Psychosocial Health & Illness

Identify the choice that best completes the statement or answers the question.

____ 1. Which of the following is considered a strength of the nursing profession?

1)
Biomedical focus
2)
Psychosocial focus
3)
Biopsychosocial focus
4)
Physical focus

____ 2. A homeless patient is admitted with an infected leg wound. According to Maslow’s Hierarchy of Needs, which nursing intervention meets one of his basic physiological needs?

1)
Providing the patient with a dinner tray
2)
Administering antibiotics as prescribed
3)
Irrigating a wound with normal saline solution
4)
Encouraging the patient to express his feelings

____ 3. Which of the following can the nurse assess using Erik Erikson’s theory?

1)
Moral development
2)
Developmental tasks
3)
Social identity
4)
Self-esteem

____ 4. Which statement best describes self-concept? An individual’s:

1)
Understanding of how other’s perceive him.
2)
Evaluation of himself.
3)
Overall view of himself.
4)
Perspective of his role in society.

____ 5. The nurse is teaching a group of parents about growth and development. Which of the following statements by a parent would indicate correct understanding of self-concept? Self-concept stabilizes during:

1)
Childhood.
2)
Preadolescence.
3)
Midadolescence.
4)
Adulthood.

____ 6. A 13-year-old patient is admitted to the hospital. There is no medical restriction on visitation. To help maintain the patient’s social identity while hospitalized, it is most important for the nurse to encourage visits by:

1)
Peers.
2)
Grandparents.
3)
Siblings.
4)
Parents.

____ 7. Which response by the patient demonstrates an internal locus of control?

1)
“My blood sugar wouldn’t be out of control if my wife prepared better foods.”
2)
“I knew I shouldn’t have come to this hospital; I’d be better if I hadn’t.”
3)
“God must be getting even with me for my past behavior.”
4)
“I’m just glad to be alive; the accident could’ve been a lot worse.”

____ 8. The nurse is caring for a group of patients on the medical-surgical unit. Which patient is most likely to experience the most difficulty in adapting to a change in body image? The patient:

1)
Who suffered a traumatic amputation of the left leg in an industrial accident.
2)
With hypothyroidism who has coarse, dry, thinning hair, and weight gain.
3)
Who is obese and who underwent gastric bypass surgery.
4)
With peripheral vascular disease who required a wound graft.

____ 9. Which individual is most likely to have a positive body image?

1)
Child who has been deaf since birth
2)
Child who was born with cystic fibrosis
3)
Adolescent of average appearance who had an appendectomy
4)
Adult born with a spinal defect and associated paralysis of the lower body

____ 10. A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following?

1)
Role strain
2)
Interpersonal role conflict
3)
Role performance
4)
Interrole conflict

____ 11. Which statement best describes self-esteem?

1)
View of oneself as a unique human being
2)
One’s mental image of one’s physical self
3)
One’s overall view of oneself
4)
How well one likes oneself

____ 12. 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?

1)
Body image
2)
Self-esteem
3)
Personal identity
4)
Role performance

____ 13. A 17-year-old 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?

1)
“Tell me what you mean by ‘looking this way.’”
2)
“OK, I’ll restrict your visitors until your face heals.”
3)
“Your friends and family love you no matter what.”
4)
“You’re young, your face will heal quickly.”

____ 14. A patient has recently had a change in a family relationship that is greatly affecting his health. Which nursing diagnosis could you probably make for this patient?

1)
Parental Role Conflict
2)
Interrupted Family Processes
3)
Compromised Family Coping
4)
Ineffective Individual Coping

____ 15. The nurse is updating a care plan for a patient who has a nursing diagnosis of Anxiety. Which patient behavior might suggest that the problem is resolving?

1)
Pacing in the hallway at intervals
2)
Using relaxation techniques
3)
Speaking rapidly when spoken to
4)
Avoiding eye contact

____ 16. Which nursing diagnosis is categorized as a psychosocial, rather than a self-concept, diagnosis?

1)
Ineffective Individual Coping
2)
Situational Low Self-Esteem
3)
Disturbed Personal Identity
4)
Disturbed Body Image

____ 17. Which statement by the nurse is best when communicating with a patient with clinical depression?

1)
“It’s a beautiful day today; you’ll feel better if you look out the window.”
2)
“You’re having a bad day; I’m sure you’ll feel better soon.”
3)
“Life seems overwhelming at times; would you like to discuss how you’re feeling?”
4)
“You are very lucky to have such a supportive family.”

____ 18. A patient who lost his job last month has now been told that his wife wants a divorce. He says, “I know I don’t have much to offer a woman. She wants more than what I am, and now I’m not even bringing home any money.” Which nursing diagnosis is most appropriate?

1)
Chronic Low Self-Esteem
2)
Situational Low Self-Esteem
3)
Disturbed Personal Identity
4)
Disturbed Body Image

____ 19. The nurse is updating the care plan of a patient who must undergo a right mastectomy for breast cancer. Which nursing diagnosis should the nurse anticipate in expectation of the body changes associated with the upcoming surgery?

1)
Deficient Knowledge
2)
Impaired Adjustment
3)
Hopelessness
4)
Grieving

____ 20. A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis?

1)
Decision Making
2)
Distorted Thought Content
3)
Role Performance
4)
Depression Level

____ 21. The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which of the following is an example of an individualized goal for that patient?

1)
Distorted Thought Control
2)
Anxiety Level
3)
Self-Mutilation Restraint
4)
No self-injury, consistently demonstrated

____ 22. A 73-year-old patient was admitted with a perforated bowel. Following surgical repair, he developed complications and required an extensive stay in the hospital. How can the medical-surgical nurse best promote self-esteem in this patient?

1)
Assist the patient to ambulate in the hallway once daily.
2)
Encourage the patient to participate in self-care.
3)
Introduce herself to the patient if he does not know her.
4)
Listen attentively when the patient speaks.

____ 23. The nurse is developing a plan of care for a mother of three small children who has been admitted with a serious acute illness, which is likely to continue long term. 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.” The purpose of this intervention is to help:

1)
Promote self-esteem.
2)
Promote positive body image.
3)
Facilitate role enhancement.
4)
Prevent depersonalization.

____ 24. A patient comes to the emergency department complaining of headache, palpitations, nausea, and dizziness. After determining that the patient is anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting?

1)
Mild anxiety
2)
Moderate anxiety
3)
Severe anxiety
4)
Panic anxiety

____ 25. The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He 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 says, “I lie awake nights worrying about everything.” He has been unable to work or care for his family for the past 6 months. What is the nurse’s priority after documenting this information in the nurses’ notes?

1)
Provide emotional support for the patient using reflective listening technique.
2)
Do nothing; people with duodenal ulcers typically cannot work.
3)
Question the patient’s family about the information received from the patient.
4)
Notify the primary care provider and ask for a referral to a mental health professional.

____ 26. An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about whether he should consent to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient?

1)
Decisional Conflict
2)
Death Anxiety
3)
Powerlessness
4)
Ineffective Denial

____ 27. Which nursing intervention specifically helps reduce a patient’s anxiety?

1)
Teaching the importance of adequate nutrition and hydration
2)
Giving clear fact pertaining to the patient’s circumstances
3)
Promoting small group activities to improve self-esteem
4)
Monitoring the patient for the risk of suicide

____ 28. The nurse caring for a patient admitted with severe depression identifies a nursing diagnosis of Hopelessness on the care plan. Which outcome is appropriate for this diagnosis?

1)
Displays stabilization and control of mood
2)
Sleeps 6 to 8 hours per night with report of feeling rested
3)
Does not engage in risky, self-injurious behavior
4)
Eats a well-balanced diet to prevent weight change

____ 29. The nurse is assessing a patient for depression. Which of the following sets of behavioral symptoms may indicate depression?

1)
Preoccupation with loss, self-blame, and ambivalence
2)
Anger, helplessness, guilt, and sadness
3)
Anorexia, insomnia, headache, and constipation
4)
Tearfulness, withdrawal, and present substance abuse

____ 30. A frail, elderly patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. What is most important for the nurse do?

1)
Recognize these symptoms as signs of normal, physiologic aging.
2)
Obtain a urine specimen before notifying the primary care provider.
3)
Be sure she is placed in room occupied with another patient.
4)
Interview the patient to screen for clinical depression.

____ 31. An elderly patient admitted from a skilled nursing residence to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of dehydration. Which of the following should lead the nurse to suspect that dementia, rather than depression or dehydration, is the source of the symptoms: The history and nursing observations indicate that the patient

1)
Rambles, speaks incoherently, answers questions inappropriately.
2)
Speaks slowly with delayed response to questions, but responds appropriately.
3)
Awakens early in the day yet sleeps almost constantly during the day.
4)
Sometimes has difficulty concentrating on details of the present situation

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Which assessment finding(s) might suggest that the patient has low self-esteem and requires more in-depth assessment? Choose all that apply.

1)
Infrequent eye contact
2)
Straight posture
3)
Overly critical of others
4)
Careful grooming

____ 2. Which intervention(s) by the nurse might help the patient maintain a sense of personhood during hospitalization? Assume that all are culturally appropriate. Choose all that apply.

1)
Addressing the patient by his first name
2)
Making eye contact if it is comfortable for the patient
3)
Always offering an explanation before beginning a procedure
4)
Speaking to others about the patient so that the patient can hear you

Chapter 11. Psychosocial Health & Illness

Answer Section

MULTIPLE CHOICE

1. ANS: 3

A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient.

PTS: 1 DIF: Easy REF: V1, p. 184

KEY: Client need: HPM | Cognitive level: Recall

2. ANS: 1

According to Abraham Maslow and his Hierarchy of Needs, basic physiological needs, such as food, should be addressed first. After the patient’s basic needs are met, the nurse can provide wound care, administer antibiotics as prescribed (safety needs), and encourage the patient to express his feelings (love and belonging or self-actualization, depending on what feelings he expresses.)

PTS: 1 DIF: Moderate REF: V1, pp. 184-185

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

3. ANS: 2

Using Erikson’s theory, the nurse can assess for successful completion of development tasks. The theory does not help the nurse assess social identity or self-esteem. However, these factors are components of developmental tasks that Erikson’s theory explores. Moral development was addressed in the Kohlberg’s theory.

PTS: 1 DIF: Easy REF: V1, p. 184

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

4. ANS: 3

Self-concept is an individual’s overall view of himself. The overall view includes his evaluation of himself and how he thinks others evaluate him.

PTS: 1 DIF: Easy REF: V1, p. 185

KEY: Client need: PSI | Cognitive level: Recall

5. ANS: 3

Self-concept is present by ages 6 or 7 years; fluctuations peak during preadolescence, and it stabilizes during midadolescence. Self-concept remains stable throughout adulthood.

PTS: 1 DIF: Moderate

REF: ESG, Chapter 11, Table 11-2; link in V1, p. 186

KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Recall

6. ANS: 1

Peers are more important than family in maintaining social identity in this age group.

PTS: 1 DIF: Moderate REF: V1, p. 186

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall

7. ANS: 4

People who demonstrate an internal locus of control take responsibility for their life experiences and their response to them. This allows them to interpret unexpected events in a positive light, as the response “. . . the accident could’ve been a lot worse” illustrates. The other options demonstrate an external locus of control; control of the situation is attributed to external factors.

PTS: 1 DIF: Moderate REF: V1, p. 186

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

8. ANS: 1

Theoretically, the patient who suffered a traumatic amputation in an industrial accident will most likely have more difficultly adjusting to his change in body image because the change occurred abruptly. The patients described in the other options will naturally have some difficulty adjusting to their body image change, but it should not be as great because the physical changes are more gradual, which allows for adaptation over time.

PTS: 1 DIF: Moderate REF: V1, p. 187

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

9. ANS: 3

The adolescent with average appearance who had an appendectomy is likely to have a positive body image because the adolescent suffered an acute, reversible illness. Those born with physical handicaps are less likely to have a positive body image because many times the handicap leaves them socially isolated. This is, of course, not to imply that no one born with a physical handicap has a positive body image; and, of course, a particular adolescent’s body image might suffer after an appendectomy. However, the question asks which is “most likely” based on theoretical knowledge of body image.

PTS: 1 DIF: Moderate REF: V1, pp. 186-187

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

10. ANS: 4

The patient’s wife is most likely experiencing interrole conflict, in which her role as a mother and worker are making competing demands on her. Role strain is a mismatch between role expectations and role performance. Interpersonal role conflict results when another person’s idea about how a role should be performed differs from that of the person who is performing the role. Role performance is defined as the actions a person takes and the behaviors he demonstrates in performing a role.

PTS: 1 DIF: Difficult REF: V1, p. 187

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

11. ANS: 4

Personal identity is one’s view of oneself as a unique human being. Body image is described as one’s mental image of one’s physical self. Self-concept is defined as one’s overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect.

PTS: 1 DIF: Moderate REF: V1, p. 188

KEY: Client need: PSI | Cognitive level: Recall

12. ANS: 2

Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem. The patient is not at risk for experiencing a crisis in body image, personal identity, or role performance.

PTS: 1 DIF: Difficult REF: V1, p. 188

KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

13. ANS: 1

“Tell me what you mean . . .” encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assume that the patient is talking about her facial wounds. “I’ll restrict your visitors . . .” assumes that the patient is speaking about her facial wounds when she might not be. The other options are examples of false reassurance and do not address the patient’s concerns.

PTS: 1 DIF: Moderate

REF: V1, p. 193; ESG, Supplemental Materials, Psychosocial Nursing Interventions | V2, p. 116; ESG, Supplemental Materials, Psychosocial Nursing Interventions

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

14. ANS: 2

Interrupted Family Processes is defined as a change in a family relationship significantly impacting upon a patient’s health. Parental Role Conflict occurs when significant role confusion by a parent results in response to crises. Compromised Family Coping occurs when support from a usual family member is compromised or disabled, causing a significant health challenge. Ineffective Individual Coping occurs when the patient is unable to comprehend and effectively judge stressors.

PTS: 1 DIF: Difficult REF: V1, p. 193

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

15. ANS: 2

Using relaxation techniques might suggest that the patient’s anxiety is resolving. Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the patient. The patient’s use of relaxation techniques indicates problem solving by the patient.

PTS: 1 DIF: Easy REF: V1, p. 190 | V1, p. 199

KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Comprehension

16. ANS: 1

Ineffective Individual Coping is considered a psychosocial nursing diagnosis. It implies poor life choices, inability to use available resources, and other interactional and relationship symptoms. The term psychosocial encompasses both psychological and social factors. The other diagnoses represent primarily individual, psychological factors. They are examples of self-concept nursing diagnoses.

PTS: 1 DIF: Moderate REF: V1, pp. 193-194

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Recall

17. ANS: 3

When caring for a patient with depression, the nurse should encourage the patient to discuss his feelings. “It’s a beautiful day . . .” and “You’re having a bad day . . .” offer false reassurance. It would not be therapeutic to say, “You are very lucky . . .”; that is offering a judgment.

PTS: 1 DIF: Moderate REF: V1, p. 203

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

18. ANS: 2

Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case of a job and a marriage). There are no data to indicate long-standing (chronic) Low Self-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself.

PTS: 1 DIF: Moderate REF: V1, pp. 195-196

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

19. ANS: 4

Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associated with the expected body changes associated with the upcoming surgery, although they could certainly occur.

PTS: 1 DIF: Moderate REF: V1, p. 196

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

20. ANS: 4

Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis, Chronic Low Self-Esteem. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem; Role performance with Ineffective role performance; and Distorted Thought Content with Disturbed Personal Identity. Although the other options might contribute to the patient’s low self-esteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate resolution of the nursing diagnosis. Decision Making is the only outcome that does that.

PTS: 1 DIF: Moderate REF: V2, p. 114

KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

21. ANS: 4

Does not injure self, consistently demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. The other options are examples of NOC outcomes; they are not written as goals.

PTS: 1 DIF: Moderate REF: V2, pp. 114-115

KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

22. ANS: 2

Encouraging the patient to his own self-care, such as bathing and brushing his teeth, encourage independence and promote self-esteem. Assisting the patient to ambulate in the hallway prevents complications of immobility. Introducing yourself and listening attentively to the patient prevents depersonalization.

PTS: 1 DIF: Difficult REF: V1, p. 197

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

23. ANS: 3

Facilitating communication between the patient and significant other regarding sharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. The intervention is not designed to promote self-esteem or positive body image or to prevent depersonalization.

PTS: 1 DIF: Moderate REF: V1, p. 198

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

24. ANS: 3

The patient experiencing severe anxiety may experience physical symptoms including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. The patient experiencing moderate anxiety might experience a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. The patient suffering from panic anxiety might believe he has a life-threatening illness. Physical symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements.

PTS: 1 DIF: Moderate REF: V1, p. 189

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

25. ANS: 4

The nurse should involve a mental health professional immediately, because the patient is exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. Doing nothing is neglectful. Questioning the patient’s family about the information violates the patient’s right to privacy, unless the nurse obtains the patient’s permission to do so.

PTS: 1 DIF: Difficult

REF: V1, p. 199; Requires synthesis; answer not given verbatim.

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

26. ANS: 1

Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is uncertain about whether he should take the surgical risk. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is suffering from Death Anxiety at this time. Powerlessness is a perceived lack of control over a current situation; this patient is trying to exert some control over his care. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge.

PTS: 1 DIF: Moderate REF: V1, p. 199

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

27. ANS: 2

Using clear and factual knowledge that is tailored to the patient’s circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promoting small group activities to improve self-esteem, and monitoring the patient for suicide risk are interventions designed to help the patient with depression.

PTS: 1 DIF: Easy REF: V1, p. 200

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall

28. ANS: 1

An outcome for the nursing diagnosis Hopelessness is “displays stabilization and control of mood.” “Sleeps 6 to 8 hours per night and reports feeling rested” and “eats a well-balanced diet to prevent weight change” are example of outcomes for the diagnosis Depressed Mood. “Does not engage in risky, self-injurious behavior” is an outcome for the nursing diagnosis Risk for Suicide.

PTS: 1 DIF: Moderate REF: V1, p. 202 | V2, p. 120

KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

29. ANS: 4

Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are affective findings associated with depression. Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain, and constipation.

PTS: 1 DIF: Moderate REF: V1, p. 200

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

30. ANS: 4

Depression is often masked in older adults and expressed as physical and personality changes. Memory loss and confusion are also common symptoms of depression in older adults. Any one of the symptoms might occur as a result of physical illness, but the combination should prompt the nurse to suspect and screen for depression before exploring physiological causes for the symptom (as with a urine specimen). Placing the patient with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes.

PTS: 1 DIF: Moderate REF: V1, pp. 191-192

KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application

31. ANS: 1

In dementia, a patient’s language is disoriented, rambling, and incoherent; and the patient responds to questions inappropriately or with “near misses.”

Speaking slowly and being slow to respond to verbal stimuli are signs of depression; and in depression, the patient usually answers questions appropriately. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragment and the person awakens often during the night. Difficulty concentrating on details is a thinking pattern seen more in depression; in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment.

PTS: 1 DIF: Difficult REF: V1, p. 201 | V2, p. 113

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 1, 3

Assessment findings that suggest low self-esteem include avoiding eye contact and being overly critical of others. You would not need to follow up if the person displayed straight posture and careful grooming.

PTS: 1 DIF: Easy REF: V1, p. 195 | V2, p. 109

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

2. ANS: 2, 3

The nurse can help the patient maintain a sense of personhood by addressing the patient by his preferred name, which might be his first name or might be surname with title. Using eye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the room are additional ways for the nurse to offer care that respects patient rights.

PTS: 1 DIF: Moderate REF: V1, p. 195

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall