Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 42
Question 1
Type: MCSA
The nurse elects to use a scale of stressful life events to assess the level of a newly admitted client’s stress. How
should the nurse explain the use of this scale to the client?
1. “We will consider only the negative life events that have happened to you recently.”
2. “You should try to remember any stressful event that has occurred to you in the last 10 years to include in the
scale.”
3. “This scale will give us a definite stress level number that can be used to compare your stress to that of others
your age.”
4. “This scale will give us some idea about your stress related to both positive and negative recent events in your
life.”
Question 2
Type: MCSA
The client has just received news of the death of a relative. Over the next few hours, what physiologic response
should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?
1. Drop in blood pressure from 130/80 to 120/75
2. A more bounding pulse
3. Slight increase in urine output
4. Some decrease in oxygen saturation
Question 3
Type: MCSA
The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of
this level of anxiety?
1. The student’s perception and learning is enhanced.
2. The student’s attention is focused solely on studying for the examination.
3. The student’s only topic of conversation is the examination.
4. The student cannot talk about the examination without crying.
Question 4
Type: MCSA
While attempting to choose a nursing diagnosis, the nurse must decide whether the client is experiencing anxiety
or fear. What key point would help the nurse make this decision?
1. Anxiety is a milder form of fear.
2. Fear results in a physiologic response, whereas anxiety is psychologic.
4. Anxiety is generally based in reality, fear is not.
Question 5
Type: MCSA
The new nurse feels overwhelmed by the demands of working on a busy acute care unit and maintaining a
growing family. What strategy should this nurse employ to lessen this stress?
1. Spend the lunch hour completing documentation while eating a sandwich.
2. Set the alarm earlier in order to get to work early.
3. Focus on work instead of on family until more familiar with the environment.
4. Differentiate between “have to do” and “nice to do” at work.
Question 6
Type: MCSA
The nurse is caring for a critically ill child. While the nurse is preparing to administer a treatment to the child, the
child’s mother becomes distraught and begins to cry loudly while stroking the child’s face. What is the nurse’s best
response to this occurrence?
1. Tell the mother that she needs to control herself for the benefit of her child.
2. Distract the mother by having her straighten the linens on the bed.
3. Explain the procedure that will occur with the treatment.
4. Take the mother out of the room and comfort her.
Question 7
Type: MCSA
A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the
nurse do in response to this outburst?
1. Call the charge nurse and refuse to take care of this client until he is under control.
2. Apologize to the client for the unit rules, but tell him the rules must be followed.
3. Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable.
4. Tell the client that he is acting like a child and that such behavior will not be tolerated.
Question 8
Type: MCSA
A client tells the nurse about being laid off from work, the spouse wanting a divorce, and being ill with a chest
cold for a month. What statement should the nurse make that reflects understanding of a client in crisis?
1. “Once you reach the crisis state, you may remain there for several months until you recover.”
2. “People generally find it easier to work through a crisis if someone is working with them.”
3. “Men often handle crisis better individually, whereas women do better with a counselor.”
4. “Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible.”
Question 9
Type: MCSA
The nurse manager suspects the nursing staff is experiencing burnout because of complaints and an increase in
absenteeism. The nurses also appear tired and anxious. What can the manager do to help reduce this burnout?
1. Ask the physician staff to take over some of the tasks they routinely ask the nurses to do.
2. Make certain that the nurses are well prepared for their responsibilities.
3. Assign each nurse to spend 30 minutes with the hospital psychologist daily.
4. Ask administration to require 30 minutes of exercise at the end of each shift.
Question 10
Type: MCSA
The nurse identifies that a client has not met the expected outcome established for the nursing diagnosis
Ineffective Individual Coping. What should the nurse do first?
1. Revise the nursing diagnosis.
2. Reassess the patient, looking for previously unknown stressors.
3. Rewrite the interventions used to address the problem.
4. Explore reasons why the outcome was not achieved.
Question 11
Type: MCSA
The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for
the nurse to understand the client’s needs. The nurse suspects the client has progressed to which anxiety level?
2. Moderate
3. Severe
4. Panic
Question 12
Type: MCSA
The physician has just told the client that the results of a biopsy performed yesterday reveal no malignancy.
During discharge teaching, the nurse finds the client to be easily distractible and unable to focus. What is the
nurse’s best interpretation of this situation?
1. The client did not understand that there is no malignancy.
2. Anxiety can result from both positive and negative stimuli.
3. Because there is no malignancy present, the client feels there is no need for teaching.
4. These findings reflect mild anxiety, but the client should retain information taught despite this distractibility.
Question 13
Type: MCSA
A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What
defense mechanism is this client exhibiting?
1. Compensation
2. Denial
3. Displacement
4. Identification
Question 14
Type: MCSA
The victim of domestic abuse tells the nurse, “I know my spouse didn’t mean to hurt me. The situation just got out
of hand.” The nurse recognizes that the client is exhibiting which defense mechanism?
1. Intellectualization
2. Introjection
3. Projection
4. Minimization
Question 15
Type: MCSA
The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she
does not like her. When the client’s husband and her mother-in-law visit, the client is very cordial and acts happy
to see both visitors. The nurse recognizes that this client may be using which defense mechanism?
1. Reaction formation
2. Rationalization
3. Regression
4. Reparation
Question 16
Type: MCSA
The parents of a school-age client who was sexually abused by a minister want to know why someone who is
sexually attracted to children would choose to go into the ministry. The nurse explains that the displacement of
sexual drives into socially acceptable activities is which type of defense mechanism?
1. Repression
2. Sublimation
3. Substitution
4. Undoing
Question 17
Type: MCSA
The assessment of a client undergoing testing for an anxiety disorder reveals an increased heart rate, an increased
respiratory rate, a low-normal hematocrit, and a low blood sugar. Which finding is contrary to what could be
explained by a normal response to anxiety?
1. The heart rate
2. The respiratory rate
3. The hematocrit
4. The blood sugar
Question 18
Type: MCSA
A newly hospitalized client is demonstrating anxiety and stress. What intervention can the nurse plan to help this
client?
1. Explain all procedures in detail before performing them.
2. Let the client make the majority of decisions about the plan of care.
3. Control the environment of healing.
4. Demonstrate staff competence by using multiple nurses for care.
Question 19
Type: MCSA
The parents of an adolescent who has a history of depression are concerned because the physician has prescribed
an SSRI antidepressant for their child. What information should the nurse use to formulate a response to these
parents’ concerns?
1. These medications are addictive and difficult to discontinue when the depressive incident is past.
2. It is difficult for teenagers to manage the dosage regimen for many of these drugs because they must be taken
with a full meal.
3. There is an FDA warning regarding antidepressant use in teenagers and the increased risk of suicide.
4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3 to 4
days of the first dose.
Question 20
Type: MCSA
A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in
bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this
client’s behavior?