Question 1

The nurse understands that which is the best description of personal identity?

Accepted Answer

Personal identity is best described as a continually evolving sense of individuality and uniqueness, reflecting the dynamic nature of how individuals perceive and express themselves over time.

Question 2

A patient undergoing fertility treatments for the past 9 months learns that despite in vitro fertilization she still is not pregnant. This patient is at risk for experiencing a crisis in which component of self-concept?

Accepted Answer

The patient is likely to experience a crisis in self-esteem, as the inability to conceive despite fertility treatments may lead to feelings of inadequacy or failure, impacting her sense of self-worth.

Question 3

The nurse is developing a plan of care for a patient who has been admitted with a serious acute illness, which is likely to continue long term. The patient is the parent of three small children. The nurse writes the following intervention: "Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness." Which purpose does this intervention address?

Accepted Answer

Facilitating communication between the patient and their significant other regarding the sharing of responsibilities helps in adjusting to the changes brought on by the illness, which directly supports role enhancement. It helps the patient and family members adapt to new roles that may be necessary due to the patient's condition, thereby enhancing their ability to fulfill these roles effectively.

Question 4

The nurse is providing care for a client newly diagnosed with anxiety. Which outcome is most realistic and appropriate in planning care for this client?

Accepted Answer

Describing coping strategies for anxious situations is a realistic and appropriate outcome when planning care for a client with anxiety. It focuses on managing symptoms and improving the client's ability to handle anxious situations, which is a practical and achievable goal in the context of anxiety management.

Question 5

The nurse understands the necessity of focusing nursing care on the entire person. Which focus is considered most appropriate for the nursing profession?

Accepted Answer

The biopsychosocial model is considered most appropriate for the nursing profession because it encompasses the biological, psychological, and social aspects of a person's well-being, offering a comprehensive approach to healthcare.

Question 6

A patient who lost their job last month has now been told that the patient's spouse wants a divorce. The patient states, "I know I don't have much to offer a spouse who wants more from life, and now I'm not even bringing home any money." Which nursing diagnosis is most appropriate for the patient?

Accepted Answer

The most appropriate nursing diagnosis for a patient experiencing a decrease in self-esteem due to recent life events (job loss and spouse wanting a divorce) is Situational Low Self-Esteem. This diagnosis is specific to individuals who are reacting to a current situation, as opposed to Chronic Low Self-Esteem, which would indicate a long-standing issue. Disturbed Personal Identity and Disturbed Body Image do not directly relate to the patient's expressed concerns about self-worth in relation to life events.

Question 7

A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which Nursing Outcomes Classification (NOC) outcome is essential for this nursing diagnosis?

Accepted Answer

Depression Level is the NOC outcome that measures the severity of depression symptoms, which is essential for evaluating the effectiveness of nursing interventions for Chronic Low Self-Esteem.

Question 8

The nurse is working with a group of clients who recently experienced health alterations that impacted physical and psychosocial functioning. When the nurse addresses self-concept, which statement best describes self-esteem?

Accepted Answer

Self-esteem refers to how much one values oneself or the degree of liking and respect one has for oneself. It is a component of self-concept, which encompasses all beliefs and feelings about oneself.

Question 9

The nurse is providing care for a patient diagnosed with clinical depression. Which statement by the nurse is best when communicating with this patient?

Accepted Answer

Option C is the best choice because it acknowledges the patient's feelings without making assumptions or minimizing their experience. It offers an open-ended invitation for the patient to discuss their feelings, which is a supportive and therapeutic communication technique in mental health care.

Question 10

The nurse is updating a plan of care for a patient who with a nursing diagnosis of Anxiety. Which patient behavior indicates to the nurse that the problem is resolving?

Accepted Answer

Using relaxation techniques indicates that the patient is employing coping mechanisms to manage their anxiety, suggesting improvement in their condition.

Question 11

The nurse is providing care for a group of patients in an acute care setting. Which comment by one of the patients demonstrates an internal locus of control?

Accepted Answer

An internal locus of control is demonstrated by individuals who believe they have control over the outcomes of their lives. Choice D reflects an internal locus of control because it shows gratitude and a positive outlook on a situation that could have been perceived negatively, indicating a belief in personal influence over life events.

Question 12

A female client tells the nurse, "I see how people look at me with my crooked back and short leg. No one has to tell me that I'm not pretty." Which conclusion does the nurse draw from the client's statements?

Accepted Answer

The client's statements reflect a negative view of herself, particularly concerning her physical appearance, which indicates she is experiencing a state of low self-concept.

Question 13

The nurse is providing care for a patient with cancer who is receiving chemotherapy. Based on Maslow's Hierarchy of Needs, which nursing intervention is the first priority?

Accepted Answer

According to Maslow's Hierarchy of Needs, physiological needs such as hunger and thirst are the most basic and must be addressed first before other needs like safety, love, esteem, and self-actualization.

Question 14

An adolescent female patient sustained facial fractures and a 6-inch laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her "looking this way." Which statement by the nurse is most appropriate?

Accepted Answer

Asking the patient to elaborate on her feelings ("Tell me what you mean by 'looking this way.'") is the most therapeutic response. It encourages the patient to express her feelings and concerns, which is an important step in emotional healing and coping with her current situation.

Question 15

The nurse is updating the plan of care for a patient scheduled to undergo a mastectomy for breast cancer. Which nursing diagnosis does the nurse anticipate in expectation of the body changes associated with the upcoming surgery?

Accepted Answer

Grieving is anticipated as the patient may experience emotional distress and loss related to the change in body image and the implications of breast cancer surgery.

Question 16

A patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his spouse misses work whenever the children are ill. The spouse is becoming increasingly distressed over the situation. Which experience does the nurse identify?

Accepted Answer

Interrole conflict occurs when the demands of one role interfere with the ability to fulfill another role, such as the spouse having to miss work to care for the children due to the patient's illness.

Question 17

The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which is an example of an individualized goal for that patient?

Accepted Answer

The goal of "No Self-Injury, Consistently Demonstrated" directly addresses the safety and well-being of the patient, which is a priority in managing a diagnosis of Disturbed Personal Identity. It focuses on a positive outcome related to the patient's behavior and identity.

Question 18

The nurse is providing care for patient who comes to the emergency department experiencing headache, palpitations, nausea, and dizziness. After determining that the patient has tachycardia and trembling, the nurse suspects anxiety. Which level of anxiety does the nurse recognize?

Accepted Answer

Severe anxiety is characterized by symptoms such as headache, palpitations, nausea, dizziness, tachycardia, and trembling, which align with the patient's presentation.

Question 19

An adolescent patient is admitted to the hospital. The nurse is aware the patient has no medical restriction on visitation. Which group of potential visitors is it most important for the nurse to encourage to help maintain the patient's social identity while hospitalized?

Accepted Answer

Peers are crucial for maintaining an adolescent's social identity, especially during hospitalization, as they provide a sense of normalcy and connection to their usual social environment.

Question 20

The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. The patient is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells the nurse that he is often "short of breath" and states, "I lie awake nights worrying about everything." The patient has been unable to work or care for family for the past 6 months. Which is the nurse's priority after documenting this information in the nurses' notes?

Accepted Answer

The patient's symptoms suggest a possible anxiety disorder or other mental health issue that is impacting his daily life. Notifying the primary care provider for a referral to a mental health professional is crucial for appropriate assessment and treatment.

Quiz 13: Psychosocial Health Illness