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Nursing > Exam 3 102 > Flashcards

Exam 3 102 Flashcards

1
Q

Theory of nursing that views the person, family, and community as constantly changing in response to environment and stressors is known as?

A

Neuman’s system model

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2
Q

A clients effort to manage psychological stress?

A

Coping

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3
Q

When teaching client about negative feedback response to stress, nurse includes what to describe the benefits of this stress response?

A

Results in neurophysiological response.

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4
Q

Nurse observes client whose home life is chaotic with intermittent homelessness, their child has spina bifida, and an abusive spouse appear to be experiencing allostatic load. As a result nurse expects to detect which of the following?

A

Chronic illness

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5
Q

DM client comes in with high blood sugar and states “That test is wrong my DM has been controlled for the last 6 months.” This client is experiencing what defense mechanism?

A

Denial

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6
Q

Young woman was in automobile accident 6 months ago and is experiencing vivid images of the crash when she hears loud, sudden noises. She is experiencing?

A

PTSD

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7
Q

Grandfather living in Japan worries about his young grandsons who disappeared after a tsunami. This is an example of?

A

An adventitious crisis.

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8
Q

During assessment interview of older woman experiencing a developmental crisis, nurse asks what question?

A

Since your husband has died, how have you been doing in the evening when you feel lonely?

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9
Q

Nurse planning care for 16 yr old male taking in stressors that are experienced most commonly by adolescents which include?

A

Search for identity with peer groups, separating from family.

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10
Q

Child that has been in house fire comes to ED with parents, child and parents are upset and tearful. During nurse’s assessment for stress the nurse says?

A

Tell me what bothers you most about this experience?

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11
Q

Increased blood volume, HR, blood glucose level, and mental alertness level occur during which part of general adaptation syndrome (GAS)?

A

Alarm reaction

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12
Q

While assessing a person for effects of the GAS nurse should be aware that?

A

Glucose increases the alarm reaction stage.

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13
Q

A newly diagnosed type 2 diabetes client exhibits denial when she says: my blood sugar was just a little high, I don’t have diabetes. The nurse responds with?

A

Silence. Nurse understands denial is a defense mechanism that assists in coping with shock.

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14
Q

Vital functions associated with survival, including HR, BP and respirations are controlled by?

A

Medulla oblongata

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15
Q

The substance secreted by pituitary gland?

A

Adrenocorticotropic hormone (ACTH)

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16
Q

Physiological signs of stress that occur during the early stage of GAS do NOT include?

A

Impaired mentation

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17
Q

Man adjusting to chronic illness this is example of?

A

Response to situational factor.

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18
Q

The nurse assists a client in connecting a stressful event with the clients reaction to the event. This approach is?

A

Crisis intervention

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19
Q

A depressed client is crying and verbalizes feeling low self esteem and self worth, best nursing response?

A

Review recent behaviors or accomplishments and demonstrate skill or ability.

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20
Q

Self concept is linked to job performance and satisfaction in what developmental stage?

A

Young adulthood

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21
Q

Client had mastectomy and refuses to eat, discourages visitors, and pays little attention to appearance. One morning she has done makeup and combed hair, nurse response?

A

I see you have combed your hair and put makeup on.

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22
Q

When individual internalizes beliefs, behavior, and values of role models into a personal, unique expression of self, this documented as?

A

Identification

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23
Q

Outcome criteria for evaluating achievement of the client’s goal, the client will express increased interest in sexual intimacy, should come from?

A

What the client identifies as the desired outcome.

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24
Q

What is most accurate description of sexual development in the school aged child?

A

The child asks specific questions about sexuality.

25
Q

Nurse educating new mother about infants sexual development, nurse understands teaching was effective when mother states?

A

My infant is beginning to tell the difference between men and women.

26
Q

What nursing measure promotes sleep in school aged children?

A

Encourage quiet activities before bedtime.

27
Q

What medication is safest to administer to adults needing assistance in falling asleep?

A

Benzodiazepines

28
Q

Client reports vivid dreams to nurse. What sleep phase is this?

A

REM sleep

29
Q

To validate suspicion of married man with sleep apnea nurse does what?

A

Questions spouse to see if she has been awoken by husbands snoring.

30
Q

What intervention is appropriate for care plan to improve older adult’s sleeping?

A

Decrease fluids 2-4 hours before sleep.

31
Q

Client with obstructive sleep apnea will most likely report what symptom?

A

Excessive daytime sleepiness.

32
Q

Phenytoin (Dilantin), an anticonvulsant causes what type of sleep problem?

A

Increased daytime sleepiness.

33
Q

Nurse developing plan of care for narcolepsy client. What intervention is appropriate to include?

A

Encourage client to take one or two 20 minute naps during the day.

34
Q

Client being discharged on around the clock opioids what should the nurse request an order for?

A

Stimulant laxative

35
Q

When setting goals for a client with chronic back pain nurse should begin by doing what?

A

Asking what does your pain prevent you from doing that you used to do?

36
Q

What sign or symptom in an opioid naive client is of greatest concern when assessing the client 1 hour after administering?

A

Difficulty arousing the client because sedation always occurs before respiratory depression.

37
Q

After returning from vacation nurse notices client has been receiving Percocet, 2 tablets by mouth every 3 hours for past 3 days, nurse most concerned about?

A

Amount of acetaminophen received daily. Maximum amount is 4g every 24 hours.

38
Q

Crisis intervention nurse working with mother whose Down syndrome child is hospitalized with pneumonia and lost her entitlement check, when can client be expected to regain stability?

A

After 6 weeks when she adjusts to the child’s respiratory status and reestablishes entitlement checks.

39
Q

Several staff members are complaining that a client has constant questions. What interpretation of this behavior helps the nurse provide care?

A

Inability of decision making reflects a self concept issue.

40
Q

20 yr old client has eating disorder with nursing diagnosis of low self esteem, what intervention would be best to address this?

A

Offer independent decision making opportunities.

41
Q

When developing outcome for 15 yr old girl, nurse considers primary developmental task of adolescence?

A

Form sense of identity.

42
Q

In planning care for 85 yr old male most important basic need to be met is?

A

Preservation of self esteem.

43
Q

Eriksons stage of development for old age?

A

Ego integrity vs. Despair

44
Q

Nurse suspects woman is being sexually abused, what should nurse do?

A

Tell client about the safe house for women.

45
Q

What question represents a nonjudgmental approach when gathering sexual health history?

A

Do you have sex with men, women, or both?

46
Q

54 year old male being treated for depression comes into clinic complaining he cannot get an erection, intervention?

A

Antidepressants may be affecting his sexual functioning.

47
Q

Older adult cautioned about long term use of sedatives and hypnotics because these medications can?

A

Lead to sleep deprivation.

48
Q

Nurse teaching client about using compounds such as melatonin for sleep?

A

Should not be used indefinitely, may interfere with prescription meds, not regulated by FDA.

49
Q

Nurse teaching client about taking benzos and that this med causes?

A

Grogginess and feeling hung over.

50
Q

What indicates further need for teaching on sleep hygiene?

A

I will have a glass of wine before bed to relax.

51
Q

To improve sleep in adolescence?

A

Do not study in bed, turn off cell phone at night, avoid coffee and soda before bed.

52
Q

Nurse taking sleep history, what statement needs further follow up?

A

I always feel tired when I wake up in the morning.

53
Q

Client returns after knee surgery and is complaining of pain, nurse response?

A

Assess characteristics of pain.

54
Q

Client states he has 6/10 pain and wife says he does not, who is the most accurate resource for assessing pain?

A

The clients report of pain is the best method for assessing pain.

55
Q

When using ice massage for pain relief?

A

Apply ice using firm pressure over skin, apply until numbness occurs and remove for 5-10 mins.

56
Q

Educating client about transcutaneous electrical nerve stimulation (TENS) what info should you include?

A

TENS electrodes are applied near or directly on the site of pain.

57
Q

While caring for cancer client, nurse knows WHO analgesic ladder recommends?

A

Transitioning use of adjuvants with NSAID drugs to opioids.

58
Q

Carpenter is primary wage earner in family and has recently become a hemiplegic what role problem is he experiencing?

A

Role conflict

Nursing (11 decks)

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