Fundamentals of Nursing Study Guide 2010

Chapter 27: Self-Concept
MULTIPLE 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 clients:
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
clients 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 clients ability to cope. However, when developing goals and
implementation strategies, the process is going to begin with the clients 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 clients interests and past accomplishments may provide information regarding a
clients identity. Identity is only one component of self-concept. The nurse needs to
determine the clients 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 ones surroundings is characteristic of a negative selfconcept.

DIF: A
REF: 412-413
OBJ: Comprehension
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 ones 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 ones care is not
consistent with a disturbance in the integrity stage of psychosocial development.
DIF: A
REF: 418
OBJ: Comprehension
TOP: Nursing Process: Evaluation
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 clients 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 clients 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
5.
The client is on the orthopedic unit following back surgery. He states, I feel like
I cant do anything anymoreand I wont 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
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 Id 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 mans role or a womans 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
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 nurses attempt to support the clients selfexploration?
1. What type of support do you feel you need?
2. Dont 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; well not judge your past actions.
ANS: 1
Encouraging the clients self-exploration by asking about the type of support needed is
achieved by accepting the clients 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 clients care, but does not support the
clients self-exploration. Self-exploration expands self-awareness. Telling the client that
staff will not try to judge the clients 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
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. Lets 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 clients 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 clients 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
9.
A clients 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 ones life and its meaning,
and being interested in providing a legacy for the next generation.
DIF: A
REF: 412
OBJ: Comprehension
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
11.
The nurse recognizes that self-concept develops throughout an individuals
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 ones 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 ones life achievements is an
expected developmental task associated with self-concept for the late 60s and older agegroup.
DIF: A
REF: 412
OBJ: Comprehension
12.
The nurse is working with a client and wants to learn about the individuals
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 clients 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 clients
perception of body image. Asking, What activities do you enjoy doing? is an example
of a question a nurse could use to assess a clients perception of self-esteem. Asking,
What is your usual day like? is an example of a question a nurse could use to assess a
clients role performance.
DIF: A
REF: 412
OBJ: Comprehension
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
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 individuals 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 ones 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
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
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
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 havent missed work due to illness in over 15 years.

When do I need to return to the clinic for a follow-up?
I dont 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 clients belief in personal health often enhances his or her self-concept. Statements
such as I can get through anything or Ive never been sick a day in my life indicate
that a persons thoughts about personal health are positive. The remaining options may
reflect the clients 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
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
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
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
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
clients current poor self-esteem image?
1. What is it about sewing that makes it so enjoyable for you?
2. Im 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
Eriksons 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 clients 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
22.
Which of the following statements best reflects the clients perception of the
female role?
1. My wife bakes the best bread.
2. All of my daughters are stay-at-home moms.
3. I dont 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 persons 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 clients 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
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 ones
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
24.
A 12-year-old girls 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 ones 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
25.
Which of the following statements best reflects a clients healthy sense of
identity?
1. My name is Susan.
2. My children are my world.
3. Im looking for my perfect job.
4. Im 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 ones
child is not an indicator of a healthy sense of identity nor is simply stating ones name.
DIF: C
REF: 412
OBJ: Analysis
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 clients body image, the effect is
likely to have less of an impact.
DIF: C
REF: 415
OBJ: Analysis
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 dont 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. Its much more difficult to socialize with friends now that I cant 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
28.
Which of the following statements best reflects a clients healthy sense of selfesteem?
1. I always try to do the best I can
2. Ill keep trying till I get it right.
3. Im not good at it but I enjoy playing guitar
4. If I cant build it, it isnt 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
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, Ill 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, Ill 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 clients
previously established sense of self-esteem.
DIF: C
REF: 416
OBJ: Analysis
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 clients needs in a nonjudgmental manner
2. Being aware of how the client will react based on the clients culture
3. Providing care that will meet the clients emotional and physical needs
4. Being careful to avoid nonverbal communication that could be misinterpreted
ANS: 1
A nurses 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
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
2.
1.
2.
3.
4.
A nurses 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 nurses 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 clients spiritual needs. The nurses 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 clients spiritual needs; however, it is
not how the nurses knowledge about spirituality begins.
DIF: A
REF: 444
OBJ: Comprehension
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
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 clients 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
clients source of strength. Assessing a clients 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 clients 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 clients 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 clients source of strength or the beliefs of the client.
DIF:
REF: 447
OBJ: Comprehension

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
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
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 clients personal belief system

ANS: 4
While working with a client to assess and support spirituality, the nurse should first
determine the clients perceptions and belief system. Exploring the clients 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 clients spirituality. The nurse needs to
first assess a clients spirituality to determine the clients 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 clients personal spiritual needs. The nurse should first assess the
clients perception and belief system before implementing any intervention.
DIF: A
REF: 444-445
OBJ: Comprehension
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
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
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
clients 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
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
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
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
14.
The nurse working in the labor and delivery area is aware that special care is
provided for the umbilical cord after the childs birth for the clients who are:
1. Catholic
2. Navajo
3. Shinto
4. Hindu
ANS: 2
After a Navajo childs delivery, the umbilical cord is taken from the newborn, dried, and
buried near a place that symbolizes what parents want for the childs 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
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 clients appetite
2. A decrease in the clients 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
16.
Which of the following statements made by a client diagnosed with terminal renal
failure best expresses the clients sense of hope?
1. My father lived for years with this disease.
2. Ive had a good life, and Ill 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 Im 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 daughters wedding provides the focus
for living. The other options are lacking that component of focus.
DIF: C
REF: 446
OBJ: Analysis
17.
The wife of a client diagnosed with Alzheimers 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 couples spiritual needs but do not directly deal with the
verbalized need. The final option is merely the nurses statement of religious practice.
DIF: C
REF: 445-446
OBJ: Analysis
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 clients 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
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. Im 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
nurses discomfort with a task but does not indicate any failure to provide effective,
appropriate nursing care.
DIF: C
REF: 448
OBJ: Analysis
20.
When asked about his or her religious affiliation, a client responds, Thats
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 clients question.
DIF: C
REF: 448
OBJ: Analysis
21.
Which of the following interview questions will best determine a clients
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 persons 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 clients spiritual well-being. The remaining options are more directed towards
assessing faith, or life satisfaction.
DIF: C
REF: 452
OBJ: Analysis
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 units 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 facilitys chaplain to attend the prayer session
4. Schedule the clients 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
clients prayers, the nurse is showing attention to the clients spiritual needs most
therapeutically. While the other options may be appropriate, they do not address the
facilitation of the clients expressed need regarding prayer.
DIF: C
REF: 444
OBJ: Analysis
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 clients systolic blood pressure after meditation
ANS: 1
The most conclusive evidence of the effectiveness of the intervention is the clients
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 clients statement.
DIF: C
REF: 457
OBJ: Analysis

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 ones
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 ones level of stress, but does not reduce
the incidence of heart disease.
DIF: A
REF: 494
OBJ: Comprehension
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 familys 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 clients reaction to it. Because an individuals or familys 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
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
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
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 clients environment. To determine the amount of anxiety the
client is experiencing, the nurse gathers information from the clients 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 clients 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 clients 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
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 individuals 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 persons level of consciousness.
DIF: A
REF: 486
OBJ: Comprehension
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
individuals anxiety. The focus is not on physical needs for the client who is experiencing
PTSD.
DIF: A
REF: 489
OBJ: Comprehension
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
ones 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
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
10.
A client recently lost a child in a severe case of poisoning. The client tells the
nurse, I dont 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
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
ones 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
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 nurses 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 persons 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
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 clients primary physical needs
2. What else is happening in the clients life
3. How the stress has influenced the clients 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 clients 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 clients
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 persons life, such as in activities of
daily living.
DIF: A
REF: 494
OBJ: Comprehension
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
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 bodys 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
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
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
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 Neumans 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
19.
The son of a client diagnosed with moderately advanced Alzheimers 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 sons 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 clients care, the familys concerns will be best managed.
DIF: C
REF: 490
OBJ: Analysis
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 everyones 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
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 Neumans 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
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 wifes 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

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
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:
REF: 487
OBJ: Analysis


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
hearts physiological limits. When stroke volume is decreased, there is an increase in
heart rate.
DIF: A
REF: 910
OBJ: Comprehension
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-Fowlers position, using gravity to assist

in lung expansion and reduce pressure from the abdomen on the diaphragm. The nurses
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
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
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 clients greatest risk is related to the level of his fracture. There is no mention
of an abnormal chest shape. This clients 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
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
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
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
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
9.
The nurse identifies that the client is unable to cough to produce a sputum
specimen, and the clients 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
10.
The nurse is checking the clients overall oxygenation. In assessment of the
presence of central cyanosis, the nurse will inspect the clients:
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

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
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 clients 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
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
clients 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 clients
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
clients mouth in relation to the clients 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
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
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
16.
It is suspected that the clients oxygenation status is deteriorating. The nurse is
aware that the abnormal assessment finding that represents the most serious indication of
the clients 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 clients 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 clients current deterioration in oxygenation status. Pursed-lip breathing is used to
slow expiratory flow. It is not the most serious indication of a clients decreased
oxygenation.
DIF: C
REF: 917
OBJ: Analysis
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
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
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-Fowlers position. The clients head is turned to the right to help
the nurse suction the left mainstem bronchus, and the clients 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
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 clients 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
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
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 clients 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 clients chest level will not help the
situation.
DIF: C
REF: 950
OBJ: Analysis
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
24.
The electrical activity of the clients 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
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
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
27.
The nurse is reviewing the results of the clients 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 clients measurement is low at 88%. The normal
pH is 7.35 to 7.45; the clients pH is high at 7.52. The normal PaCO2 is 35 to 45 mm Hg;
the clients 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
28.
The nurse is completing a physical examination for a client who is anemic. In
assessing the clients 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
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
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 doesnt 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
31.
When the nurse is reviewing a clients laboratory results, a low calcium level is
noted. When the nurse then reviews the clients 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
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 clients 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 clients work of breathing increases. Although the remaining options are not
incorrect, they are not the primary source of the clients fatigue.
DIF: C
REF: 911
OBJ: Analysis
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 clients 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 clients clavicles during inspiration
ANS: 4
During an assessment, observe for elevation of the clients 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
34.
Pregnancy affects a womans 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 clients
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
35.
in:
The primary effect of chronic fevers on the bodys respiratory functioning is seen
1.
2.
3.
4.
Increased oxygen requirements that exceed the bodys ability to satisfy its needs
Increased respiratory rates that tax the bodys 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
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 clients motivation to deep breathe, contributing to shallow,
diminished inspirations
4. Pain will decrease the clients 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
37.
The nurse observes that a clients 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 clients further need for assessment?
1. Ill wait 15 minutes and reevaluate the clients pulse rate.
2. Her pulse rate is usually in the mid 60s, so there isnt a problem.
3. Ill need to assess her for the presence of chest pain and/or dizziness.
4. You run an electrocardiogram, and Ill 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
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
39.
The nurse is preparing to discuss myocardial infarctions (MIs) with a womens
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. Womens 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

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 clients 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 clients blood oxygen is the most
therapeutic intervention.
DIF: B
REF: 916-917
OBJ: Application
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
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. Ill 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. Well 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
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
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
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 hearts 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
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
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
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
49.
A 47-year-old female client tells the nurse that her heart feels as though it is
racing. The clients 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
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
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
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 clients 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
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
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
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
2.
Which of the following are factors that affect the bloods 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
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
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

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
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
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
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
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
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 childs parents regarding this assessment?
1. What are the childs 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 childs 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 childs usual sleep patterns. The nurse
should first assess the childs usual sleep pattern to determine if the child is adhering to a
bedtime. A sleep problem is often the cause of fatigue.
DIF: C
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
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
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
10.
A 74-year-old client has been having sleeping difficulties. To have a better idea of
the clients problem, the nurse should respond:
1. What do you do just before going to bed?
2. Lets make sure that your bedroom is completely darkened at night.
3. Why dont you try napping more during the daytime?
4. Do you eat a small snack before going to bed?
ANS: 1
To assess the clients 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 clients 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 clients sleeping problem. The client does
not always have to eat something before going to bed.
DIF: C
11.
Which of the following information provided by the clients 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 clients 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

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
13.
The nurse knows that which of the following habits may interfere with a clients
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
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
15.
The nurse is completing an assessment of the clients 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
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
17.
A client is concerned that her habit of sleeping during the day and being awake at
night is not healthy or normal. The nurses most therapeutic response to the clients
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 dont 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 isnt abnormal or unhealthy.
ANS: 4
All persons have biological clocks that synchronize their sleep cycles. If the sleep pattern
does not adversely affect the clients health or ability to function, it is not problematic.
DIF: C
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 individuals usual sleep-wake cycle negatively influences the clients overall health.
Although the other options are not inappropriate, they are not as directly aimed at
determining the cause of the changes.
DIF: C
19.
The nurse and a client are discussing possible behaviors that might be interfering
with the clients ability to fall asleep. Which of the following assessment questions is
most likely to identify possible problems with the clients 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
20.
An older adult client diagnosed as being in the early stage of Alzheimers 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 clients 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
21.
A 9-year-old client asks the nurse, Why do I need to sleep? The nurses 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. Youll be able to do so much better in school if youre 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 childs question. The body needs sleep to routinely restore
biological processes.
DIF: C
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
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
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 Crohns 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
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
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
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 mothers 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 arent sure exactly, but it may have something to do with undetected cardiac or
oxygen problems.
3. Research is inconclusive, but its 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 mothers question, whereas the remaining options stress preventive
measures.
DIF: C
28.
The client asks the nurse, How will I know if Im really rested? The nurses
most therapeutic response is:
1. Everyones definition of rested is different. How would you define rested?
2. When you arent 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
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 nurses
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 clients 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
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
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 clients 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
32.
The nurse and the parents of a 3-year-old are discussing their childs sleep habits.
They share a concern over the childs 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 wouldnt 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. Its
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
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
34.
A 22-year-old male client shares with the nurse that he is always tired. In
assessing the clients 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
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
36.
The night nurse goes quietly into the sleeping clients 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
37.
A 25-year-old clients 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:
REF: 1037
OBJ: Analysis

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 adults 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
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
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 clients 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
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
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. Alzheimers 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
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
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 dont 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

Fundamentals of Nursing Study Guide 2010

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Chapter 27: Self-Concept

interest in what is happening in ones surroundings is characteristic of a negative selfconcept.

I havent missed work due to illness in over 15 years.

3. Experiencing a substantial increase in breast size

either state a sense of perseverance, an expression of a lack of talent, or an unrealistic

Potter & Perry: Fundamentals of Nursing, 7 Edition

Chapter 29: Spiritual Health

A nurses knowledge about spirituality begins with him or her:

TOP: Nursing Process: Implementation

4. Determine the clients personal belief system

1. I offer to pray with my clients as I prepare them for transport to surgery.

3. To whom do you turn when you have a problem to deal with?

Potter & Perry: Fundamentals of Nursing, 7 Edition

An adult client exercises to the point of fatigue

Avoid discussion of job problems

2. Complete an in-depth evaluation of stressors and responses

3. Psychosocial factors are the greatest threats

4. How has this experience affected your life?

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping

TOP: Nursing Process: Assessment

Potter & Perry: Fundamentals of Nursing, 7 Edition

cardiopulmonary disease is the 45-degree semi-Fowlers position, using gravity to assist

MSC: NCLEX test plan designation: Physiological Integrity/Physiological

4. Exercise stress test

MSC: NCLEX test plan designation: Physiological Integrity/Physiological

4. Poor coronary arterial circulation

fibrillation. Immediate defibrillation is needed after assessment of ABCs of CPR.

Potter & Perry: Fundamentals of Nursing, 7 Edition

3. Allow the child to sleep longer in the mornings

3. Take less time to fall asleep

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and

3. Eliminating naps during the day

3. Do you have any idea what might be causing these problems?

4. A manifestation of the disease process causing the brain disorder

TOP: Nursing Process: Assessment

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