DIF: A REF: 494 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 2. An adolescent child, who is having behavioral problems has had added responsibilities put upon her because the father has just loss his job and is experiencing periods of depression and the mother has a chronic debilitating illness. The nurse is involved in crisis intervention and intervenes to specifically focus the family on their feelings by: 1. Pointing out the connection between the situation and their responses 2. Encouraging the use of the family’s usual coping skills 3. Working on time management skills 4. Discussing past experiences ANS: 1 When using a crisis intervention approach, pointing out the connections between situation and responses, the nurse helps the client make the mental connection between the stressful event and the client’s reaction to it. Because an individual’s or family’s usual coping strategies are ineffective in managing the stress of the precipitating event in a crisis situation, the use of new coping mechanisms is required. Time management skills will not help reduce the stress of the precipitating event in a crisis situation. What may have worked in past experiences is ineffective in managing the stress of the precipitating event in a crisis situation. DIF: A REF: 498 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 3. A mother and her child sit in a playroom on the pediatric unit. The boy wants to play with a toy that another child has but the mother says no. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as: 1. Displacement 2. Compensation 3. Conversion 4. Denial ANS: 1 Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that might cause intolerable emotional pain. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 4. Clients undergoing stress may have periods of regression. The nurse assesses this regressive behavior in the situation where: 1. 2. 3. 4. An adult client exercises to the point of fatigue An 8-year-old child sucks his thumb and wets the bed An adult client avoids speaking about health concerns An 11-year-old child experiences stomach cramps and headaches ANS: 2 Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period, such as an 8-year-old child sucking his thumb and wetting the bed. An adult client who exercises to the point of fatigue is not demonstrating regression. An adult client who avoids speaking about health concerns may be using denial as a coping mechanism. An 11-year-old who develops stomach cramps and headaches is an example of conversion. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 5. During the end-of-shift report the nurse notes that a client had been very nervous and preoccupied during the evening and that no family visited. To determine the amount of anxiety that the client is experiencing, the nurse should respond: 1. “Would you like for me to call a family member to come support you?” 2. “Would you like to talk with another client who had the same surgery?” 3. “How serious do you think the illness you are experiencing really is?” 4. “You seem worried about something. Would it help to talk about it?” ANS: 4 The nurse learns from the client both by asking questions and by making observations of nonverbal behavior and the client’s environment. To determine the amount of anxiety the client is experiencing, the nurse gathers information from the client’s perspective. Noting that he seems worried and offering to discuss it is the correct response. Asking if the client desires for family to be called is not assessing the client’s level of anxiety. The nurse should first focus on developing a trusting relationship with the client. If the nurse takes the client to visit someone who had the same surgery, the nurse would not be able to assess the client’s current level of anxiety. Asking the client about how serious he deems the illness to be is not the best response. It does not assess the amount of anxiety the client is currently experiencing. DIF: A REF: 491 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 6. A 23-year-old man who recently had a head injury from a motor vehicle accident (MVA) is in a state of unconsciousness. Which of the following physiological adaptations is primarily responsible for his level of consciousness? 1. Pituitary gland 2. Medulla oblongata 3. Reticular formation 4. External stress response ANS: 3 The reticular formation is primarily responsible for an individual’s level of consciousness. The pituitary gland supplies hormones that control vital functions. The pituitary gland produces hormones necessary for adaptation to stress (e.g., adrenocorticotropic hormone). The medulla oblongata controls vital functions such as heart rate, blood pressure, and respiration. The external stress response is not primarily responsible for a person’s level of consciousness. DIF: A REF: 486 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 7. Clients experiencing post-traumatic stress disorder (PTSD) following the World Trade Tower bombing work with nurses in the medical center. An approach that is appropriate and should be incorporated into the plan of care is: 1. Suppression of anxiety-producing memories 2. Reinforcement that the PTSD is short term 3. Promotion of relaxation strategies 4. Focus on physical needs ANS: 3 Teaching the client relaxation strategies can help reduce the stress of anxiety-provoking thoughts and events, as seen in PTSD, and reinforces an adaptive coping strategy. Suppression would be a maladaptive coping mechanism. PSTD persists longer than 1 month. The focus should be on developing adaptive coping mechanisms and lowering the individual’s anxiety. The focus is not on physical needs for the client who is experiencing PTSD. DIF: A REF: 489 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 8. A client is experiencing job-related stress. The nurse is working with the client in an outpatient health care setting. The nurse believes this client is dissociated as a result of observing the client: 1. 2. 3. 4. Avoid discussion of job problems Act like another colleague on the job Experience chronic headaches and stomach aches Sit quietly and not interacting with any of the staff ANS: 4 Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings. The client who is sitting quietly and not interacting with any of the staff may be displaying dissociation. The client who avoids discussion of the problem may be using denial as an ego-defense mechanism. The client who acts like another colleague on the job is using identification as an ego-defense mechanism. The client who experiences headaches and stomach aches is using the ego-defense mechanism of conversion. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 9. A 72-year-old client is in a long-term care facility after having had a cerebrovascular accident. The client is noncommunicative, enteral feedings are not being absorbed, and respirations are becoming labored. Which of the stages of the GAS is the client experiencing? 1. Alarm reaction 2. Resistance stage 3. Exhaustion stage 4. Reflex pain response ANS: 3 The exhaustion stage occurs when the body can no longer resist the effects of the stressor and when the energy necessary to maintain adaptation is depleted. During the alarm reaction, rising hormone levels result in increased blood volume, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. During the resistance stage, the body stabilizes. Reflex pain response is not a stage of GAS. DIF: A REF: 487 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 10. A client recently lost a child in a severe case of poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indicators of stress? 1. Spiritual indicator 2. Emotional indicator 3. Intellectual indicator 4. Sociocultural indicator ANS: 4 The client who recently experienced a loss and does not want to meet new people is an example of a sociocultural indicator of stress. Spiritual indicator is not an example of a spiritual indicator of stress. The client is not restless or verbalizing discontent with a higher being. Emotional indicator is not an example of an emotional indicator of stress. The client is not displaying anger or crying. Intellectual indicator is not an example of an intellectual indicator of stress. DIF: A REF: 490 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 11. A corporate executive works 60 to 80 hours/week. The client is experiencing some physical signs of stress. The practitioner teaches the client to “include 15 minutes of biofeedback.” This is an example of which of the following health promotion interventions? 1. Guided imagery 2. Regular exercise 3. Time management 4. Relaxation technique ANS: 4 Relaxation technique is correct. Biofeedback is a training program designed to develop one’s ability to control the autonomic (involuntary) nervous system. Clients learn to monitor their functioning such as heart rate, blood pressure, skin temperature, or muscle tension, and learn to relax in response in order to create desired changes. Guided imagery is a relaxed state in which a person actively uses imagination in a way that allows visualization of a soothing, peaceful setting. This is not an example of guided imagery. Regular exercise is not an example of a regular exercise program. It does not improve muscle tone and reduce the risk of cardiovascular disease. Time management techniques include developing lists of tasks to be performed in order of priority. This is not an example of time management. DIF: A REF: 497 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 12. It appears to the nurse the client is experiencing a crisis. The nurse plans to: 1. Allow the client to work through independent problem-solving 2. Complete an in-depth evaluation of stressors and responses 3. Focus on immediate stress reduction 4. Recommend ongoing therapy ANS: 3 The nurse’s focus for a client experiencing a crisis is immediate stress reduction. The client experiencing a crisis is unable to work through independent problem solving. Completing an in-depth evaluation of stressors and responses to the situation would be inappropriate for the client who is experiencing a crisis. A person who has experienced a crisis has changed, and the effects may last for years or for the rest of the person’s life. If a person has successfully coped with a crisis and its consequences, he or she becomes a more mature and healthy person, and ongoing therapy may not be necessary. DIF: A REF: 498 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 13. What priority assessment area has been noticed by a nurse while working with clients who are experiencing a significant degree of stress? 1. The client’s primary physical needs 2. What else is happening in the client’s life 3. How the stress has influenced the client’s activities of daily living 4. Determining whether the client is thinking about harming self or others ANS: 4 A priority assessment is to determine if the person is suicidal or homicidal by asking directly. The priority assessment for the client who is experiencing a significant degree of stress is not the client’s physical needs. The nurse should first determine if the client is a danger to self or others. After determining if the client is suicidal or homicidal, the nurse can begin the problem-solving process and assess what else is happening in the client’s life. The nurse should first determine if the client is a danger to self or others. Then the nurse can examine the degree of disruption in the person’s life, such as in activities of daily living. DIF: A REF: 494 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 14. The response to stress for older adults may be manifested differently than in younger adults. The nurse recognizes that. For the older adult client, the nurse is aware that: 1. Losses are more stress-provoking 2. Anxiety disorders are most prevalent 3. Psychosocial factors are the greatest threats 4. Timing of stress-inducing events is not significant ANS: 2 Anxiety disorders are the most prevalent disorders in later life and are continuations of life-long illnesses. Losses in later life may be less stress provoking than generally assumed, partly because certain life transitions are anticipated and people prepare by coping in advance. The effect of psychosocial factors on health status is not altered by age. The timing of stress-inducing events can significantly influence older adults’ ability to cope. The fact that older adults may have several stressful events (e.g., loss of a spouse and new medical diagnosis) occur with a short period of time can result in detrimental effects on coping. DIF: A REF: 491 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 15. A client who has experienced massive soft tissue trauma is handling both the physical and emotional stressors via the generalized adaptation syndrome (GAS). The major benefit of this defense mechanism is through the: 1. Identification of foreign antigens on invading bacteria 2. Production of endorphins that decrease awareness of pain 3. Increased epinephrine, resulting in improved cardiac output 4. Increased norepinephrine directed towards sustaining blood pressure ANS: 2 Endorphins, hormones that act on the mind like morphine and opiates, produce a sense of well-being and reduce pain. It is the body’s immune system that recognizes antigens on the surface of the bacteria cells and thus identifies bacteria as invaders. During the alarm reaction stage of the GAS process, rising epinephrine and norepinephrine levels result in increased heart rate and blood flow. DIF: A REF: 486-487 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 16. The nurse is caring for a client who was admitted with various physical traumas resulting from an assault by a stranger attempting to steal her purse. Which of the following statements made by the nurse is most therapeutic in assessing the degree of stress the event has caused the client? 1. “Would you like to talk about the attack?” 2. “What may I do to help you emotionally?” 3. “Has being attacked been traumatic for you?” 4. “How has this experience affected your life?” ANS: 4 The vital question for a person in crisis is, “What does this mean to you; how is it going to affect your life?” What causes extreme stress for one person is not always stressful to another. The perception of the event, the situational supports, and the coping mechanisms all influence return of equilibrium or homeostasis. The other options are not as effective at opening up client-directed communication concerning the effects of the event. DIF: C REF: 488 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 17. Which of the following clients shows the greatest risk factor for stress coping related to situational stressors? 1. An 18-year-old high school athlete who breaks his leg just before college football tryouts 2. A 75-year-old widow whose only son is severely injured in an automobile accident 3. A 36-year-old who loses his job days after his marriage to his high school sweetheart 4. A 60-year-old who is diagnosed with prostate cancer after deciding to retire from his job of 26 years ANS: 2 The timing of stress-inducing events significantly influences older adults’ ability to cope. The fact that older adults have several stressful events (i.e., loss of a spouse and new medical diagnosis) occur within a short period of time often results in negative effects on coping ability. The remaining options reflect stressful situations but to lesser degrees. DIF: C REF: 489 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 18. Which of the following client behaviors best reflects Neuman Systems Model of primary prevention? The client who: 1. Swims daily to strengthen muscles weakened as a result of shoulder surgery 2. Follows a low-fat diet in order to bring her high-density lipids to under 200 mg/dL 3. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mm Hg 4. Attends a survivor support group after the loss of a spouse in an automobile accident ANS: 3 According to Neuman’s theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention. DIF: C REF: 489 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 19. The son of a client diagnosed with moderately advanced Alzheimer’s disease shows concern over the care his mother will receive after making the decision to institutionalize her. Which of the following statements made by the admitting nurse is most therapeutic in addressing the son’s concerns? 1. “We care deeply for all our clients and take great pride in the care and attention we give each one of them.” 2. “Please feel free to talk to our staff and to the other clients about the care and attention we give to each of our clients.” 3. “I hope that you will be able to visit your mother often and offer us suggestions on how best to meet her physical and emotional needs.” 4. “I know it has been a difficult decision, and you must have concerns about leaving her, but rest assured we have her best interest at heart.” ANS: 3 The decision to institutionalize a family member and the aftermath of that decision cause emotional distress and are a threat to family members’ psychological well-being. When their role shifted from primary caregiver to advocate for the patient, the family members felt empowered. Previous studies showed that institutionalized residents have a better quality of life when family members are involved. By encouraging frequent visits and including them in the client’s care, the family’s concerns will be best managed. DIF: C REF: 490 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 20. Which of the following statements reflects the correct interpretation of the effect of age on coping strategies? 1. “The young adult client generally handles stress more effectively than does the elder adult.” 2. “Life provides the older adult with more opportunities to effectively manage their stressful events.” 3. “Children appear to be less aware of stressors in their lives and so are less negatively affected by it.” 4. “Stress is evident in everyone’s life and we all learn to cope with it regardless of our age or life experiences.” ANS: 4 There are very few age-related differences in coping strategies, and older adults are just as effective at coping as younger adults (Varcarolis and others, 2006). DIF: A REF: 489 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 21. Which of the following client behaviors best reflects Neuman Systems Model of tertiary prevention? The client who: 1. Swims daily to strengthen muscles weakened as a result of hip surgery 2. Follows a low-fat diet in order to bring her high-density lipids to under 200 mg/dL 3. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mm Hg 4. Attends a survivor support group after the loss of a spouse in an automobile accident ANS: 1 According to Neuman’s theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear such as muscle strengthening post surgery. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention. DIF: C REF: 494 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 22. The husband of a client with terminal cancer has expressed a high degree of stress over his role as caregiver. When asked whether he has suicidal or homicidal thoughts he answered, “Sometimes.” Which of the following nursing statements is most therapeutic initially? 1. “What is the hardest part about your wife’s impending death?” 2. “Can you describe your plan for killing yourself and your wife?” 3. “What can I do to help make caring for your wife less stressful?” 4. “Can you tell me how caring for your wife has affected you personally?” ANS: 2 If a client indicates suicidal or homicidal ideations, the nurse should first determine in a caring and concerned manner if the person has a plan and determine how lethal the means are. The remaining options represent appropriate questions but only after the safety issues have been addressed. DIF: C REF: 497 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 23. Which of the following statements made by the nurse shows the best understanding of the therapeutic value of a support system for a client experiencing stress? 1. “They will be there when you need them and make sure you will have your needs met.” 2. “They will provide you with someone to talk with about your problems and support your decisions.” 3. “When you are experiencing stress, it is always comforting to have people who care about you nearby.” 4. “These individuals have experienced what you are going though and can offer you effective suggestions.” ANS: 2 A support system of family, friends, and colleagues who will listen, offer advice, and provide emotional support benefits a client experiencing stress. The individuals need not have actually experienced the same stressors nor is it necessary or reasonable to expect that they will meet all your needs. DIF: C REF: 486 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management MULTIPLE RESPONSE 1. The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the resulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.) 1. Rectal temperature of 102.2° F 2. Pulse Ox of 97% on room air 3. Respirations of 30 breaths per minute 4. Heart rate greater than 100 beats per minute 5. Fasting glucose level of 118 mg/dL 6. Systolic blood pressure 26 mm Hg above baseline ANS: 3, 4, 5, 6 This reaction prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar levels. Body temperature and oxygen saturation are not typically affected by fight or flight. DIF: C REF: 487 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management Potter & Perry: Fundamentals of Nursing, 7 Edition th Test Bank Chapter 40: Oxygenation MULTIPLE CHOICE 1. The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? 1. Stimulating the parasympathetic system would cause the heart rate to go up. 2. When a person has heart muscle disease, the heart muscles stretches as far as is necessary to maintain function. 3. The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles. 4. When stroke volume decreases, there is a resultant decrease in heart rate. ANS: 3 The QRS complex indicates that the electrical impulse has traveled through the ventricles. Stimulating the parasympathetic system would cause the heart rate to decrease, not increase. In the diseased heart, the stretch of the myocardium is beyond the heart’s physiological limits. When stroke volume is decreased, there is an increase in heart rate. DIF: A REF: 910 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 2. The nurse is working on a respiratory care unit in the hospital. Upon entering the room of a client with emphysema, it is noted that the client is experiencing respiratory distress. The nurse should: 1. Instruct the client to breathe rapidly 2. Provide 20% oxygen at 2 L/min via nasal cannula 3. Place the client in the supine position 4. Go to contact the health care provider ANS: 2 The nurse should provide a low concentration of oxygen to the client. The client should be instructed to use pursed-lip breathing. The most effective position for the client with cardiopulmonary disease is the 45-degree semi-Fowler’s position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm. The nurse’s first priority should be to attend to the client who is in respiratory distress, not to contact the health care provider. DIF: B REF: 960 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 3. A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The electrocardiogram (ECG) reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and rate of 108 beats per minute. The nurse should recognize this cardiac dysrhythmia as: 1. Sinus dysrhythmia 2. Sinus tachycardia 3. Supraventricular tachycardia 4. Ventricular tachycardia ANS: 2 The client is experiencing sinus tachycardia. The rhythm is regular with a normal P wave, normal QRS complex, and a rate of 100 to 180 beats per minute. A sinus dysrhythmia has a rate of 60 to 100 beats per minute and slows during inspiration and increases with expiration. The client is not experiencing a sinus dysrhythmia. With supraventricular tachycardia, the heart rate is 150 to 250 beats per minute, the P wave may be buried in the preceding T wave, and the P-R interval is variable. This client is not experiencing supraventricular tachycardia. With ventricular tachycardia the rhythm is slightly irregular at a rate of 100 to 200 beats per minute, the P wave is absent, the P-R interval is absent, and the QRS complex is wide. This client is not experiencing ventricular tachycardia. DIF: C REF: 914 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 4. A client recently fractured his spinal cord at the C3 level and is at great risk for developing pneumonia primarily because the: 1. Resulting paralysis immobilizes him, and secretions will increase in his lungs 2. Innervation to the phrenic nerve is absent, preventing chest expansion 3. Resulting abnormal chest shape disallows efficient ventilatory movement 4. Trauma decreases the ability of his red blood cells to carry oxygen ANS: 2 Cervical trauma at C3 to C5 can result in paralysis of the phrenic nerve, preventing chest expansion. Although the increase in lung secretions as a result of immobility is a risk factor, the client’s greatest risk is related to the level of his fracture. There is no mention of an abnormal chest shape. This client’s greatest risk for developing pneumonia is related to the level of his fracture. If the client were anemic as a result of blood loss from trauma, his oxygen-carrying capacity of blood would be decreased. There is no mention of excessive blood loss, nor would this place him at great risk for developing pneumonia. DIF: C REF: 910 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 5. The client has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the client may experience that the nurse is alert to is: 1. Jugular neck vein distention 2. Pulmonary congestion 3. Peripheral edema 4. Liver enlargement ANS: 2 Pulmonary congestion may be experienced in left-sided heart failure. Jugular neck vein distention is characteristic of right-sided heart failure. Peripheral edema is characteristic of right-sided heart failure. Hepatomegaly (liver enlargement) is characteristic of rightsided heart failure. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 6. On admitting a client, the nurse finds that there is a history of myocardial ischemia. The most disconcerting dysrhythmia for electrocardiography to reveal is: 1. Sinus bradycardia 2. Sinus dysrhythmia 3. Ventricular tachycardia 4. Atrial fibrillation ANS: 3 Ventricular tachycardia would be the most disconcerting dysrhythmia of the four options. Ventricular tachycardia results in a decreased cardiac output; it may lead to severe hypotension and loss of pulse rate and consciousness. Sinus bradycardia would not be of concern for this client. It is of no clinical significance unless it is associated with signs and symptoms of a decreased cardiac output. Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased rate. Atrial fibrillation is not as detrimental as ventricular tachycardia. DIF: C REF: 915 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 7. A client develops acute renal failure and a resulting metabolic acidosis. The nurse recognizes that the respiratory system compensates through: 1. Hypoventilation and increase of bicarbonate levels in the bloodstream 2. Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH 3. Hyperventilation to decrease the serum CO2 level and thereby raise the pH 4. Expansion of the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues ANS: 3 The respiratory system tries to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH. The respiratory system would compensate for metabolic acidosis with increased respirations, not hypoventilation. Bicarbonate is the renal component of acid-base balance, not the respiratory component. The pH measures hydrogen ion concentration. Alternating deep versus shallow breaths is not a compensating mechanism of the respiratory system for metabolic acidosis. The respiratory system does not compensate by expanding the lung tissues to their fullest. In metabolic acidosis, the respiratory system compensates by exhaling a greater amount of carbon dioxide. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 8. A client with a suspected narcotic (heroin) overdose is brought to the emergency department by the police. The nurse anticipates that assessment findings will reveal: 1. Agitation 2. Hyperpnea 3. Restlessness 4. Decreased level of consciousness ANS: 4 With a narcotic overdose, the respiratory center is depressed, reducing the rate and depth of respiration and the amount of inhaled oxygen. The client may display signs of hypoventilation, such as a decreased level of consciousness. A narcotic (heroin) overdose would cause sedation and respiratory depression, not agitation. The client would experience bradypnea, not hyperpnea. A narcotic (heroin) overdose would cause sedation and respiratory depression, not restlessness. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 9. The nurse identifies that the client is unable to cough to produce a sputum specimen, and the client’s secretions must be suctioned. Which suctioning route is preferred for obtaining this specimen? 1. Nasopharyngeal 2. Nasotracheal 3. Oropharyngeal 4. Orotracheal ANS: 2 Nasotracheal suctioning is the preferred route for obtaining a sputum specimen when the client is unable to cough to produce a sputum specimen on his or her own. The nasopharyngeal route for suctioning is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The oropharyngeal route is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The orotracheal route is used when the client is unable to manage secretions by coughing. The nasotracheal route is preferred over the orotracheal route because stimulation of the gag reflex is minimal. DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 10. The nurse is checking the client’s overall oxygenation. In assessment of the presence of central cyanosis, the nurse will inspect the client’s: 1. Palms and soles of the feet 2. Nail beds 3. Earlobes 4. Tongue ANS: 4 Central cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, where blood flow is high. Central cyanosis indicates hypoxemia. Peripheral cyanosis seen in the palms and soles of the feet, nail beds, or earlobes is often a result of vasoconstriction and stagnant blood flow. DIF: A REF: 917 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 11. A client has recently had mitral valve replacement surgery. To prevent excess serosanguineous fluid buildup, the nurse anticipates that care will include: 1. Increased oxygen therapy 2. Frequent chest physiotherapy 3. Incentive spirometry on a regularly scheduled basis 4. Chest tube placement in the thoracic cavity ANS: 4 Chest tubes are inserted to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, and to reestablish normal intrapleural and intrapulmonic pressures. The client who had mitral valve replacement surgery would be expected to have a chest tube postoperatively to prevent excess fluid buildup in the pleural space. Increased oxygen will not prevent excess fluid buildup. Frequent chest physiotherapy may help facilitate removal of secretions but will not prevent excess fluid buildup. Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid buildup. DIF: A REF: 950 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 12. The client is admitted to the emergency department with a pneumothorax. The nurse anticipates that the client will be experiencing: 1. Dyspnea 2. Eupnea 3. Fremitus 4. Orthopnea ANS: 1 The client with a pneumothorax (collapsed lung) will exhibit dyspnea and pain. Eupnea is normal, easy breathing. It would not be expected in the case of a pneumothorax. Fremitus is the vibration felt when the hand is placed on the client’s chest and the client speaks (vocal fremitus). Fremitus would be decreased with a pneumothorax. Orthopnea is a condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The client with a pneumothorax would be exhibiting dyspnea. DIF: A REF: 951 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 13. The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the following interventions does the nurse plan to include in the client’s care? 1. Assess nares for skin breakdown every 6 hours. 2. Check patency of the cannula every 2 hours. 3. Inspect the mouth every 6 hours. 4. Check oxygen flow every 24 hours. ANS: 1 The nurse caring for the client with a nasal cannula should plan to assess the client’s nares and superior surface of both ears for skin breakdown every 6 hours. The nurse should check patency of the cannula every 8 hours. The nurse does not need to check the client’s mouth in relation to the client’s use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures. Oxygen flow should be checked every 8 hours, not every 24 hours. DIF: A REF: 957 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 14. All of the following clients are experiencing increased respiratory secretions and require intervention to assist in their removal. Chest percussion is indicated and appropriate for the client experiencing: 1. Thrombocytopenia 2. Cystic fibrosis 3. Osteoporosis 4. Spinal fracture ANS: 2 Chest percussion is indicated and appropriate for the client with cystic fibrosis to assist in mobilizing the thick pulmonary secretions. Percussion is contraindicated in clients with bleeding disorders, such as the client with thrombocytopenia. Percussion is also contraindicated in the client with osteoporosis and the client with a spinal fracture or with fractured ribs. DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 15. The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the clients, which is: 1. 2. 3. 4. Cyanosis Restlessness A decreased respiratory rate A decreased blood pressure ANS: 2 Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability. Cyanosis is a late sign of hypoxia. A decreased respiratory rate is not an early sign of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As the hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 16. It is suspected that the client’s oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client’s decreased oxygenation is: 1. Poor skin turgor 2. Clubbing of the nails 3. Central cyanosis 4. Pursed-lip breathing ANS: 3 Central cyanosis is the most serious finding because it indicates hypoxemia. Poor skin turgor indicates dehydration. It is not an indication of the client’s decreased oxygenation. Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time and is not an indication of the client’s current deterioration in oxygenation status. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a client’s decreased oxygenation. DIF: C REF: 917 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 17. In teaching a client about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material? 1. Holter monitor 2. Echocardiography 3. Cardiac catheterization 4. Exercise stress test ANS: 3 A cardiac catheterization involves the injection of contrast material in order to visualize the cardiac chambers, valves, the great vessels, and coronary arteries. It also is used to measure the pressures and volumes within the chambers of the heart. A Holter monitor is a portable ECG worn by the client. It does not require contrast media. An echocardiography is a noninvasive measure that graphically depicts overall cardiac performance. An exercise stress test evaluates the cardiac response to the physical stress of the client on a treadmill. Contrast material is not used for this test. DIF: A REF: 925 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 18. At a community health fair the nurse informs the residents that the influenza vaccine is recommended for clients: 1. Only older than age 65 2. 40 to 60 years of age 3. In any age-group who have a chronic disease 4. Who have an acute febrile illness ANS: 3 Annual influenza vaccine is recommended for clients of any age with a chronic disease. Annual influenza vaccine is recommended for clients older than age 65, but this is not the only group. Annual influenza vaccine is recommended for any age-group, including those age 40 to 60, who have a chronic disease of the heart, lung, or kidneys; clients with diabetes; clients with immunosuppression or severe forms of anemia; or those in close or frequent contact with anyone in a high-risk group. Clients with an acute febrile illness should not be vaccinated. DIF: A REF: 927 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 19. The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning? 1. Placing the client in a supine position 2. Preparing for a clean or nonsterile technique 3. Suctioning the oropharyngeal area first, then the nasotracheal area 4. Applying intermittent suction for 10 seconds during catheter removal ANS: 4 Intermittent suction for up to 10 to 15 seconds should be applied during catheter removal to prevent injury to the mucosa. The client is not placed in a supine position. The client is usually placed in a semi-Fowler’s position. The client’s head is turned to the right to help the nurse suction the left mainstem bronchus, and the client’s head is then turned to the left to help the nurse suction the right mainstem bronchus. Nasotracheal suctioning is a sterile procedure. The nasotracheal area should be suctioned first, then the oropharyngeal area. The mouth and pharynx contain more bacteria than the trachea. DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 20. The client has chest tubes in place following thoracic surgery. In working with a client who has a chest tube, the nurse should: 1. Clamp the tubes except during client assessments 2. Remove the tubing from the connection to check for adequate suction power 3. Milk or strip the tubes every 15 to 30 minutes to maintain drainage 4. Coil and secure excess tubing next to the client ANS: 4 If the client is in a chair and the tubing is coiled, the tubing should be lifted every 15 minutes to promote drainage. Care should be taken to ensure the tubing remains secure. Clamping the tubes except during client assessments is an inaccurate statement. Clamping a chest tube is contraindicated when the client is ambulating or being transported. In a water-sealed system, gentle bubbling in the suction-control chamber indicates it is functioning. The suction source may be checked to verify it is on the appropriate setting. In a waterless system, the suction control (float ball) indicates the amount of suction the client’s intrapleural space is receiving. The tubing should not be disconnected. The chest tube should be stripped or milked only if indicated (e.g., there is clotted drainage in the tube) (check institutional policy). It is believed that stripping the tube greatly increases intrapleural pressure, which could damage the pleural tissue and cause or worsen an existing pneumothorax. Milking causes less of a pressure change. DIF: A REF: 950 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 21. The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to: 1. Suction continuously for 30-second intervals 2. Replace the oxygen and allow rest in between suctioning passes 3. Increase the amount of suction pressure to 200 mm Hg 4. Complete a number of suctioning passes until the catheter comes back clear ANS: 2 To promote maximum oxygenation, the nurse should replace the oxygen and allow rest in between suctioning passes. Suctioning should be intermittent for up to 10 to 15 seconds. Wall suction is set at 80 to 120 mm Hg; portable suction is set at 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk for trauma to mucosa and can induce greater hypoxia. The number of suctioning passes is determined by client assessment and need. Repeated passes can remove oxygen and may induce laryngospasm. The client is not suctioned until the catheter comes back clear. DIF: A REF: 936 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 22. A client with a chest tube in place is being transported via stretcher to another room closer to the nurses' station. During the transport the collection unit bangs against the wall and breaks open. The nurse immediately: 1. Clamps the tube 2. Tells the client to hyperventilate 3. Raises the tubing above the client’s chest level 4. Places the end of the tube in a container of sterile water ANS: 4 If the drainage unit is broken, the end of the chest tube can be quickly submerged in a container of sterile water to reestablish the seal. Clamping the chest tube may result in a tension pneumothorax. If the tubing becomes disconnected, the client should be instructed to exhale as much as possible and to cough. The client should not hyperventilate. Raising the tubing above the client’s chest level will not help the situation. DIF: C REF: 950 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 23. The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. Upon entering the room, the nurse expects to find the client: 1. Extremely fatigued 2. Complaining of chest pain 3. Experiencing a “fluttering” sensation in the chest 4. Having no clinical signs based on the assessment ANS: 4 The nurse would expect to find the client experiencing a sinus dysrhythmia at a rate of 82 beats per minute to have no clinical symptoms. The client with atrial fibrillation may complain of fatigue. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain. The client with atrial fibrillation may complain of a “fluttering” sensation in the chest. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 24. The electrical activity of the client’s heart is being continuously monitored while the client is on the coronary care unit. Suddenly the nurse finds that the client is experiencing ventricular fibrillation. The nurse will prepare to: 1. Administer atropine 2. Prepare for cardiopulmonary resuscitation (CPR) 3. Prepare the client for surgical placement of a pacemaker 4. Instruct the client to perform the Valsalva maneuver ANS: 2 The nurse should prepare for CPR for the client experiencing ventricular fibrillation. Atropine is used for sinus bradycardia with hypotension and decreased cardiac output. In this case, the nurse should prepare to administer CPR, not atropine. A pacemaker may be required for the client with sinus bradycardia. It is not the treatment for ventricular fibrillation. The Valsalva maneuver is used to treat supraventricular tachycardia, not ventricular fibrillation. DIF: B REF: 913 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 25. The client is admitted to the medical center with a diagnosis of right-sided heart failure. In assessment of this client, the nurse expects to find: 1. Dyspnea 2. Confusion 3. Dizziness 4. Peripheral edema ANS: 4 Peripheral edema is an expected assessment finding in the client diagnosed with rightsided heart failure. Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure. Confusion is a symptom of hypoventilation. Dizziness is an expected assessment finding in the client experiencing hypoxia. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 26. The nurse is preparing to teach a group of adult women about the signs and symptoms of a myocardial infarction (heart attack). The nurse will include in the teaching plan the results of research that demonstrate women may experience specific symptoms, such as: 1. Visual difficulties 2. Epigastric pain 3. Loss of motor function unilaterally 4. Right scapular discomfort and stiffness ANS: 2 Epigastric pain is a symptom of a myocardial infarction in women. Visual disturbances, loss of motor function unilaterally, and right scapular discomfort and stiffness are not symptoms of a myocardial infarction in women. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 27. The nurse is reviewing the results of the client’s diagnostic testing for pulmonary function. Of the following results, the finding that falls within expected or normal limits is: 1. SpO2 88% 2. pH 7.52 3. PaCO2 55 mm Hg 4. Decreased peak expiratory flow rate (PEFR) from prior assessment ANS: 3 The normal SpO2 is 98% to 100%; the client’s measurement is low at 88%. The normal pH is 7.35 to 7.45; the client’s pH is high at 7.52. The normal PaCO2 is 35 to 45 mm Hg; the client’s PaCO2 is elevated at 55 mm Hg. The normal PEFR should increase or remain the same when compared to the prior assessment. A decreased PEFR would indicate airway obstruction. Predicted values are based on age, sex, and height. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 28. The nurse is completing a physical examination for a client who is anemic. In assessing the client’s eyes, a sign assessed by the nurse that is consistent with the diagnosis is: 1. Xanthelasma 2. Petechiae 3. Corneal arcus 4. Pale conjunctiva ANS: 4 Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia. Xanthelasma is caused by hyperlipidemia. Petechiae appear on the skin in clients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae is consistent with a fat embolus or bacterial endocarditis. Corneal arcus is caused by hyperlipidemia in young to middle-age adults. It is a normal finding in older adults with arcus senilis. DIF: A REF: 923 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 29. Several nursing students are discussing cardiac conduction with their clinical instructor. When asked where a heart rate of 56 beats per minute most likely originates, the most informed student replies: 1. The atrioventricular (AV) node 2. The sinoatrial (SA) node 3. The Purkinje network 4. The bundle of His ANS: 1 The conduction system originates with the sinoatrial (SA) node, the “pacemaker” of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate between 60 and 100 beats per minute. The electrical impulses are transmitted through the atria along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulses between the atria and the ventricles. The intrinsic rate of the normal AV node is between 40 and 60 beats per minute. The AV node assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network. The intrinsic rate of the bundle of His and the ventricular Purkinje network is between 20 and 40 beats per minute. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 30. A client asks the nurse, “I was told that my heart is beating in normal sinus rhythm (NSR). What does that mean?” The nurse replies most therapeutically when responding with which of the following? 1. “Are you worried about how your heart is working?” 2. “It means your heart is working just the way it is supposed to work.” 3. “A damaged heart doesn’t beat in normal sinus rhythm like yours does.” 4. “Each beat starts in the SA node and then causes the chambers to contract.” ANS: 4 NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system. DIF: C REF: 913 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 31. When the nurse is reviewing a client’s laboratory results, a low calcium level is noted. When the nurse then reviews the client’s electrocardiogram, the most likely change noted will be a(n): 1. Increased Q-T interval 2. Increased P-R interval 3. Q-T interval less than 0.12 seconds 4. QRS interval greater than 0.12 seconds ANS: 1 The normal Q-T interval is 0.12 to 0.42 second. Changes in electrolyte values, such as hypocalcemia, or therapy with drugs such as disopyramide or amiodarone increase the QT interval. The remaining options do not reflect a low calcium level. DIF: A REF: 910 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 32. The primary reason a client with chronic obstructive pulmonary disease (COPD) often experiences fatigue and activity intolerance is related to: 1. The increased presence of surfactant that results in “sticky” alveoli 2. The presence of chronic infections in the lungs and bronchial tree 3. The extra energy that is needed to exhale the air from the damaged lungs 4. The client’s elevated anxiety level related to the air hunger being experienced ANS: 3 Clients with advanced COPD lose the elastic recoil of the lungs and thorax. As a result, the client’s work of breathing increases. Although the remaining options are not incorrect, they are not the primary source of the client’s fatigue. DIF: C REF: 911 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 33. The nurse is assessing a client with a history of chronic obstructive pulmonary disease. When assessing for the presence of air hunger, the nurse should: 1. Monitor the client’s pulse oximetry reading 2. Measure the movement of air by counting respirations 3. Auscultate breath sounds both anteriorly and posteriorly 4. Observe for the elevation of the client’s clavicles during inspiration ANS: 4 During an assessment, observe for elevation of the client’s clavicles during inspiration. Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Although the remaining options are assessment methods, they are not as effective for determining air hunger. DIF: C REF: 911 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 34. Pregnancy affects a woman’s oxygenation needs primarily because of: 1. The increased metabolic demands required to support the fetus 2. The increased tendency to develop anemia as a result of low iron reserves 3. The decreased ability to engage in the physical exercise required to promote circulation 4. The decreased lung capacity resulting from the pressure of the uterus on the diaphragm ANS: 1 Increased metabolic demands, such as pregnancy or fever and infection, affect a client’s oxygen-carrying capacity (of the blood). The remaining options can affect respiratory function but are not the primary cause of increased oxygenation requirements. DIF: C REF: 912 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 35. in: The primary effect of chronic fevers on the body’s respiratory functioning is seen 1. 2. 3. 4. Increased oxygen requirements that exceed the body’s ability to satisfy its needs Increased respiratory rates that tax the body’s reserves of stored energy Breakdown of muscle mass, causing ineffective intercostal muscle function The presence of a sense of general malaise that stresses the immune system ANS: 3 When fever persists, the metabolic rate remains high and the body begins to break down protein stores, resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostal muscles are also wasted. Although the remaining options are not incorrect, they do not represent the primary effect. DIF: C REF: 912 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 36. The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures) as a result of a motorcycle accident. The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because: 1. Pain increases metabolic needs, thus increasing oxygen consumption 2. Pain increases emotional distress, which can lead to hyperventilation 3. Pain will decrease the client’s motivation to deep breathe, contributing to shallow, diminished inspirations 4. Pain will decrease the client’s ability to both relax and recuperate, thus extending the period of recovery ANS: 3 Chest wall trauma and upper abdominal incisions decrease chest wall movement as the client uses shallow respirations to minimize chest wall movement to avoid pain. DIF: C REF: 913 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 37. The nurse observes that a client’s pulse rate is 58 beats per minute and regular in rhythm. Which of the following statements made by the nurse shows the appropriate understanding of the client’s further need for assessment? 1. “I’ll wait 15 minutes and reevaluate the client’s pulse rate.” 2. “Her pulse rate is usually in the mid 60s, so there isn’t a problem.” 3. “I’ll need to assess her for the presence of chest pain and/or dizziness.” 4. “You run an electrocardiogram, and I’ll notify her health care provider.” ANS: 3 A low but regular heart rate has no clinical significance unless associated with signs and symptoms of reduced cardiac output such as dizziness or syncope or the presence of chest pain. DIF: C REF: 914 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 38. The nurse suspects that a 59-year-old client has experienced angina pectoris. Which of the following assessment questions will most likely produce information that will assist in the diagnosis? 1. “How long did the pain last?” 2. “Can you describe the pain for me?” 3. “Did the pain radiate into your left arm?” 4. “What were you doing when the pain started?” ANS: 1 Unlike the pain resulting from a myocardial infarction, anginal pain usually lasts from 1 to 15 minutes. The remaining questions could also relate to cardiac pain from other origins. DIF: C REF: 916 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 39. The nurse is preparing to discuss myocardial infarctions (MIs) with a women’s group. Which of the following assessment findings should be included when discussing the typically observed signs and symptoms in females experiencing an MI? 1. Originates both at rest and upon exertion 2. Pain lasting longer than 30 minutes 3. Pain radiating up into left jaw 4. Significant gastric indigestion ANS: 4 There is a significant difference between men and women in relation to coronary artery disease. Women’s symptoms differ from those seen in men. The most common initial symptom in women is angina, but atypical symptoms of fatigue, “indigestion,” vasospasm, shortness of breath, or back or jaw pain are also present. The remaining options are reflective of symptoms experienced by both men and women. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 40. When assisting with PM care for an 82-year-old client recuperating from pneumonia, the nurse observes that the client appears to be uncharacteristically confused, asking “Where am I?” Which of the following interventions is the most therapeutic for this particular client? 1. Listen for lung sounds. 2. Reorient the client to place. 3. Ask some simple questions to confirm the confusion. 4. Assess the client’s pulse oximetry reading on room air. ANS: 4 Because mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability, assessing the client’s blood oxygen is the most therapeutic intervention. DIF: B REF: 916-917 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 41. When interviewing a newly admitted client, the nurse learns that the client is a cigarette smoker. It is determined that the client has a 50 pack-year history. This means that the client has smoked: 1. 2 packs of cigarettes a day for 25 years 2. 50 cigarettes a week for the last year 3. 1 pack a week for the last year 4. 50 packs within the last year ANS: 2 If a client smoked 2 packs a day for 20 years, the client has a 40 pack-year history (packages per day x years smoked). DIF: A REF: 920 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 42. A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath. The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully. The nurse best describes this position to the client as: 1. “I’ll use pillows to take the pressure off your lungs so that they can expand more effectively.” 2. “By leaning forward and resting on these pillows, you will be least likely to be short of breath.” 3. “This is an upright position that you will be comfortable in and able to breathe more effectively.” 4. “We’ll place two pillows behind your back so you are sitting more upright; that will let you rest better.” ANS: 4 Orthopnea is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The number of pillows used, such as two or three pillows, usually helps to quantify the orthopnea (e.g., two- or three-pillow orthopnea). DIF: C REF: 920 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 43. The nurse is preparing an educational handout for older adults with chronic respiratory diseases. To best minimize the risk for infection, the nurse should include which of the following guidelines in the material? 1. Remember to take your respiratory medication on schedule. 2. If you are prescribed breathing treatments, take them as ordered. 3. Avoid large, crowded places, especially during the winter months. 4. Remember to talk with your health care provider about a flu vaccination. ANS: 3 Clients with cardiopulmonary alterations need to minimize their risk for infection, especially during the winter months. Teach clients to avoid large, crowded places; keep their mouth and nose covered; and be sure to dress warmly, including a scarf, hat, and gloves. This is especially important during the peak of the influenza season. A flu shot may be recommended, but it does not protect against the various other infections commonly encountered. The remaining options are not directly related to infection but are more relevant to general management DIF: C REF: 921 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 44. The nurse working on the cardiac unit notes that the client has an S2 murmur, which the nurse understands is caused by: 1. Pulmonic or aortic valve backflow or regurgitation 2. Mitral valve backflow or regurgitation 3. Tricuspid valve backflow or regurgitation 4. Poor coronary arterial circulation ANS: 1 Closure of aortic and pulmonic valves represents S2, or the second heart sound. Some clients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open and blood flows from the higher-pressure atria into the relaxed ventricles. This represents S1, or the first heart sound. A murmur is caused by blood turbulence, not coronary artery disease DIF: A REF: 912-913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 45. A client with coronary artery disease is being prepared for a coronary arterial bypass graft surgery. The nurse knows that the coronary artery that carries the most blood and can cause the most harm when blocked is the: 1. Left coronary artery 2. Posterior interventricular artery 3. Circumflex artery 4. Anterior interventricular artery ANS: 1 The left coronary artery, the most abundant blood supply, feeds the left ventricular myocardium, which is more muscular and does most of the heart’s work. The posterior and anterior interventricular arteries supply blood to the walls of both ventricles. The circumflex artery supplies blood to the walls of the left atrium and left ventricle. DIF: A REF: 912 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 46. A client who has a history of a major myocardial infarction is taking digoxin. The nurse explains this medication helps increase cardiac output by: 1. Increasing the heart rate 2. Reducing the resistance of pulmonary circulation 3. Increasing the force of the myocardial contraction 4. Increasing cardiac conduction ANS: 3 Myocardial contractility affects stroke volume and cardiac output. Increased contraction increases the amount of blood ejected by the ventricles. Digoxin increases cardiac output by inhibiting the sodium-potassium ATPase, which makes more calcium available for contractile proteins, which results in a positive inotropic effect. One of the adverse reactions of digoxin is bradycardia. Digoxin does not reduce the resistance of pulmonary circulation or affect the electrical conduction of the heart. DIF: A REF: 912 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 47. When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that: 1. A low heart rate is normal in well-conditioned athletes 2. The health care provider needs to be notified immediately 3. The heart rate needs to be rechecked before taking any action 4. The heart rate could be caused by hyperthyroidism ANS: 1 A heart rate lower then 60 is a normal response to sleep or in a well-conditioned athlete; diminished blood flow to SA node, vagal stimulation, hypothyroidism, increased intracranial pressure, or pharmacological agents (e.g., digoxin, propranolol, quinidine, procainamide) sometimes cause abnormal drops in rate. Any action that the nurse is considering taking should occur only after verifying an abnormal vital sign. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 48. During pretesting for an elective surgery, it is discovered that the older adult client has atrial fibrillation. The nurse knows that this is a common dysrhythmia in older people and can cause: 1. Fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid 2. Acute loss of pulse and respiration 3. Severe hypotension and loss of pulse and consciousness 4. Dizziness, syncope, or chest pain ANS: 1 There is a loss of the atrial kick (portion of the cardiac output squeezed in the ventricles with a coordinated atrial contraction), pooling of blood in the atria, and development of microemboli. The client often complains of fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid. It is a commonly occurring dysrhythmia in the aging and older adult. Acute loss of pulse and respiration is indicative of ventricular fibrillation. Immediate defibrillation is needed after assessment of ABCs of CPR. Ventricular tachycardia results in decreased cardiac output due to decreased ventricular filling time and often leads to severe hypotension and loss of pulse and consciousness. Sinus bradycardia may present signs and symptoms of reduced cardiac output such as dizziness, syncope, or presence of chest pain. DIF: A REF: 908 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 49. A 47-year-old female client tells the nurse that her heart feels as though it is racing. The client’s pulse is 160 beats per minute. The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to: 1. Bear down as though she is having a bowel movement 2. Take a hot shower 3. Take a cold bath 4. Hold her breath ANS: 1 Paroxysmal supraventricular tachycardia is a sudden rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. When needed, treatment includes vagal stimulation such as carotid sinus massage or Valsalva maneuver to decrease the ventricular response. A hot shower would cause the heart to beat faster in order to cool down the body. A cold bath could cause additional stress and would not be appropriate. Holding the breath will increase the heart rate as it compensates for the lack of oxygen intake and buildup of carbon dioxide. DIF: B REF: 908 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 50. A client has been admitted to the emergency department with an aspirin overdose. The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate) poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for: 1. Decreased hemoglobin 2. Excess carbon monoxide 3. Decreased oxygen 4. Excess carbon dioxide ANS: 4 The body is attempting to correct the acid-base balance, so the respiratory system causes the body to breathe faster in order to try to blow off the excessive carbon dioxide. The hemoglobin is not decreased but does not release oxygen to tissues as readily, and tissue hypoxia results. The body does not produce carbon monoxide. Oxygen levels are not decreased, but the body is attempting to compensate for metabolic acidosis by producing a respiratory alkalosis. DIF: A REF: 909 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 51. The nurse knows that the client who smokes is how much more likely to develop lung cancer than a nonsmoker? 1. Twice 2. Three times 3. Five times 4. Ten times ANS: 4 According to the American Cancer Society, the risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer and cardiovascular disease. DIF: A REF: 909 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 52. A 45-year-old male client shares with the nurse that he has noticed that when he is anxious he feels short of breath. The nurse shares with the client that dyspnea can be caused by many conditions and that the client can make an objective assessment of the severity of the dyspnea by using which of the following? 1. Peak expiratory flow rate meter (PEFR) 2. Chest x-ray examination 3. Pulmonary function test 4. Visual analog scale from 1 to 10 ANS: 4 The use of a visual analog scale (VAS) helps clients to make an objective assessment of their dyspnea. The visual analog scale is a 100-mm vertical line; 0 is equated with no dyspnea, and 100 is equated with the worst breathlessness the client has experienced. The use of the VAS to evaluate the level of a client’s dyspnea is useful in evaluating nursing interventions designed to reduce dyspnea. The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. Daily measurement is for early detection of asthma exacerbations. Chest x-ray examination is used to observe the lung fields for fluid, masses, fractures, pneumothorax, and other abnormal processes. The pulmonary function test determines the ability of the lungs to efficiently exchange oxygen and carbon dioxide. It is used to differentiate pulmonary obstructive from restrictive disease. DIF: C REF: 915 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 53. The nurse working on the pulmonary unit is asked to obtain an acid-fast bacillus (AFB) sputum specimen from a client. The nurse knows that this test is used to screen for: 1. Cancer 2. Tuberculosis (TB) 3. Cystic fibrosis 4. Histoplasmosis ANS: 2 The test is used to screen for the presence of AFB for detection of TB by early morning specimens on 3 consecutive days. Cancer would be tested by a sputum specimen for cytologic examination. Cystic fibrosis and histoplasmosis are not screened for through sputum tests. DIF: A REF: 913 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 54. A humidity tent is frequently used for infants and young children to liquefy secretions and help reduce a fever. The nurse knows that humidified air puts the client at risk for: 1. Respiratory distress 2. Infection 3. Skin breakdown 4. Hypothermia ANS: 4 Air in the humidity tent sometimes becomes cool and falls below 20° C (68° F), causing the child to become chilled. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry. Humidified air helps in keeping the airway open by providing hydration to liquefy secretions, and the cool environment helps reduce bronchospasms. Humidified air liquefies secretions, allowing the child to cough them up, which reduces the risk for an infection. Humidified air should not lead to skin breakdown as long as the linens and clothing are not allowed to remain wet. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems MULTIPLE RESPONSE 1. Which of the following situations would cause the nurse to expect an increase in cardiac output in a client who is experiencing no health issues? (Select all that apply.) 1. After playing a set of doubles’ tennis 2. Being 31 weeks' pregnant with twins 3. Upon rising from a 45-minute afternoon nap 4. During a panic attack resulting from an unknown trigger 5. Experiencing a 100° F temperature resulting from a bacterial infection 6. Following a 60-minute session that included aerobic exercise ANS: 1, 2, 4, 5, 6 Exercise, pregnancy, and fever increase cardiac output, but during sleep it decreases. DIF: A REF: 918 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 2. Which of the following are factors that affect the blood’s capacity to carry sufficient oxygen to the various body organs? (Select all that apply.) 1. The size of the individual 2. The age of the individual 3. The gender of the individual 4. The amount of oxygen present in the blood 5. The amount of hemoglobin present in the blood 6. The amount of oxyhemoglobin present in the blood ANS: 4, 5, 6 Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen. The remaining options are not directly involved. DIF: A REF: 920 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 3. The nurse caring for a morbidly obese client who is recovering from abdominal surgery recognizes that this client is at risk for respiratory complications specifically caused by: (Select all that apply.) 1. Poor muscle tone, resulting in decreased respiratory muscle function 2. Increased risk for infection, resulting in increased oxygen requirements 3. Deceased lung volume resulting from compression of abdominal organs 4. Increased presence of pulmonary secretions in the lower lobes bilaterally 5. Obesity-hypoventilation syndrome resulting from chronic carbon dioxide retention 6. Pain resulting in reluctance to deep breathe and facilitate exchange of oxygen and carbon dioxide ANS: 1, 2, 3, 4, 5 Morbidly obese clients have a reduction in compliance as a result of encroachment of the abdomen into the chest, increased work of breathing, and decreased lung volumes. In some clients an obesity-hypoventilation syndrome develops in which oxygenation is decreased and carbon dioxide is retained. The obese client is also susceptible to pneumonia after surgery or an upper respiratory tract infection because the lungs do not fully expand and the lower lobes retain pulmonary secretions. Pain is a universal barrier to effective breathing; it is not unique to the obese client. DIF: C REF: 924 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 4. The nurse expects to observe which of the following assessment findings in a client diagnosed with left-sided heart failure? (Select all that apply.) 1. Ankle edema 2. Bilateral crackles 3. Mental confusion 4. Distended neck veins 5. Activity-induced dyspnea 6. Being awakened by shortness of breath ANS: 2, 3, 5, 6 Clinical findings of left-sided heart failure include crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea. The remaining options are more reflective of right-sided failure. DIF: A REF: 930 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems Potter & Perry: Fundamentals of Nursing, 7 Edition th Test Bank Chapter 42: Sleep MULTIPLE CHOICE 1. The physiology of sleep is complex. Which of the following is the most appropriate statement in regard to this process? 1. Ultradian rhythms occur in a cycle longer than 24 hours. 2. Nonrapid eye movement (NREM) refers to the cycle that most clients experience when in a high-stimulus environment. 3. The reticular activating system is partly responsible for the level of consciousness of a person. 4. The bulbar synchronizing region (BSR) causes the rapid eye movement (REM) sleep in most normal adults. ANS: 3 The ascending reticular activating system (RAS) located in the upper brain stem is believed to contain special cells that maintain alertness and wakefulness. Infradian rhythms, not ultradian rhythms, occur in a cycle longer than 24 hours. Nonrapid eye movement refers to the sleep cycle that most clients experience in a low-stimulus environment. The bulbar synchronizing region is the area of the brain where serotonin is released to produce sleep. It is not responsible for REM sleep. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 2. The nurse understands that the client with which of the following conditions is at risk for obstructive sleep apnea? 1. Heart disease 2. Respiratory tract infections 3. Nasal polyps 4. Obesity ANS: 3 Structural abnormalities, such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea. Individuals with mixed apnea often have signs and symptoms of right-sided heart failure. Respiratory tract infections do not predispose a client to obstructive sleep apnea. Clients with obstructive apnea are often middle-age, obese men. Obesity itself does not predispose a client to obstructive sleep apnea. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 3. Which of the following symptoms should the nurse assess with a client who is deprived of sleep? 1. Elevated blood pressure and confusion 2. Confusion and irritability 3. Inappropriateness and rapid respirations 4. Decreased temperature and talkativeness ANS: 2 Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 4. A new mother is concerned that her 2-week-old daughter is not sleeping through the night. The nurse should respond that infants usually develop a nighttime pattern of sleep by: 1. 1 month 2. 2 months 3. 3 months 4. 6 months ANS: 3 Infants usually develop a nighttime pattern of sleep by 3 months of age. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 5. The mother of a 2-year-old child is frustrated because the child does not want to go to bed at the scheduled bedtime. The nurse should suggest that the parent: 1. Offer the child a bedtime snack 2. Eliminate one of the naps during the day 3. Allow the child to sleep longer in the mornings 4. Maintain consistency in the same bedtime ritual ANS: 4 The nurse should advise the parent to maintain a regular bedtime and wake-up schedule and to reinforce patterns of preparing for bedtime. A bedtime routine (e.g., same hour for bedtime, quiet activity) used consistently helps young children avoid delaying sleep. It is most important that the parent maintains a consistent bedtime routine. If a bedtime snack is already part of that routine, then this is allowable. If it is not, then the child may only use having a snack as a measure of procrastination. After 3 years of age the child may give up daytime naps. A bedtime routine used consistently will be more effective in helping the child who resists going to sleep. The same regular bedtime and wake-up schedule should be maintained. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 6. An 11-year-old boy in middle school is currently experiencing sleep-related fatigue during classes. Which of the following is the most appropriate response by the school nurse when counseling the child’s parents regarding this assessment? 1. “What are the child’s usual sleep patterns?” 2. “Establish bedtimes for the child, and withhold his allowance whenever those times are not adhered to.” 3. “We need to explore other health-related problems, because sleep problems are not likely the cause of his fatigue.” 4. “The bulbar synchronizing region of the child’s central nervous system is causing these insomniac problems.” ANS: 1 A school-age child will be tired the following day if allowed to stay up later than usual. The nurse should ask a question to assess the child’s usual sleep patterns. The nurse should first assess the child’s usual sleep pattern to determine if the child is adhering to a bedtime. A sleep problem is often the cause of fatigue. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 7. The nurse recognizes that the sleep patterns of older adults differ and older adults generally: 1. Are more difficult to arouse 2. Require more sleep than middle-age adults 3. Take less time to fall asleep 4. Have a decline in stage 4 sleep ANS: 4 As people age, there is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have almost no stage 4, or deep, sleep. Older people do not become more difficult to arouse, not do they require more sleep than the middle-age adult. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 8. Teaching for a client who is currently taking a diuretic should include information that he or she may experience: 1. Nocturia 2. Nightmares 3. Increased daytime sleepiness 4. Reduced REM sleep ANS: 1 For the client who is currently taking a diuretic, the nurse should inform the client that he or she might experience nighttime awakening caused by nocturia. Diuretic use does not cause nightmares or daytime sleepiness or reduce REM sleep. DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 9. New research indicates that to increase safety the nurse should instruct parents to do which of the following? 1. Provide a stuffed toy for comfort. 2. Cover the infant loosely with a blanket. 3. Place the infant on his or her back. 4. Use small pillows in the crib. ANS: 3 Infants are usually placed on their backs to prevent suffocation or on their sides to prevent aspiration of stomach contents. To reduce the chance of suffocation, pillows, stuffed toys, or the ends of loose blankets should not be placed in cribs. Infants should not be covered loosely with a blanket because infants might pull them over their faces and suffocate. To reduce the chance of suffocation, pillows should not be placed in cribs. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 10. A 74-year-old client has been having sleeping difficulties. To have a better idea of the client’s problem, the nurse should respond: 1. “What do you do just before going to bed?” 2. “Let’s make sure that your bedroom is completely darkened at night.” 3. “Why don’t you try napping more during the daytime?” 4. “Do you eat a small snack before going to bed?” ANS: 1 To assess the client’s sleeping problem, the nurse should inquire about predisposing factors, such as by asking “What do you do just before going to bed?” Assessment is aimed at understanding the characteristics of any sleep problem and the client’s usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the client’s sleeping problem. The client does not always have to eat something before going to bed. DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 11. Which of the following information provided by the client’s bed partner is most associated with sleep apnea? 1. Restlessness 2. Talking during sleep 3. Somnambulism 4. Excessive snoring ANS: 4 Partners of clients with sleep apnea often complain that the client’s snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders). DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 12. The nurse should instruct the client to do which of the following to promote good sleep hygiene at home? 1. Use the bedroom only for sleep or sexual activity. 2. Eat a large meal 1 to 2 hours before bedtime. 3. Exercise vigorously before bedtime. 4. Stay in bed if sleep does not come after hour. ANS: 1 The nurse should explain that, if possible, the bedroom should not be used for intensive studying, snacking, TV watching, or other nonsleep activity, besides sex. The nurse should instruct the client to avoid heavy meals for 3 hours before bedtime; a light snack may help. The nurse should also instruct the client to try to exercise daily, preferably in morning or afternoon, and to avoid vigorous exercise in the evening within 2 hours of bedtime. Getting out of bed and doing some quiet activity until feeling sleepy enough to go back to bed if the client does not fall asleep within 30 minutes of going to bed may also help. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 13. The nurse knows that which of the following habits may interfere with a client’s sleep? 1. Listening to classical music 2. Finishing office work 3. Reading novels 4. Drinking warm milk ANS: 2 At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. Reading a light novel, watching an enjoyable television program, or listening to music helps a person to relax. Relaxation exercises can be useful at bedtime. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 14. It is determined that the client will need pharmacological treatment to assist with the client's sleep patterns. The nurse anticipates that treatment with an anxiety-reducing, relaxation-promoting medication will include the use of: 1. Barbiturates 2. Amphetamines 3. Benzodiazepines 4. Tricyclic antidepressants ANS: 3 The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the action of neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal. Withdrawal from CNS depressants, such as barbiturates, can cause insomnia and must be managed carefully. Barbiturates can cause tolerance and dependence. Central nervous system stimulants, such as amphetamines, should be used sparingly and under medical management. Amphetamine sulfate may be used to treat narcolepsy. Prolonged use may cause drug dependence. Tricyclic antidepressants can cause insomnia when withdrawn and should be managed carefully. They are used primarily to treat depression. DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 15. The nurse is completing an assessment of the client’s sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: 1. “How easily do you fall asleep?” 2. “Do you have vivid, lifelike dreams?” 3. “Do you ever experience loss of muscle control or falling?” 4. “Do you snore loudly or experience headaches?” ANS: 4 To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, “Do you snore loudly?” and “Do you experience headaches after awakening?” A positive response may indicate the client experiences sleep apnea. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 16. Which of the following may improve the sleep of an older adult client? 1. Drinking an alcoholic beverage before bedtime 2. Using an over-the-counter sleeping agent 3. Eliminating naps during the day 4. Going to bed at a consistent time even if not feeling sleepy ANS: 3 To promote sleep, daytime naps should be eliminated. If naps are used, they should be limited to 20 minutes or less twice a day. Alcohol should be limited in the late afternoon and evening because it has an insomnia-producing effect. The use of nonprescription sleeping medications is not advisable. Over the long term, these drugs can lead to further sleep disruption even when they initially seemed to be effective. Following a bedtime routine should be consistent, not necessarily going to bed. The client should engage in quiet activities that promote relaxation and then may go to bed. If the client has not fallen asleep in 30 minutes, the client should get up out of bed and do some quiet activity until feeling sleepy enough to go back to bed. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 17. A client is concerned that her habit of sleeping during the day and being awake at night is not “healthy or normal.” The nurse’s most therapeutic response to the client’s concern is: 1. “What makes you think that sleeping during the day and being up at night is unhealthy or abnormal?” 2. “Many people share your sleep habits. As long as you feel all right, I don’t think there is anything to worry about.” 3. “Are you interested in changing your sleep habits for any particular reason? Is sleeping during the day a problem for you?” 4. “Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn’t abnormal or unhealthy.” ANS: 4 All persons have biological clocks that synchronize their sleep cycles. If the sleep pattern does not adversely affect the client’s health or ability to function, it is not problematic. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 18. A client is discussing his recent restlessness and increased irritability. Which of the following assessment questions is likely to be most helping in determining the cause of these complaints? 1. “When did you start noticing these changes?” 2. “Has anything caused you to change your usual routine lately?” 3. “Do you have any idea what might be causing these problems?” 4. “What makes you think that you are more irritable than is normal for you?” ANS: 2 When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions usually change as well. For example, the person experiences a decreased appetite and loses weight. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Failure to maintain the individual’s usual sleep-wake cycle negatively influences the client’s overall health. Although the other options are not inappropriate, they are not as directly aimed at determining the cause of the changes. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 19. The nurse and a client are discussing possible behaviors that might be interfering with the client’s ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client’s sleep routine that possibly are contributing to the difficulty? 1. “When do you usually retire for the night?” 2. “What do you do to help yourself fall asleep?” 3. “How much time does it usually take for you to fall asleep?” 4. “Have you changed anything about your presleep ritual lately?” ANS: 2 As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 20. An older adult client diagnosed as being in the early stage of Alzheimer’s disease shares with the nurse that her sleep is interrupted by “the noises I hear all through the night.” The nurse explains that the most likely reason for this problem is: 1. The client’s age 2. A lack of presleep relaxation 3. The amount of noise entering into the client's environment 4. A manifestation of the disease process causing the brain disorder ANS: 1 With aging, sleep becomes more fragmented, and a person spends more time in lighter stages that are easily disturbed by noise. The remaining options may be a factor but not to the degree of normal aging. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 21. A 9-year-old client asks the nurse, “Why do I need to sleep?” The nurse’s most age-appropriate, informative response is: 1. “Everyone needs to sleep to feel rested.” 2. “It gives your body a chance to really rest.” 3. “You’ll be able to do so much better in school if you’re rested.” 4. “Your body needs to rest in order to grow and be really healthy.” ANS: 4 Sleep contributes to physiological and psychological restoration, maintenance, and growth of the body at any age. The remaining options are not as effective at providing a thorough answer to the child’s question. The body needs sleep to routinely restore biological processes. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 22. A client has reported to the nurse that his sprained ankle resulted from “a careless accident. I seem so clumsy and unfocused lately.” Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms? 1. “How many accidents have you had lately?” 2. “Have the accidents resulted in serious injuries?” 3. “Have there been any changes in your daily routine lately?” 4. “Do you have any idea what is responsible for this lack of focus?” ANS: 4 A loss of REM sleep leads to feelings of confusion and suspicion. Various body functions (e.g., mood, motor performance, memory, and equilibrium) are altered when prolonged sleep loss occurs. Research estimates that traffic, home, and work-related accidents caused by falling asleep are often a result of sleep loss. This answer is the best question because it directly opens up the opportunity for the client to discuss possible sleep problems if they exist. The other questions are not inappropriate but are less likely to reveal the possible cause of the accidents. DIF: C REF: 1031 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 23. Which of the following clients is most likely to experience difficulty returning to sleep? 1. A 60-year-old with benign hypertropic prostatic disease 2. A 15-year-old with type 1 diabetes 3. A 35-year-old diagnosed with hypothyroidism 4. A 55-year-old diagnosed with hypertension ANS: 1 Nocturia, or urination during the night, disrupts sleep and the sleep cycle. This condition is most common in older people with reduced bladder tone or persons with cardiac disease, diabetes, urethritis, or prostatic disease. After a person awakens repeatedly to urinate, returning to sleep is difficult. Although all the clients may have difficulty falling back to sleep when awakened, the answer represents the client with the greatest tendency to be awakened during the night. DIF: C REF: 1032 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 24. Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea (OSA)? 1. A 15-year-old boy with type 1 diabetes 2. A 22-year-old diagnosed with Crohn’s disease 3. A 49-year-old man who is an avid cross-county runner 4. A 58-year-old woman diagnosed with chronic depression ANS: 4 Many think OSA affects middle-age men more frequently, particularly when they are obese. However, obstructive sleep apnea is also common in postmenopausal women, younger women, and children. Although the clients in all of the options may experience OSA, the postmenopausal woman has the greatest risk. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 25. A client shares with the nurse that “My wife complains about my snoring, and I never really feel rested.” Which of the following responses best attempts to explain the cause of the problem to the client? 1. “Sleep disturbances can really affect all aspects of your life. How long have you been experiencing this problem?” 2. “You need to get help to breathe more effortlessly at night so both you and your wife can get sufficient deep stage sleep.” 3. “Something is interfering with your ability to breathe while you are asleep. Have you talked with your health care provider about the problem?” 4. “Your upper airway is blocked, and that is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage.” ANS: 4 The upper airway becomes partially or completely blocked, and diminished nasal airflow (hypopnea) can result for as long as 30 seconds. The person attempts to breathe, which often results in loud snoring and snorting sounds. The effort to breathe during sleep results in arousals from deep sleep, often to the stage 2 cycle, causing interference with deep sleep and thus the client's not feeling rested. The remaining options are not inappropriate, but they are not as directed at explaining the problem to the client. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 26. A client hospitalized for a myocardial infarction in a cardiac critical care unit (CCU) is most likely to experience sleep deprivation as a result of: 1. A drug-disrupted circadian sleep pattern 2. Generally diminished cardiac output 3. Unfamiliar environmental stimuli 4. Increased emotional stressors ANS: 3 Hospitalization, especially in intensive care units, makes clients particularly vulnerable to the extrinsic and circadian sleep disorders that cause the “ICU syndrome of sleep deprivation.” Constant environmental stimuli within the intensive care unit (ICU), such as strange noises from equipment, the frequent monitoring and care given by nurses, and ever-present lights, confuse clients and lead to sleep deprivation. Although the other options may be contributing factors, they are not as directly responsible. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 27. The nurse is discussing child care strategies with a mother of a newborn. The mother asks the nurse, “What causes sudden infant death syndrome (SIDS)?” Which of the following responses is most likely to answer the mother’s question therapeutically? 1. “SIDS is a common fear for new mothers. The best advice is to put your baby to sleep on her back.” 2. “We aren’t sure exactly, but it may have something to do with undetected cardiac or oxygen problems.” 3. “Research is inconclusive, but it’s thought to be a result of a nervous system problem that occurs when the baby is asleep.” 4. “Your pediatrician wants you to put your baby to sleep on her back because research has shown that more stomach sleepers are victims.” ANS: 3 Some have hypothesized that sudden infant death syndrome (SIDS) is caused by abnormalities in the autonomic nervous system that are manifested during sleep, resulting in apnea, hypoxia, and/or cardiac dysrhythmias. This answer provides the most thorough answer to the mother’s question, whereas the remaining options stress preventive measures. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 28. The client asks the nurse, “How will I know if I’m really rested?” The nurse’s most therapeutic response is: 1. “Everyone’s definition of rested is different. How would you define rested?” 2. “When you aren’t tired when you get up in the morning or after an afternoon nap.” 3. “When you are mentally, physically, and emotionally ready to go about your daily activities.” 4. “You are rested if you fall asleep easily and sleep uninterruptedly for at least 6 to 8 hours.” ANS: 3 When people are at rest they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day. The remaining options ask questions or provide a limited view on what rested means. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 29. The nurse is caring for a 35-year-old father of three young children who has experienced a compound fractured femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The nurse’s most immediate concern is that: 1. The client needs medication to prevent depression 2. The lack of appropriate rest will affect his healing process 3. An occupational therapy consult should be ordered to help him regain his ability to return to his job 4. A psychiatric consult should be ordered to help the client deal with his various emotional concerns ANS: 2 You must always be aware of the client’s need for rest. A lack of rest for long periods causes illness or worsening of existing illness. Although the other options are appropriate concerns, they are not as immediate in nature as is the sleep problem. DIF: C REF: 1034-1035 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 30. A 63-year-old client is discussing the recent problem the client is experiencing with falling asleep. The nurse is discussing strategies to minimize this problem. Which of the following bedtime snacks would be the most likely to induce sleep? 1. One slice of cheese on four wheat crackers and a glass of skim milk 2. Two cups of air-popped popcorn and a glass of fruit juice 3. Two fig cookies and a cup of decaffeinated tea 4. One small pear and a glass of soymilk ANS: 1 One substance that promotes sleep in many people is L-tryptophan, a natural protein found in foods such as milk, cheese, and meats. DIF: C REF: 1036 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 31. A 70-year-old client is reporting to the nurse a concern over “taking longer to fall asleep and waking up three to four times during the night.” The most therapeutic nursing response to the client’s concern is: 1. “I think you need to mention your concerns to your health care provider.” 2. “Older adults seem to need less sleep. Do you still feel rested in the morning?” 3. “I suggest that you plan for a nap in the afternoon to make up for that missed sleep.” 4. “As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?” ANS: 4 An older adult awakens more often during the night, and it takes more time for an older adult to fall asleep. The answer provides an opportunity for a discussion about the effect this problem may be creating. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 32. The nurse and the parents of a 3-year-old are discussing their child’s sleep habits. They share a concern over the child’s tendency to wake up several times during the night crying out loudly but not really being awake. The nurse addresses the parents’ concern most therapeutically by responding: 1. “Have you ever tried reading a bedtime story before putting her to bed?” 2. “If she does that only a few times a week, I wouldn’t be too overly concerned.” 3. “Children her age often become poor sleepers. Have you discussed this with her pediatrician?” 4. “It is common for children to have trouble relaxing, and this behavior is the result. It’s usually temporary.” ANS: 4 The preschooler usually has difficulty relaxing or quieting down after long, active days and has problems with bedtime fears, waking during the night, or nightmares. Partial wakening followed by normal return to sleep is frequent. In the waking period, the child exhibits brief crying, walking around, unintelligible speech, sleepwalking, or bedwetting. The other options either ask questions or provide possible tactics for preventing the problems. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 33. A 44-year-old female client shares with the nurse that she is having difficulty falling asleep at night, even though she is exhausted. The nurse knows that which of the following could be causing the sleeplessness? 1. Two cups of hot cocoa every evening 2. Vegetarian diet 3. Afternoon exercise program 4. Hot bath in the evening ANS: 1 Caffeine is a stimulant and can cause difficulty in falling asleep. There is about 30 mg of caffeine in two cups of hot cocoa. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 34. A 22-year-old male client shares with the nurse that he is always tired. In assessing the client’s sleep pattern to determine the quantity of sleep the client is getting, the nurse should ask: 1. “On a scale from 0 to 10, how much sleep to you think you get each night?” 2. “What time do you usually go to bed?” 3. “What time do you usually get up?” 4. “Do you have a bedtime ritual?” ANS: 1 This question helps quantify the length of sleep that the client receives. A brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. Ask individuals to separately rate their quantity and quality of sleep on the scale. Instruct clients to indicate with a number between 0 and 10 their sleep quantity then their quality of sleep with 0 being the worst sleep and 10 being the best sleep DIF: A REF: 1033 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 35. On a 2-week follow-up visit to the health care provider, a 64-year-old female postoperative client shares with the nurse that she is having difficulty sleeping and has never had a history of sleeping problems. The nurse shares with the client that: 1. Because of her age, the client should expect to begin having some problems sleeping 2. It may take a while to get used to sleeping in her bed at home after getting used to sleeping on a hospital bed 3. The medications used for anesthesia can disturb sleep cycles for several weeks following surgery 4. She may not be sleeping as well with her partner after being in a bed by herself while being hospitalized ANS: 3 If the client has recently had surgery, expect the client to experience some disturbance in sleep. Clients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 36. The night nurse goes quietly into the sleeping client’s room to assess him. The client wakes up as soon as the nurse is in the room. The nurse knows that the client was most likely in which stage of sleep? 1. Stage 1: NREM 2. Stage 2: NREM 3. Stage 3: NREM 4. Stage 4: NREM ANS: 1 Stage 1 NREM includes the lightest level of sleep. Sensory stimuli such as noise easily arouses the person. The stage lasts a few minutes. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Awakened, person feels as though daydreaming has occurred. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. Stage 4 NREM is the deepest stage of sleep. It is very difficult to arouse the sleeper. DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 37. A 25-year-old client’s wife complains to the nurse that he sleepwalks during the night. The nurse knows that this behavior normally occurs in which stage of sleep? 1. Stage 2: NREM 2. Stage 3: NREM 3. Stage 4: NREM 4. REM ANS: 3 Stage 4 NREM sleep is the deepest stage of sleep. It is very difficult to arouse the sleeper. If sleep loss has occurred, the sleeper will spend a considerable portion of the night in this stage. Vital signs are significantly lower than during waking hours. The stage lasts approximately 15 to 30 minutes. Sleepwalking and enuresis (bed-wetting) sometimes occur. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. REM sleep involves vivid, full-color dreaming. Loss of skeletal muscle tone occurs. It is very difficult to arouse the sleeper. Less vivid dreaming occurs in other stages. The stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. DIF: C REF: 1037 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 38. The assistive nursing personnel reports that the heart rate of the sleeping 23-yearold athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening. The nurse knows that this is considered: 1. Normal, and they will continue to monitor the vital signs as ordered 2. Abnormally slow, and the health care provider should be notified immediately 3. Abnormally slow, and the nurse will recheck the heart rate before taking any action 4. Abnormally slow, signaling that the client may be hemorrhaging ANS: 1 A healthy adult’s normal heart rate throughout the day averages 70 to 80 beats per minute or less if the individual is in excellent physical condition. However, during sleep the heart rate falls to 60 beats per minute or less. This means that the heart beats 10 to 20 fewer times in each minute during sleep or 60 to 120 fewer times in each hour. If the client were hemorrhaging, the heart rate would initially be tachycardic as the body attempts to compensate for the lost blood volume. DIF: C REF: 1038 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 39. A female client describes the most elaborate dreams to the nurse. She states that she could see colors, hear music, and even had the sensation of flying. The nurse replies to the client that her dreams indicate that she must be: 1. Depressed 2. Pragmatic 3. Creative 4. Mentally ill ANS: 3 Personality influences the quality of dreams; for example, a creative person has elaborate and complex dreams, whereas a depressed person dreams of helplessness. Most people dream about immediate concerns such as an argument with a spouse or worries over work. Sometimes a person is unaware of fears represented in bizarre dreams. DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 40. A 73-year-old male client who normally sleeps on his right side recently underwent a right-side hip replacement surgery and now has trouble sleeping. One of the interventions that the nurse might try with this client is to: 1. Request medication to help the client sleep while in the hospital 2. Carefully prop the client on his operative side using pillows to support the hip 3. Schedule therapy for the evening to help the client become tired so he can sleep 4. Question the client to learn more about his normal sleep pattern ANS: 4 Knowing a client’s usual, preferred sleep pattern allows a nurse to try to match sleeping conditions in a health care setting with those in the home. DIF: C REF: 1029 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep MULTIPLE RESPONSE 1. The nurse and a client are discussing the importance of an effective 24-hour sleep cycle. Which of the following responses by the client may be a direct result of an inadequate sleep pattern? (Select all that apply.) 1. Gaining weight 2. Usually feeling cold 3. Always feeling “tired” 4. A heart that beats “really fast” 5. Often feeling “blue” or depressed 6. Feeling dizzy when getting up from a chair ANS: 2, 3, 4, 5, 6 The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. Weight gain is not typically a result of poor sleep patterns. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 2. Although the most common effect of obstructive sleep apnea is a disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (Select all that apply.) 1. Hypertension 2. Angina attacks 3. Alzheimer’s disease 4. Cardiac dysrhythmias 5. Cerebral vascular accidents 6. Type 2 diabetes ANS: 1, 2, 4, 5 Obstructive apnea causes a serious decline in arterial oxygen saturation level. Clients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension. The other options are not directly related to a diminished supply of arterial oxygen. DIF: A REF: 1030 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 3. The nurse is preparing to discuss the management of the sleeping disorder narcolepsy. In addition to the prescription of stimulants and antidepressants, which of the following nonpharmaceutical strategies should be included and shared with the client? (Select all that apply.) 1. Wine with meals 2. Regular use of a sauna 3. Light but high-protein meals 4. Regular use of chewing gum 5. Adoption of a regular exercise routine 6. Brief daytime naps of 20 minutes or less ANS: 3, 4, 5, 6 Narcoleptics may be helped by brief daytime naps no longer than 20 minutes, a regular exercise program, avoiding shifts in sleep, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Clients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, longdistance driving, and long periods of sitting in hot, stuffy rooms). DIF: C REF: 1031 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 4. Which of the following client statements made by young adults suggest a risk factor for sleep disturbance problems? (Select all that apply.) 1. “I have a job that requires my attention 110% of the time.” 2. “I really enjoy fishing; I wish we lived closer to a river or pond.” 3. “My wife just found out she is pregnant for the third time in 5 years.” 4. “My father recently suffered a heart attack, and Mom is so very worried about him.” 5. “The kids are so active in after-school things that we never have an evening at home.” 6. “Gardening always gave me such a sense of accomplishment, but I don’t have much free time now.” ANS: 1, 3, 4, 5 It is common for the stresses of jobs, family relationships, and social activities to lead frequently to insomnia and the use of medication for sleep. The remaining options reflect a sense of loss but not necessarily of stress. DIF: C REF: 1036 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep