Ramont2e Rev TIF Ch16
-
Upload
jiger-shah -
Category
Documents
-
view
225 -
download
0
Transcript of Ramont2e Rev TIF Ch16
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 1/24
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test
Bank
Chapter 16Question 1
Type: MCSA
The wife of a client who was in an MVA reports that she has started running every day, sometimes twice a daysince her husband was hospitalized. This is an eample of!
1. Sublimation
2. "egression
. #ntellectualization
!. Compensation
Corre"t #ns$er: $
Rationa%e 1! %isplacement of energy associated with more primitive seual or aggressive drives into socially
acceptable activities is &now as sublimation.
Rationa%e 2! "esorting to an earlier level of functioning that is characteristically less demanding when faced with
an aniety producing situation is &nown as regression.
Rationa%e ! 'vading an emotional response that would normally accompany an uncomfortable or painfulsituation by using rational eplanations that remove any personal significance and feelings is &nown as
intellectualization.
Rationa%e !! Compensation is covering up wea&nesses by overachievement in a more comfortable area.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 2
Type: MCMA
The nurse is assessing the family of a pediatric client who has been confined to bed after an accident. Adaptation
is epressed by!
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 2/24
*tandard Tet: Select all that apply.
1. 'ffective coping
2. #neffective coping
. Appropriate behavior
!. Minimization
/. +ndoing
Corre"t #ns$er: $,
Rationa%e 1! 'ffective coping is a an epression of adaptive behavior.
Rationa%e 2! #neffective coping s&ills cause maladaptation to a health change.
Rationa%e ! Appropriate behavior is a result of adaptation to a health change.
Rationa%e !! Minimization is an eample of maladaptation to a health concern.
Rationa%e /! +ndoing is an eample of a maladaptive coping s&ill.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question
Type: MCSA
The nurse is caring for the parents of a newborn and eplaining that many new parents feel stress at this time.
/hen the parents epress surprise at the use of the term stress, the nurse eplains that the birth of a child can be
categorized as a0n1!
1. #nternal source of stress
2. An eternal source of stress
. %evelopmental
!. Situational
Corre"t #ns$er: 2
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 3/24
Rationa%e 1! %epression is an eample of an internal source of stress.
Rationa%e 2! Moving from one state to another is an eample of an eternal source of stress.
Rationa%e ! (eer pressure is an eample of developmental stress.
Rationa%e !! The birth of a child, or a divorce, are eamples of situational stress.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question !
Type: MCMA
The nurse is interviewing a female client who is being admitted to a psychiatric facility for evaluation. /hile
assessing the client, the nurse evaluates the client3s self concept by identifying!
*tandard Tet: Select all that apply.
1. 4ow she views herself
2. "ole epectations
. eliefs and values
!. 4er standards and performance in comparison to those of others and her ideal self
/. 4er family structure
Corre"t #ns$er: $,*,
Rationa%e 1! The nurse will identify the client3s body image5 the image of the physical self that a client perceivesthe size and functioning of the body and its parts.
Rationa%e 2! "ole performance relates to what a person does in a particular role, in relation to the behaviors
epected of that role.
Rationa%e ! The client3s personal identity is the conscious sense of individuality and uni6ueness that evolvescontinually throughout life.
Rationa%e !! Self esteem is one3s 7udgment of one3s own worth.
Rationa%e /! The family structure is involved in personal identity, self esteem, body image, and role performance
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 4/24
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question /Type: MCMA
The nurse is collecting data about an adolescent3s self8concept. The following are developmental factors that
affect the client3s self concept!
*tandard Tet: Select all that apply.
1. irth order
2. irth family
. 9reedom to eplore
!. Stereotyping
/. Supportive environment
Corre"t #ns$er: $,*,2,:
Rationa%e 1! irth order is a family and cultural factor that affects the client3s self concept.
Rationa%e 2! The culture of the birth family is a cultural;family factor that affects the client3s self concept.
Rationa%e ! eing allowed the freedom to eplore as an infant, as well as throughout childhood and adolescence
is a developmental factor
Rationa%e !! Stereotyping by others of the client3s culture is a cultural;family factor that affects the client3s self
concept.
Rationa%e /! 4aving a supportive environment, physically, as an infant, as well as emotionally through
adolescence and on is a developmental factor that influences self8concept.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 5/24
Question 6
Type: MCSA
A mother of three toddlers who has 7ust been told she needs surgery. She begins calling neighbors to arrange for
carpools. This is an eample of
1. 'motion8focused coping
2. Maladaptive coping
. (roblem8focused coping
!. #neffective coping
Corre"t #ns$er:
Rationa%e 1! 'motion focused coping involves using thoughts and actions to relieve emotional distress.
Rationa%e 2! Maladaptive coping results in unnecessary distress5 this action is not maladaptive.
Rationa%e ! This is an eample of problem8focused coping5 the client is ta&ing action to improve a situation.
Rationa%e !! The coping mechanism has 7ust been initiated5 efficacy has yet to be determined.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 0
Type: MCMA
The nurse is caring for a single client who is scheduled for another surgery. The nurse realizes that!
*tandard Tet: Select all that apply.
1. The client3s coping s&ills are influenced by age
2. The client may have difficulty coping due to the number of surgeries eperienced
. A generally anious client may have difficulty coping with the additional stressor
!. The duration of the illness has minimal effect on the client3s coping s&ills
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 6/24
/. The client may use adaptive mechanisms unconsciously
Corre"t #ns$er: *,,:
Rationa%e 1! The client3s coping s&ills are influenced by many factors, including eperience, but not specificallyage.
Rationa%e 2! The additional surgery may be a stressor that the client is unable to manage.
Rationa%e ! The personal 6ualities of the client impact the ability to cope with stressors.
Rationa%e !! The duration and intensity of stressors influences the coping s&ills of the client.
Rationa%e /! The client may use adaptive mechanisms consciously or unconsciously.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question
Type: MCSA
The visiting nurse is tal&ing to the wife of a client, who reports eperiencing sleep difficulties recently. The nurse
identifies the client3s wife as developing
1. Caregiver burden
2. Self8esteem reaction to stress
. %epression
!. %isplacement
Corre"t #ns$er: $
Rationa%e 1! 9amily members who underta&e the care of a person in the home for a long period develop long8
term stress called caregiver burden, with responses such as chronic fatigue, sleep difficulties, and high blood pressure.
Rationa%e 2! Clients who are under stress may have a decrease in self esteem, manifested by isolation, becominga wor&aholic.
Rationa%e ! Sleep difficulties may be an indicator of depression but with the information given, this is not the
best response.
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 7/24
Rationa%e !! The transferring of emotional reactions from one ob7ect or person to another is not the reactiondescribed.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis)earning -ut"ome:
Question
Type: MCSA
The school nurse observes behavior in the school cafeteria, and identifies students with a positive self concept as
one who
1. ullies other students
2. 4as a stable relationship with several groups of friends
. Spends much of the lunch period alone, loo&ing at other students
!. 9inishes the lunches of other students
Corre"t #ns$er: *
Rationa%e 1! Students who bully others often have low self esteem.
Rationa%e 2! The student with a stable relationship with several groups of friends shows the ability to give andreceive love, as well as treating others with respect.
Rationa%e ! The student who is unable to ta&e action and change things may have a negative self concept.
Rationa%e !! The student who finishes others3 lunches may have a negative self concept5 more information is
needed in this scenario.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrityC%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 13
Type: MCMA
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 8/24
The nurse who collects data for the admission assessment as&s 6uestions about self8concept, including those that
deal with
*tandard Tet: Select all that apply.
1. Career
2. #<
. (ersonal appearance
!. Coping abilities
/. Self care
Corre"t #ns$er: $,2,:
Rationa%e 1! The nurse as&s the client about career development and performance.
Rationa%e 2! The nurse would not as& 6uestions about a client3s #<5 rather the client3s ability to answer 6uestionsand follow directions would be noted.
Rationa%e ! The nurse would not as& 6uestions about a client3s personal appearance, rather person appearance
would be noted if deficits were apparent.
Rationa%e !! The admission assessment would include 6uestions regarding a client3s ability to cop with andresolve problems they have faced in the past.
Rationa%e /! The client3s ability to meet self care needs is an important admission 6uestion.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Analyzing
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 11
Type: MCMA
The nurse is caring for an = year old client who needs surgery. The client3s self concept may be affected by
which of the following identity stressors>
*tandard Tet: Select all that apply.
1. Seuality concerns
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 9/24
2. %eclining physical abilities
. (oor coping ability
!. Change in physical appearance
/. "elationship concerns
Corre"t #ns$er: $,*,2,:
Rationa%e 1! The = year8old client may have concerns about ability to function after surgery.
Rationa%e 2! The client may be concerned about the ability to function independently after surgery.
Rationa%e ! This is a potential self8esteem stressor.
Rationa%e !! The client may be concerned about scarring.
Rationa%e /! The client may be concerned about changes in relationships or .
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 12
Type: MCSA
)urses in the long8term care facility understand that residents
1. Are unable to have se
2. Are incapable of orgasm
. Continue to need seual epression
!. )ot at ris& for ST#s
Corre"t #ns$er:
Rationa%e 1! ?lder adults may need increased time to achieve erection and lubrication, but are able to have seua
intercourse.
Rationa%e 2! ?lder adults are capable of orgasm, but may ta&e longer to achieve.
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 10/24
Rationa%e ! Seuality refers to all aspects of being seual, and is sub7ect to lifelong dynamic change.
Rationa%e !! Anyone with multiple se partners is at ris& for ST#s.
&%o'a% Rationa%e:
Cogniti(e )e(e%: "emembering
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 1
Type: MCMA
The pediatric nurse identifies the following pediatric and adolescent considerations about se and seuality!
*tandard Tet: Select all that apply.
1. #nfants begin to develop a gender identity
2. 9emale children are at ris& for seual abuse
. Adolescent seual behaviors are influenced by culture and peers
!. TS' and S' are unnecessary until young adulthood
/. (regnancy prevention should be addressed
Corre"t #ns$er: *,,:
Rationa%e 1! @ender identity begins by three years of age.
Rationa%e 2! 9emale children are at higher ris& for seual abuse than male children.
Rationa%e ! Attitudes about seuality are highly influence by cultural rules and epectations.
Rationa%e !! TS' and S' should be taught and practiced starting in adolescence.
Rationa%e /! (regnancy prevention should be addressed with the adolescent and young adult.
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 11/24
Question 1!
Type: MCSA
The prenatal client will need information regarding
1. Seuality and body image changes
2. #nfertility and body image
. Contraception
!. Avoiding intercourse
Corre"t #ns$er: $
Rationa%e 1! ody image changes constantly during pregnancy and can affect one3s seuality.
Rationa%e 2! #nfertility is not an issue for the currently pregnant client.
Rationa%e ! Contraception is not an issue for the currently pregnant client.
Rationa%e !! #ntercourse may continues in a normal, uncomplicated pregnancy, until the amniotic sac brea&s or
the client goes into labor.
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 1/
Type: MCMA
/hile conducting an assessment interview regarding stress and coping patterns, the nurse identifies 6uestions tha
will encourage the client to communicate information!
*tandard Tet: Select all that apply.
1. 4ow do you usually handle stressful situations>
2. 4ow would you describe yourself as a person>
. %o you li&e your wor&>
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 12/24
!. /hat are your strengths in relationships>
/. Are you having any stress at wor&>
Corre"t #ns$er: $,*,2
Rationa%e 1! This open ended 6uestion encourages the client to describe behaviors with more than a one or two
word answer.
Rationa%e 2! This open ended 6uestion encourages the client to be introspective.
Rationa%e ! This closed8ended 6uestion does not invite the client to epand on li&es and disli&es regarding wor&
Rationa%e !! This open ended 6uestion invited the client to be introspection, and evaluate the 6uality ofrelationships.
Rationa%e /! This closed8ended 6uestion does not invite the client to epand on li&es and disli&es regarding wor&
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 16
Type: MCSA
/hen discussing seuality with the older adult, the nurse remembers that
1. ?lder men are infertile
2. ?lder women lose interest in seual activity after menopause
. The phases of seual response may ta&e longer to occur
!. Seual activity is to be avoided after heart surgery
Corre"t #ns$er:
Rationa%e 1! ?lder men remain fertile into old age.
Rationa%e 2! ?lder women may eperience an increase in desire after menopause.
Rationa%e ! The phases of seual response in older women and men may ta&e longer to occur.
Rationa%e !! Seual activity may be resumed based on reactions to eercise.
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 13/24
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 10Type: MCSA
The wife of a client who was in an MVA reports that she has started running every day, sometimes twice a day,since her husband was hospitalized. This is an eample of!
1. Sublimation.
2. "egression.
. #ntellectualization.
!. Compensation.
Corre"t #ns$er: $
Rationa%e 1! %isplacement of energy associated with more primitive seual or aggressive drives into socially
acceptable activities is &nown as sublimation.
Rationa%e 2! "esorting to an earlier level of functioning that is characteristically less demanding when faced withan aniety8producing situation is &nown as regression.
Rationa%e ! 'vading an emotional response that would normally accompany an uncomfortable or painful
situation by using rational eplanations that remove any personal significance and feelings is &nown asintellectualization.
Rationa%e !! Compensation is covering up wea&nesses by overachievement in a more comfortable area.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 1
Type: MCMA
The nurse is assessing the family of a pediatric client who has been confined to bed after an accident. Adaptation
is epressed by!
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 14/24
*tandard Tet: Select all that apply.
1. 'ffective coping.
2. #neffective coping.
. Appropriate behavior.
!. Minimization.
/. +ndoing.
Corre"t #ns$er: $,
Rationa%e 1! 'ffective coping is an epression of adaptive behavior.
Rationa%e 2! #neffective coping s&ills cause maladaptation to a health change.
Rationa%e ! Appropriate behavior is a result of adaptation to a health change.
Rationa%e !! Minimization is an eample of maladaptation to a health concern.
Rationa%e /! +ndoing is an eample of a maladaptive coping s&ill.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 1
Type: MCSA
The nurse is caring for the parents of a newborn and eplaining that many new parents feel stress at this time./hen the parents epress surprise at the use of the term stress, the nurse eplains that the birth of a child can be
categorized as!
1. An internal source of stress.
2. An eternal source of stress.
. %evelopmental.
!. Situational.
Corre"t #ns$er: 2
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 15/24
Rationa%e 1! %epression is an eample of an internal source of stress.
Rationa%e 2! Moving from one state to another is an eample of an eternal source of stress.
Rationa%e ! (eer pressure is an eample of developmental stress.
Rationa%e !! The birth of a child or a divorce is an eample of situational stress.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 23
Type: MCMA
The nurse is interviewing a female client who is being admitted to a psychiatric facility for evaluation. /hile
assessing the client, the nurse evaluates the client3s self8concept by identifying!
*tandard Tet: Select all that apply.
1. 4ow she views herself.
2. "ole epectations.
. eliefs and values.
!. 4er standards and performance in comparison to those of others and of her ideal self.
/. 4er family structure.
Corre"t #ns$er: $,*,
Rationa%e 1! The nurse will identify the client3s body image5 the image of the physical self that a client perceives
and the size and functioning of the body and its parts.
Rationa%e 2! "ole performance relates to what a person does in a particular role, in relation to the behaviors
epected of that role.
Rationa%e ! The client3s personal identity is the conscious sense of individuality and uni6ueness that evolvescontinually throughout life.
Rationa%e !! Self8esteem is one3s 7udgment of one3s own worth.
Rationa%e /! The family structure is involved in personal identity, self8esteem, body image, and role performance
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 16/24
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 21Type: MCSA
The nurse is collecting data about an adolescent3s self8concept. The following are developmental factors thataffect the client3s self8concept!
1. irth order
2. irth family
. 9reedom to eplore
!. Stereotyping
/. Supportive environment
Corre"t #ns$er: :
Rationa%e 1! irth order is a family and cultural factor that affects the client3s self8concept.
Rationa%e 2! The culture of the birth family is a cultural;family factor that affects the client3s self8concept.
Rationa%e ! eing allowed the freedom to eplore as an infant, as well as throughout childhood and adolescence
is a developmental factor.
Rationa%e !! Stereotyping by others of the client3s culture is a cultural;family factor that affects the client3s self8
concept.
Rationa%e /! 4aving a supportive environment physically as an infant, as well as emotionally throughadolescence and on, is a developmental factor that influences self8concept.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 22
Type: MCSA
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 17/24
A mother of three toddlers has 7ust been told she needs surgery. She begins calling neighbors to arrange forcarpools. This is an eample of!
1. 'motion8focused coping.
2. Maladaptive coping.
. (roblem8focused coping.
!. #neffective coping.
Corre"t #ns$er:
Rationa%e 1! 'motion8focused coping involves using thoughts and actions to relieve emotional distress.
Rationa%e 2! Maladaptive coping results in unnecessary distress5 this action is not maladaptive.
Rationa%e ! This is an eample of problem8focused coping5 the client is ta&ing action to improve a situation.
Rationa%e !! The coping mechanism has 7ust been initiated5 efficacy has yet to be determined.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 2
Type: MCMAThe nurse is caring for a single client who is scheduled for another surgery. The nurse realizes that!
*tandard Tet: Select all that apply.
1. The client3s coping s&ills are influenced by age.
2. The client might have difficulty coping due to the number of surgeries eperienced.
. A generally anious client might have difficulty coping with the additional stressor.
!. The duration of the illness has minimal effect on the client3s coping s&ills.
/. The client might use adaptive mechanisms unconsciously.
Corre"t #ns$er: *,,:
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 18/24
Rationa%e 1! The client3s coping s&ills are influenced by many factors, including eperience, but not specificallyage.
Rationa%e 2! The additional surgery can be a stressor that the client is unable to manage.
Rationa%e ! The personal 6ualities of the client impact the ability to cope with stressors.
Rationa%e !! The duration and intensity of stressors influence the coping s&ills of the client.
Rationa%e /! The client might use adaptive mechanisms consciously or unconsciously.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 2!Type: MCSA
The visiting nurse is tal&ing to the wife of a client. She reports eperiencing sleep difficulties recently. The nurseidentifies the client3s wife as developing!
1. Caregiver burden.
2. Self8esteem reaction to stress.
. %epression.
!. %isplacement.
Corre"t #ns$er: $
Rationa%e 1! 9amily members who underta&e the care of a person in the home for a long period develop long8
term stress called caregiver burden, with responses such as chronic fatigue, sleep difficulties, and high blood pressure.
Rationa%e 2! Clients who are under stress can have a decrease in self8esteem, manifested by isolation, becoming
wor&aholics.
Rationa%e ! Sleep difficulties can be an indicator of depression, but with the information given, this is not the best response.
Rationa%e !! The transferring of emotional reactions from one ob7ect or person to another is not the reaction
described.
&%o'a% Rationa%e:
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 19/24
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 2/
Type: MCSAThe school nurse observes behavior in the school cafeteria, and identifies the student with a positive self8concept
as the one who!
1. ullies other students.
2. 4as a stable relationship with several groups of friends.
. Spends much of the lunch period alone, loo&ing at other students.
!. 9inishes the lunches of other students.
Corre"t #ns$er: *
Rationa%e 1! Students who bully others often have low self8esteem.
Rationa%e 2! The student with a stable relationship with several groups of friends shows the ability to give and
receive love, as well as treat others with respect.
Rationa%e ! The student who is unable to ta&e action and change things might have a negative self8concept.
Rationa%e !! The student who finishes others3 lunches might have a negative self8concept5 more information is
needed in this scenario.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 26Type: MCMA
The nurse who collects data for the admission assessment as&s 6uestions about self8concept, including those that
deal with!
*tandard Tet: Select all that apply.
1. Career.
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 20/24
2. #<.
. (ersonal appearance.
!. Coping abilities.
/. Self8care.
Corre"t #ns$er: $,2,:
Rationa%e 1! The nurse as&s the client about career development and performance.
Rationa%e 2! The nurse would not as& 6uestions about a client3s #<5 rather, the client3s ability to answer 6uestions
and follow directions would be noted.
Rationa%e ! The nurse would not as& 6uestions about a client3s personal appearance5 rather, personal appearancewould be noted if deficits were apparent.
Rationa%e !! The admission assessment would include 6uestions regarding a client3s ability to cope with and
resolve problems she has faced in the past.
Rationa%e /! The client3s ability to meet self8care needs is an important admission assessment.
&%o'a% Rationa%e:
Cogniti(e )e(e%: Analyzing
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 20
Type: MCMA
The nurse is caring for an =8year8old client who needs surgery. The client3s self8concept could be affected by
which of the following identity stressors>
*tandard Tet: Select all that apply.
1. Seuality concerns
2. %eclining physical abilities
. (oor coping ability
!. Change in physical appearance
/. "elationship concerns
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 21/24
Corre"t #ns$er: *,2,:
Rationa%e 1! The =8year8old client might have concerns about ability to function after surgery.
Rationa%e 2! The client might be concerned about the ability to function independently after surgery.
Rationa%e ! This is a potential self8esteem stressor.
Rationa%e !! The client might be concerned about scarring.
Rationa%e /! The client might be concerned about changes in relationships..
&%o'a% Rationa%e:
Cogniti(e )e(e%: Applying
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! %iagnosis
)earning -ut"ome:
Question 2
Type: MCSA
)urses in the long8term care facility understand that residents!
1. Are unable to have se.
2. Are incapable of orgasm.
. Continue to need seual epression.
!. Are not at ris& for ST#s.
Corre"t #ns$er:
Rationa%e 1! ?lder adults might need increased time to achieve erection and lubrication, but are able to haveseual intercourse.
Rationa%e 2! ?lder adults are capable of orgasm, but might ta&e longer to achieve it.
Rationa%e ! Seuality refers to all aspects of being seual, and is sub7ect to lifelong dynamic change.
Rationa%e !! Anyone with multiple se partners is at ris& for ST#s.
&%o'a% Rationa%e:
Cogniti(e )e(e%: "emembering
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 22/24
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 2
Type: MCMA
The pediatric nurse identifies the following pediatric and adolescent considerations about se and seuality!
*tandard Tet: Select all that apply.
1. #nfants begin to develop a gender identity.
2. 9emale children are at ris& for seual abuse.
. Adolescent seual behaviors are influenced by culture and peers.
!. TS' and S' are unnecessary until young adulthood.
/. (regnancy prevention should be addressed.
Corre"t #ns$er: *,,:
Rationa%e 1! @ender identity begins by years of age.
Rationa%e 2! 9emale children are at higher ris& for seual abuse than male children.
Rationa%e ! Attitudes about seuality are highly influenced by cultural rules and epectations.
Rationa%e !! TS' and S' should be taught and practiced starting in adolescence.
Rationa%e /! (regnancy prevention should be addressed with the adolescent and young adult.
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 3
Type: MCSAThe prenatal client will need information regarding!
1. Seuality and body image changes.
2. #nfertility and body image.
. Contraception.
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 23/24
!. Avoiding intercourse.
Corre"t #ns$er: $
Rationa%e 1! ody image changes constantly during pregnancy, and can affect one3s seuality.
Rationa%e 2! #nfertility is not an issue for the currently pregnant client.
Rationa%e ! Contraception is not an issue for the currently pregnant client.
Rationa%e !! #ntercourse may continue in a normal, uncomplicated pregnancy, until the amniotic sac brea&s or th
client goes into labor.
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 1
Type: MCMA
/hile conducting an assessment interview regarding stress and coping patterns, the nurse identifies the following
6uestions that will encourage the client to communicate information!
*tandard Tet: Select all that apply.
1. 4ow do you usually handle stressful situations>
2. 4ow would you describe yourself as a person>
. %o you li&e your wor&>
!. /hat are your strengths in relationships>
/. Are you having any stress at wor&>
Corre"t #ns$er: $,*,2
Rationa%e 1! This open8ended 6uestion encourages the client to describe behaviors with more than a one8 or two8
word answer.
Rationa%e 2! This open8ended 6uestion encourages the client to be introspective.
Rationa%e ! This closed8ended 6uestion does not invite the client to epand on li&es and disli&es regarding wor&
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation, #nc.
8/20/2019 Ramont2e Rev TIF Ch16
http://slidepdf.com/reader/full/ramont2e-rev-tif-ch16 24/24
Rationa%e !! This open8ended 6uestion invites the client to be introspective, and evaluate the 6uality ofrelationships.
Rationa%e /! This closed8ended 6uestion does not invite the client to epand on li&es and disli&es regarding wor&
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrityC%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
Question 2
Type: MCSA
/hen discussing seuality with the older adult, the nurse remembers that!
1. ?lder men are infertile.
2. ?lder women lose interest in seual activity after menopause.
. The phases of seual response can ta&e longer to occur.
!. Seual activity is to be avoided after heart surgery.
Corre"t #ns$er:
Rationa%e 1! ?lder men remain fertile into old age.
Rationa%e 2! ?lder women can eperience an increase in desire after menopause.
Rationa%e ! The phases of seual response in older women and men can ta&e longer to occur.
Rationa%e !! Seual activity may be resumed based on reactions to eercise.
&%o'a% Rationa%e:
Cogniti(e )e(e%: +nderstanding
C%ient Need: (sychosocial #ntegrity
C%ient Need *u':
Nursing+ntegrated Con"epts: )ursing (rocess! Assessment
)earning -ut"ome:
"amont, )iedringhous, Comprehensive Nursing Care *nd 'dition +pdate Test an&
Copyright *-$* by (earson 'ducation #nc