Lecture Exam Practice Questions - Pt II
- 1.
Maslow's Hierarchy of Needs theory helps the nurse to identify the patient's:
- A.
Problem that has the top priority
- B.
Developmental level
- C.
Coping patterns
- D.
Health beliefs
Correct Answer
A. Problem that has the top priorityExplanation
Patient problems and needs are ranked in order of ascending importance in terms of survival.
Erikson's developmental theory identifies a person's developmental level.
Maslow's is not designed to identify a person's coping patterns in response to illness.
Rosenstock's and Becker's health belief models are used to identify the relationship between health beliefs and the use of preventative actions to promote health, not Maslow.Rate this question:
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- 2.
According to Maslow's hierarchy of needs, the nurse identifies that the level of need that should be met just before self-esteem needs can be met is:
- A.
Safety
- B.
Belonging
- C.
Physiologic
- D.
Self-actualization
Correct Answer
B. BelongingExplanation
From lowest to highest, the hierarchy goes:
-Physiologic
-Safety
-Love and Belonging
-Self-esteem
-Self actualizationRate this question:
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- 3.
According to Maslow, which behavior least describes someone who is self-actualized? A person who:
- A.
Is autonomous
- B.
Is able to see the good in others
- C.
Has the ability to problem-solve
- D.
Has an external locus of control
Correct Answer
D. Has an external locus of controlExplanation
An external locus of control means that the individual responds to rewards or recognition that comes from outside the self -- people who are self-actualized strive to develop their maximum potential based on motivation from within.
The other choices reflect qualities of someone who is self-actualized.Rate this question:
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- 4.
The main purpose of the working phase of a therapeutic nurse-patient relationship is to:
- A.
Establish a formal or informal contract that addresses the patient's problems
- B.
Implement nursing interventions that are designed to achieve expected patient outcomes
- C.
Develop rapport and trust so the patient feels protected and an initial plan can be identified
- D.
Clearly identify the role of the nurse and establish parameters of the professional relationship
Correct Answer
B. Implement nursing interventions that are designed to achieve expected patient outcomesExplanation
During the working phase, the nurse is assisting the patient to explore and understand their thoughts and feelings, and facilitating and supporting patient decisions and actions.
Formal or informal contracts are developed during the introductory (orientation) phase.
The development of trust is the primary goal of the introductory (orientation) phase.
Clarifying the role of the nurse and the parameters of the professional relationship are is done during the introductory (orientation) phase.Rate this question:
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- 5.
A patient says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the patient?
- A.
"You sound scared."
- B.
"You think you will die."
- C.
"Surgery can be frightening."
- D.
"Everything will be alright."
Correct Answer
D. "Everything will be alright."Explanation
Saying everything will be alright is providing false reassurance; it denies the patient's concerns and does not invite the patient to elaborate.
"You sound scared" is an example of a reflective technique (reflecting patient's feelings).
"You think you will die" is an example of paraphrasing and restates the content of the patient's message, which promotes communication.
"Surgery can be frightening" is also a reflective technique; it focuses on the patient's feelings and promotes communication.Rate this question:
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- 6.
The patient states, "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." What is the best response by the nurse?
- A.
"I'm sure your wife will be willing to make that sacrifice in exchange for your well-being."
- B.
"The doctors are getting great results with nerve-repairing surgery today."
- C.
"Your wife may not put as much emphasis on sex as you think."
- D.
"Let's talk about how you feel about this surgery."
Correct Answer
D. "Let's talk about how you feel about this surgery."Explanation
The "exchange" comment is false reassurance.
The "nerve-repairing surgery" comment is true information, but negates the patient's concerns and cuts off communication.
The "emphasis" comment may or may not be true; only his wife can make this statement.
The patient may be using projection to cope with the potential for impotence; inviting him to talk about his feelings regarding the surgery indicates that it is acceptable to talk about sexuality and invites the patient to verbalize concerns.Rate this question:
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- 7.
A patient verbally communicates with the nurse while exhibiting nonverbal behavior. To confirm the meaning of the nonverbal behavior, the nurse should:
- A.
Look for similarity in meaning between the patient's verbal and nonverbal behavior
- B.
Ask family members to help interpret the patient's behavior
- C.
Validate inferences by asking the patient direct questions
- D.
Recognize that what a patient says is most important
Correct Answer
A. Look for similarity in meaning between the patient's verbal and nonverbal behaviorExplanation
The patient is the primary source of information. When nonverbal communication reinforces the verbal message, the message reflects the true feelings of the patient. Nonverbal behavior is less under conscious control than verbal statements.
Asking family abdicates the nurse's responsibility onto others and obtains a response that is influenced by emotion and subjectivity.
Direct questions are too specific; open-ended questions that point out any incongruity between words and nonverbal behaviors would be more effective.
Nonverbal behaviors, rather than verbal behaviors, better reflect true feelings. Actions speak louder than words!Rate this question:
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- 8.
The nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion?
- A.
"What brought you to the hospital?"
- B.
"Would it help to discuss your feelings?"
- C.
"Do you want to talk about your concerns?"
- D.
"Would you like to talk about why you are here?"
Correct Answer
A. "What brought you to the hospital?"Explanation
The desire to talk and the need to talk are two different things (asking if they'd like to talk about why they are here). It is helpful to collect as much significant data as possible.
"would it help to discuss" and "do you want to talk about..." are direct, "yes or no" questions and cut off communication.
Asking what brought them to the hospital is a focused, open-ended statement that invites the patient to communicate while centering on the reason for seeking health care.Rate this question:
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- 9.
The patient is upset and crying and mentions something about her job that the nurse cannot understand. The nurse's best response is:
- A.
"It's natural to be worried about your job."
- B.
"Your job must be very important to you."
- C.
"Calm down so that I can understand what you are saying."
- D.
"I'm not quite sure I heard what you were saying about your job."
Correct Answer
D. "I'm not quite sure I heard what you were saying about your job."Explanation
The best response requests additional information in an attempt to clarify an unclear message.
Telling the patient to calm down is patronizing and treats the patient in a condescending manner; the patient cannot calm down.
The remaining two responses are assumptions and may not be true.Rate this question:
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- 10.
When providing nursing care, humor should be used to:
- A.
Diminish feelings of anger
- B.
Refocus the patient's attention
- C.
Maintain a balanced perspective
- D.
Delay dealing with the inevitable
Correct Answer
C. Maintain a balanced perspectiveExplanation
Humor is an interpersonal tool and a healing strategy.
Coping strategies should not be delayed because delay increases stress and anxiety and prolongs the process.
Humor used inappropriately can cause anger to be increased, suppressed, or repressed - anger should be expressed safely.
The focus should be on the patient's concerns, not refocused.Rate this question:
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- 11.
What is the best response by the nurse when the patient's husband says, "I just don't know what to say to my wife if she asks how I feel about her breast cancer."
- A.
"How do you feel about your wife's diagnosis?"
- B.
"This is a difficult topic. However, let's talk about it."
- C.
"Do you think you could be as supportive as you possibly can be?"
- D.
"Men don't always understand what women are going through. Ask her how she feels."
Correct Answer
B. "This is a difficult topic. However, let's talk about it."Explanation
Asking the husband how he feels about the diagnosis is too direct; he may not be in touch with his feelings and will be unable to answer the question.
Asking him if he could be supportive focuses on the patient's needs and ignores the husband's concerns.
Saying that men do not understand is condescending and focuses on the patient's, not the husband's, needs.
The best response acknowledges that the patient is in a dilemma and it offers an opportunity to explore the situation. Validation and an invitation to talk provide emotional support, even if the opportunity to talk is declined.Rate this question:
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- 12.
The nurse understands that evaluation most directly relates to which aspect of the nursing process?
- A.
Goal
- B.
Problem
- C.
Etiology
- D.
Implementation
Correct Answer
A. GoalExplanation
To evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcomes with the expected patient outcomes. The expected outcomes are the measurable data that reflect goal achievement; the actual outcomes are what actually happened.
The Problem is associated with the first half of the nursing diagnosis (problem statement), not the evaluation step of the nursing process.
Etiology (r/t) is used to identify the factors that relate to the problem statement of the nursing diagnosis, not the evaluation step of the nursing process.
Implementation is a step separate from evaluation in the nursing process. Nursing care must be implemented before it can be evaluated.Rate this question:
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- 13.
The nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect the information?
- A.
Observing
- B.
Inspecting
- C.
Auscultation
- D.
Interviewing
Correct Answer
D. InterviewingExplanation
Interviewing the patient is the most effective method when gathering subjective data associated with a patient's anxiety -- the patient is the primary source of subjective data about beliefs, values, concerns, feelings, perceptions, and fears.
Although nurses make inferences based on observations (using all the senses), this is not as effective as interviewing as a data collection method for subjective data associated with the patient's anxiety. Inspection is the act of making observations of physical features and behavior.
Auscultation is listening for sounds within the body.Rate this question:
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- 14.
During which of the five steps of the nursing process does the nurse analyze data critically?
- A.
Diagnosis
- B.
Clustering
- C.
Collection
- D.
Assessment
Correct Answer
A. DiagnosisExplanation
During the diagnosis step of the nursing process, data are analyzed critically and interpreted; the significance of the data is determined; inferences are made and validated; signs and symptoms and clusters of signs and symptoms are compared with the defining characteristics of nursing diagnoses; and nursing diagnoses are identified and organized in order of priority.
Clustering data is not a step in the nursing process; it is a part of the Diagnosis step.
Collection is not a step in the nursing process; during the Assessment step data are collected from different sources using different methods.Rate this question:
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- 15.
The nurse understands that the appropriateness of a nursing diagnosis is supported by its:
- A.
Defining characteristics
- B.
Planned interventions
- C.
Diagnostic statement
- D.
Related risk factors
Correct Answer
A. Defining characteristicsExplanation
The defining characteristics are the major and minor cues that form a cluster that support or validate the presence of a nursing diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for the patient.
Planned interventions do not support the nursing diagnosis; they are the nursing actions designed to help resolve the 'r/t' factors and achieve expected patient outcomes that reflect goal achievement.
The diagnostic statement cannot support the nursing diagnosis; the diagnostic statement is the same as the problem statement, which is the first part of the nursing diagnosis.
Related risk factors cannot support the nursing diagnosis; they follow the problem statement in the nursing diagnosis.Rate this question:
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- 16.
The nurse is planning care for a patient who has an intolerance to activity. What is the first assessment that should be made by the nurse?
- A.
Influence on other family members
- B.
Impact on functional health patterns
- C.
Pattern of vitals
- D.
Range of motion
Correct Answer
C. Pattern of vitalsExplanation
Activity intolerance is related to the inability to maintain adequate oxygenation to body cells, which is associated with respiratory and cardiovascular problems. Obtaining the vitals will provide valuable information about these systems.
Although influence on other family members and impact on functional health patterns might eventually be assessed, neither are a main priority.
Activity intolerance is related to the cardiovascular and respiratory systems, not the nervous and musculoskeletal (Range of Motion) systems.Rate this question:
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- 17.
The nurse understands that the skin protects the body from infections because the:
- A.
Cells of the skin are constantly being replaced, thereby eliminating external pathogens
- B.
Epithelial cells are loosely compacted on skin, providing a barrier against pathogens
- C.
Moisture on the skin surface prevents colonization of pathogens
- D.
Alkalinity of the skin limits the growth of pathogens
Correct Answer
A. Cells of the skin are constantly being replaced, thereby eliminating external pathogensExplanation
Epithelial cells are regularly shed along with potentially dangerous pathogens that adhere to the skin's outer layers, thereby reducing the risk of infection.
Epithelial cells are closely, not loosely compacted, providing a barrier against pathogens.
Moisture on the skin facilitates, not prevents, microorganisms from colonizing.
Acidity, not alkalinity, of the skin limits the growth of pathogens.Rate this question:
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- 18.
A nurse identifies that a patient has an inflammatory response. Which local adaptation supports this conclusion?
- A.
Fever
- B.
Erythema
- C.
Bradypnea
- D.
Tachycardia
Correct Answer
B. ErythemaExplanation
A fever is a systemic, not local, response to inflammation.
Bradypnea is regular but abnormally slow breathing and is not an adaptation to a systemic or local inflammatory response.
Tachycardia is a heart rate >100 bpm and is unrelated to local adaptation.
Local trauma or infection stimulates the release of kinins, which increase capillary permeability and blood flow to the local area, They increase of blood flow causes erythema (redness).Rate this question:
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- 19.
The nurse understands that the secondary line of defense against infection is the:
- A.
Mucous membranes of the respiratory tract
- B.
Urinary tract environment
- C.
Integumentary system
- D.
Immune response
Correct Answer
D. Immune responseExplanation
The immune response is a specific, secondary line of defense against pathogenic microorganisms. The production of antibodies to neutralize and eliminate pathogens and their toxins is activated when phagocytes fail to completely destroy the invading microorganisms.
The primary, nonspecific defenses work in harmony with the secondary line of defense and includes anatomical, mechanical, chemical and inflammatory defenses; these are found in the remaining examples above (skin, the mucous and the cilia of the respiratory tract, urine flowing out the body and urine acidity).Rate this question:
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- 20.
The nurse understands that a primary (nonspecific) defense that protects the body from infection is:
- A.
Antibiotic therapy
- B.
The high pH of the skin
- C.
Cilia in the respiratory tract
- D.
The alkaline environment of the vagina
Correct Answer
C. Cilia in the respiratory tractExplanation
Cilia in the respiratory tract are a primary defense -- mucous traps microorganisms and the cilia propel them away from the lungs.
Antibiotic therapy is chemotherapeutic agent(s) used to control or eliminate bacteria and is not a primary defense. (In fact, it can disrupt the normal flora and predispose an individual to additional infections.)
The pH of the skin is low (acidic), not high (alkaline; basic).
The pH of the environment in the vagina is acidic, not alkaline (basic).Rate this question:
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Current Version
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Mar 20, 2023Quiz Edited by
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Sep 23, 2014Quiz Created by
Andrealibby