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Results for Lesson 4: Psychosocial Integrity

Questions are numbered by the order in which they appeared in the test.
Represents the correct answer.
Question 1
A client who has a belief based in Hinduism is nearing Answers Correct A
death. The nurse should plan for which action? Student's A
After death a Hindu priest will pour water into the
A) mouth of the client and tie a thread around the client's
wrist
The elders may be with the client during the process
B)
of dying and no last rites are given
The family must be with the client during the process
C) of dying and be the only ones to wash the body after
death
The body is ritually cleansed and burial occurs as
D)
soon as possible after the death
Review Information: The correct answer is A: After death a Hindu priest will pour
water into the mouth of the client and tie a thread around the client''s wrist
This action indicates a blessing in the practice of Hinduism. The family of a client
whose belief system based in Hinduism is particular about who touches the dead body,
and cremation is preferred. In addition, last rites are carefully prescribed. The actions
in option B are expected with persons from the Church of Jesus Christ of Latter Day
Saints (also known as Mormons), and cremation is discouraged. Option C lists
practices of the Islamic religion, which specifies that only the family and friends may
touch the body. Option D lists practices of Judaism, and some Jewish groups also
prohibit autopsy and require a rabbi’s pre-approval of organ donation or transplants .

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.


(2nd ed). Clinton Park, New York: Delmar.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 2
A client says, "It's raining outside and it's raining in my Answers Correct D
heart. Did you know that St. Patrick drove the snakes out Student's D
of Ireland? I've never been to Ireland." The nurse would
document this behavior as
A) perseveration
B) circumstantiality
C) neologisms
D) flight of ideas
Review Information: The correct answer is D: flight of ideas
Flight of ideas is characterized by over productivity of talk and verbally skipping from
one idea to another. It is classic with clients diagnosed with bipolar disorder and
occurs in the manic state of this disease. Flight of ideas can also occur in
schizophrenia and intoxication with psychoactive substances.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical


Approach (4th ed.). Philadelphia: Saunders.

Question 3
A mother with a Roman Catholic belief system has given Answers Correct D
birth in an ambulance on the way to the hospital. The Student's D
neonate is in very critical condition with little expectation
of surviving the trip to the hospital. Which of these
requests should the nurse in the ambulance anticipate and
be prepared to encounter?
The refusal of any treatment for the mother and the
A)
neonate until a reader is consulted.
The placement of a rosary necklace around the
B) neonate's neck that is not to be removed unless
absolutely necessary.
Arrange for a church elder to be at the emergency
C) department when the ambulance arrives so a "laying
on hands" can be done.
Pour fluid over the forehead backwards towards the
D) back of the head and say "I baptize you in the name
of the father, the son and the holy spirit. Amen."
Review Information: The correct answer is D: Pour fluid over the forehead
backwards towards the back of the head and say "I baptize you in the name of the
father, the son and the holy spirit. Amen."
Infant baptism is mandatory according to Roman Catholic beliefs, especially if a
neonate is not expected to live. Anyone may perform this if an infant or child is
gravely ill. Option A refers to the Christian Science belief system. Option B is a belief
of Russian Orthodoxy. Mormons believe in divine healing with the laying on of hands,
as represented in option C.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.


(2nd ed). Clinton Park, New York: Delmar.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 4
A client diagnosed with anorexia nervosa states after lunch, Answers Correct A
"I shouldn’t have eaten all of that sandwich, I don’t know Student's A
why I ate it, I wasn’t hungry." The client’s comments
indicate that the client is likely experiencing
A) Guilt
B) Bloating
C) Anxiety
D) Fear
Review Information: The correct answer is A: Guilt
If people with anorexia lose control and eat more than they believe to be appropriate,
they experience guilt.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical


Approach (4th ed.). Philadelphia: Saunders.

Question 5
Which of these statements by the nurse reflects the best Answers Correct A
use of therapeutic interaction techniques? Student's A
A) "You look upset. Would you like to talk about it?"
"I'd like to know more about your family. Tell me
B)
about them."
"I understand that you lost your partner. I don't think
C)
I could go on if that happened to me."
"You look very sad. How long have you been this
D)
way?"
Review Information: The correct answer is A: "You look upset. Would you like to
talk about it?"
Giving broad opening statements and making observations are examples of
therapeutic communication. Option B is not supported by any assessment data
provided, and therefore would not be therapeutic in the absence of a reason to inquire
about the client’s family. Option C is incorrect because it is an inappropriately
personal remark by the nurse. Option D is not as therapeutic as option B because it
does not offer the client a broad opportunity to talk about concerns and is vaguely
critical of the client as phrased

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.
(2nd ed). Clinton Park, New York: Delmar.

Question 6
An explosion has occurred at a high school for children Answers Correct B
with special needs and severe developmental delays. One Student's C
of the students, accompanied by a parent, is seen at a
community health center a day later. After the initial
assessment the nurse concludes that the student appears to
be in a crisis state. Which of these interventions, based on
crisis intervention principles, is appropriate to implement
next?
A) Make the student identify a specific problem
B) Ask the parent to identify the major problem
C) Ask the student to think of different alternatives
D) Examine a variety of options with the parent
Review Information: The correct answer is B: Ask the parent to identify the major
problem
If a client is unable to participate in problem solving because of developmental delays
or altered mental status, then crisis intervention should not be attempted. However, the
family can be approached using crisis intervention methods. The crisis intervention
method includes 5 steps: identify the problem and then the alternatives, selection of an
alternative, implementation, and evaluation.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.


(2nd ed). Clinton Park, New York: Delmar.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 7
A teenage female is admitted with the diagnosis of Answers Correct C
anorexia nervosa. Upon admission, the nurse finds a bottle Student's C
of assorted pills in the client’s drawer. The client tells the
nurse that they are antacids for stomach pains. The best
verbal response by the nurse would be
"These pills aren’t antacids since they are all
A)
different."
B) "Some teenagers use pills to lose weight."
C) "Tell me about your week prior to being admitted."
D) "Are you taking pills to change your weight?."
Review Information: The correct answer is C: "Tell me about your week prior to
being admitted."
This is an open-ended question which is nonjudgmental and allows for further
discussion. The topic is also nonthreatening yet will give the nurse insight into the
client''s view of events leading up to admission. It is the only option that is client
centered. The other options focus on the pills.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Question 8
A Native American chief visits his newborn son and Answers Correct D
performs a traditional ceremony that involves feathers and Student's C
chanting. The attending nurse tells a colleague, "I wonder
if he has any idea how ridiculous he looks -- he's a grown
man!" The nurse's response is an example of
A) discrimination
B) stereotyping
C) ethnocentrism
D) prejudice
Review Information: The correct answer is D: prejudice
Prejudice is a hostile attitude toward individuals simply because they belong to a
particular group presumed to have objectionable qualities. Prejudice refers to
preconceived ideas, beliefs, or opinions about an individual, group, or culture that
limit a full and accurate understanding of the individual, culture, gender, race, event,
or situation.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories,


Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 9
An elderly client who lives in a retirement community is Answers Correct B
admitted with these findings as reported by the daughter: Student's C
absence at the daily senior group activity, missing the
weekly card games, a change in calling the daughter from
daily to once a week, and allowing the client's tomato
garden to become overgrown with weeds. The nurse should
assign this client to a room with which one of these
clients?
An adolescent who was admitted the day before with
A)
acute situational depression
A middle-aged person who has been on the unit for
B)
72 hours with a dysthymia
An elderly person who was admitted 3 hours ago
C)
with cyclothymia
A young adult who was admitted 24 hours ago for
D)
detoxification
Review Information: The correct answer is B: A middle-aged person who has been
on the unit for 72 hours with a dysthymia
The findings suggest a client who is depressed. The most therapeutic milieu or
environment for this client would include clients with similar problems and those who
might be more stable. A secondary consideration is matching roommates’ ages as
closely as possible, because they potentially would share similar developmental
challenges and needs. The client in option A has depression and would is more likely
to be unstable since they have been in the agency for only 24 hours. Dysthymia is
defined as a mild depression with findings of trouble falling asleep or no difficulty
falling asleep but then wakes up in the middle of the night and with difficulty is able
to fall back asleep. Cyclothymia is the occurrence of behavioral periods that do not
meet all of the criteria for manic or major depressive episodes.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.


(2nd ed). Clinton Park, New York: Delmar.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 10
Which statement by the client during the initial assessment Answers Correct D
in the emergency department is most indicative of Student's B
suspected domestic violence?
A) "I am determined to leave my house in a week."
"No one else in the family is as accident prone as I
B)
am."
C) "I have only been married for 2 months."
"I have tried leaving home, but have always gone
D)
back."
Review Information: The correct answer is D: "I have tried leaving home, but have
always gone back."
Victims develop a high tolerance for abuse. They blame themselves for being
victimized. All members in the family suffer from the effects of abuse, even if they are
not the actual victims. For these reasons, victims often have an extensive history of
abuse and struggle for a long time before they can leave permanently.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical,


Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 11
A nurse in the emergency department suspects domestic Answers Correct B
violence as the cause of a client's injuries. What action Student's B
should the nurse take first?
A) Ask client if there are any old injuries also present
Interview the client without the persons who came
B)
with the client
Gain client's trust by not being hurried during the
C)
intake process
D) Photograph the specific injuries in question
Review Information: The correct answer is B: Interview the client without the
persons who came with the client
It is critical to separate the client from their partner or significant other. With the use
of the nursing process the nurse’s first action when a client is unstable or has potential
problems is further assessment of the situation.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness.
Upper Saddle River, New Jersey: Prentice Hall.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 12
Which statement made by a client to the admitting nurse Answers Correct C
suggests that the client is experiencing a manic episode? Student's B
A) "I think all children should have their heads shaved."
B) "I have been restricted in thought and harmed."
"I have powers to get you whatever you wish, no
C)
matter the cost."
"I think all of my contacts last week have attempted
D)
to poison me."
Review Information: The correct answer is C: "I have powers to get you whatever
you wish, no matter the cost."
Grandiosity is characteristic of a manic episode.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.
Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical
Approach (4th ed.). Philadelphia: Saunders.

Question 13
During the change-of-shift report the assigned nurse notes Answers Correct D
a Catholic client is scheduled to be admitted for the Student's D
delivery of a ninth child. Which comment stated angrily to
a colleague by this nurse indicates an attitude of prejudice?
A) "I wonder who is paying for this trip to the hospital?"
B) "I think she needs to go to the city hospital."
"I guess she doesn’t understand how to use birth
C)
control."
D) "All those people indulge in large families!"
Review Information: The correct answer is D: "All those people indulge in large
families!"
Prejudice is a hostile attitude toward individuals simply because they belong to a
particular group presumed to have objectionable qualities. Prejudice refers to
preconceived ideas, beliefs, or opinions about an individual, group, or culture that
limit a full and accurate understanding of the individual, culture, gender, race, event,
or situation.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories,


Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 14
A 2 day-old child with spina bifida and meningomyelocele Answers Correct D
is in the intensive care unit after the initial surgery. As the Student's D
nurse accompanies the grandparents for a first visit, which
response should the nurse anticipate of the grandparents?
A) Depression
B) Anger
C) Frustration
D) Disbelief
Review Information: The correct answer is D: Disbelief
The first phase of the grieving process is shock, denial or disbelief. Then follows
anger, bargaining, depression and acceptance. Each stage can take any amount of time
to work through. Clients often go back and forth the stages before acceptance occurs.
Some client get stuck in 1 or 2 of the stages.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.
Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Question 15
A 65-year-old Catholic Hispanic-Latino client with Answers Correct C
prostate cancer adamantly refuses pain medication because Student's D
the client believes that suffering is part of life. The client
states, “Everyone’s life is in God's hands.” The next action
for the nurse to take is to
A) report the situation to the health care provider
B) discuss the situation with the client's family
C) ask the client if talking with a priest would be desired
D) document the situation on the notes
Review Information: The correct answer is C: ask the client if talking with a priest
would be desired
Beliefs regarding pain are one of the oldest culturally-related research areas in health
care. Astute observations and careful assessments must be completed to determine the
level of pain a person can tolerate. Health care practitioners must investigate the
meaning of pain to each person within a cultural explanatory framework.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:


Assessment & management of clinical problems. St. Louis: Mosby.

Question 16
A client with a new diagnosis of diabetes mellitus is Answers Correct B
referred for home care. A family member present expresses Student's D
concern that the client seems depressed. The nurse should
initially focus assessment by using which approach?
Administer a standardized tool that measures
A)
depression
B) Observe the client’s affect and behavior
C) Inquire about use of alcohol
Obtain a family health history, including emotional
D)
problems or mental illness
Review Information: The correct answer is B: Observe the client’s affect and
behavior
Although it is important to begin an assessment for depression immediately, the
assessment should not be aggressively intrusive unless the nurse has confirmed the
observation of the family member or if there are concerns about the risk of suicide.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition).
Prentice Hall: Upper Saddle River, New Jersey.
Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Question 17
A client who is thought to be homeless is brought to the Answers Correct D
emergency department (ED) by police. The client is Student's D
unkempt, has difficulty concentrating, is unable to sit still,
and speaks in a loud tone of voice. Which of these actions
is the appropriate nursing intervention for the client at this
time?
Allow the client to randomly move about the holding
A)
area until a hospital room is available
Engage the client in an activity that requires focus
B)
and individual effort
Isolate the client in a secure room until control is
C)
regained by the client
Locate a room that features minimal stimulation
D)
during the admission process
Review Information: The correct answer is D: Locate a room that features minimal
stimulation during the admission process
This intervention allows the client with moderate anxiety or agitation to have human
contact in an environment that does not exacerbate the condition. It also facilitates
efficiency in the initial screening and admission process to the ED, may prevent
behavioral escalation, and thereby promotes safety for all involved .

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.

Question 18
A client expresses anger when the call light is not answered Answers Correct D
within 5 minutes. The client demanded a blanket. The best Student's D
response for the nurse to make is
"I apologize for the delay. I was involved in an
A)
emergency."
B) "Let's talk. Why are you upset about this?"
"I am surprised that you are upset. The request could
C)
have waited a few more minutes."
"I see this is frustrating for you. I have a few minutes
D)
so let's talk."
Review Information: The correct answer is D: "I see this is frustrating for you. I have
a few minutes so let''s talk."
This is the best response because it gives credence to the client''s feelings and then
concerns. Option B does not acknowledge or validate the client''s feelings.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical


Approach (4th ed.). Philadelphia: Saunders.

Question 19
A nurse states, "I dislike caring for African-American Answers Correct C
clients because they are all so hostile." The nurse's Student's C
statement is an example of
A) prejudice
B) discrimination
C) stereotyping
D) racism
Review Information: The correct answer is C: stereotyping
Stereotyping refers to defining people and institutions, mentally or by attitudes, with
narrow, fixed traits, rigid patterns, or with inflexible "boxlike" profile characteristics.
Stereotyping is one of the most common concerns of nurses when they begin to study
different cultures and learn about transcultural nursing.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories,


Research and Practice. New York: McGraw Hill/ Appleton and Long.

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing.
Upper Saddle River, N.J.: Pearson Prentice Hall.

Question 20
Which of these findings would indicate that the nurse- Answers Correct D
client relationship has passed from the orientation phase to Student's D
the working phase? The client
has revitalized a relationship with her family to help
A)
cope with the death of a daughter
had recognized regressive behavior as a defense
B)
mechanism
C) expresses a desire to be cared for and pampered
D) recognizes feelings and expresses them appropriately
Review Information: The correct answer is D: recognizes feelings and expresses
them appropriately
During the working phase, the client is able to focus on both pleasant and unpleasant
feelings and express them appropriately.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.


(2nd ed). Clinton Park, New York: Delmar.