Preview Extract
Chapter 13
1. A patient tells the nurse that she needs help bathing even though she independently walks
in the room and accesses personal belongings without assistance. The nurse realizes this
patient is demonstrating which of the following ego defense mechanisms?
1. Regression
2. Projection
3. Sublimation
4. Compensation
Answer: Regression
Rationale:
Regression is a mechanism whereby a person returns to a time and level of less demanding
functioning. The patient, who is independent, is asking for help with the basic care task of
bathing. Projection occurs when individuals acknowledge their own shortcomings by blaming
others or the environment for their behavior. Sublimation describes a person who avoids
acting in an unacceptable way by substituting acceptable behavior. Compensation describes a
person who overcomes a deficit by overachieving in a more comfortable area.
2. The daughter of an ill patient tells the nurse that her father would not be so sick if she had
spent more time with him over the years. The nurse realizes the daughter is exhibiting which
of the following cognitive distortions?
1. Personalization
2. Selective abstraction
3. Overgeneralization
4. Magnification
Answer: Personalization
Rationale:
Personalization is when external events are attributed to oneself without any evidence to
support the causal relationship. The daughter believes that visiting her father would have
prevented the illness. Selective abstraction is the conceptualization of a situation while
ignoring contradictory information. Overgeneralization is taking specific information and
generalizing it broadly to unrelated situations. Magnification is seeing something as far more
important than it is.
3. A patient with a history of multiple childhood illnesses tells the nurse that she dislikes
doctors and hospitals because “nothing good ever happens in a hospital.” The nurse’s
understanding of cognitive concepts helps him realize this patient’s comment demonstrates:
1. A cognitive triad.
2. Selective abstraction.
3. Dichotomous thinking.
4. Minimization.
Answer: Cognitive triad.
Rationale:
The cognitive triad is a group of three negative recurring patterns of thought that influence
people to see themselves as inadequate, negatively misinterpret an experience, and view the
future in a negative way. The patient had many childhood illnesses and may have experienced
at an early age that hospitals and doctors mean illness, and therefore a bad experience.
Selective abstraction occurs when a situation is conceptualized while ignoring contradictory
information. In dichotomous thinking, experiences are categorized with all-or-nothing
reasoning. Minimization is seeing something as far less important than it is.
4. A student nurse is having difficulty establishing relationships with patients. Which of the
following should this student be counseled to do?
1. Develop self-awareness to focus on being helpful to patients.
2. Study cognitive theory.
3. Review the concepts of caring.
4. Focus on the purpose of a therapeutic alliance.
Answer: Develop self-awareness to focus on being helpful to patients.
Rationale:
One aspect of the nurse−patient relationship is that of the nurse’s self-awareness. The nurse
needs to be responsible to expand insight into her own personality. The theorist Peplau
explains that a basic task of nursing education should be the development of each nurse as a
person who wants to nurse patients in a helpful way. The nurse should be encouraged to
develop a helpful nature to her personality. Cognitive theory does not assist with the
development of the nurse−patient relationship. The concepts of caring might assist the nurse,
but will not help with the nurse’s personality development. A therapeutic alliance is when the
nurse and patient work together to reach mutually agreed-upon goals.
5. While changing a patient’s abdominal dressing, the nurse talks about aspects of wound
care, the need to check the skin, and the protection of the wound from infection or injury. The
nurse and patient are currently in the _________ phase of the nurse−patient relationship.
1. Working
2. Orientation
3. Termination
4. Caring
Answer: Working
Rationale:
The working phase of the nurse−patient relationship describes the participation of the patient
and nurse in interventions to achieve mutually agreed-upon goals. Most patient education
occurs during this phase. The orientation phase is the first phase of the relationship in which
introductions occur and the trusting relationship begins to develop. The termination phase
describes the time during which the nurse and patient review what has occurred during the
working phase and the progress of goal achievement. There is not a caring phase within the
nurse−patient relationship.
6. A patient tells the nurse that he is “happy to see” her because she “helps me and gets me
what I need” when the other nurses do not. The nurse realizes the patient is describing the
interpersonal competence theme of:
1. Going the extra mile.
2. Translating.
3. Getting to know you.
4. Establishing trust.
Answer: Going the extra mile.
Rationale:
The patient is comparing the current nurse with others who do not “get him what he needs.”
This is a description of the nurse “going the extra mile.” Translating describes the nurse being
able to understand what a patient is describing or needing. In the “getting to know you”
phase, the nurse takes the time to communicate with patients in an effort to understand their
needs and goals. Trust is established when the nurse portrays nonjudgmental behavior and
accepts the patient as a unique individual.
7. Prior to assessing a patient from a different culture, which of the following should the
nurse do to ensure cultural competence?
1. Review the patient’s culture to ensure cultural awareness.
2. Find another nurse who knows the patient’s native language.
3. Conduct the assessment as any other assessment would be done.
4. Leave the assessment to be done by another nurse.
Answer: Review the patient’s culture to ensure cultural awareness.
Rationale:
To provide the best care for the patient, the nurse should review information about the
patient’s culture to ensure awareness. As nurses enter into therapeutic relationships, they do
so with persons of diverse beliefs and values. These beliefs and values are born from cultural
and subcultural socialization. Nurses are expected to be culturally sensitive and competent,
continually striving to provide culturally appropriate care to patients and families. The nurse
should not seek another nurse to do the assessment or negate the fact that the patient is from
another culture. The nurse should not leave the assessment for another nurse to complete.
8. While conducting an assessment, the nurse asks the patient to explain more about the type
of pain she is experiencing. The nurse is utilizing which of the following therapeutic
communication techniques?
1. Exploring
2. Focusing
3. Accepting
4. Offering self
Answer: Exploring
Rationale:
The nurse uses the exploring technique to delve deeper into a subject, as when the nurse asks
the patient to explain more about the type of pain. Focusing is a technique that helps when a
patient moves quickly between topics. Accepting is when the nurse conveys an attitude of
reception and regard that is characterized by head nodding and eye contact. Offering self
describes the nurse making herself available to the patient by either sitting or staying with the
patient.
9. A patient tells the nurse that he thinks he has cancer because every other male family
member was diagnosed with cancer at the same age. The nurse tells the patient that
“everything will be all right.” the nurse’s response exemplifies the nontherapeutic technique
of:
1. Giving reassurance.
2. Agreeing.
3. Giving advice.
4. Probing.
Answer: Giving reassurance
Rationale:
The nurse provided the nontherapeutic technique of giving reassurance, which indicates to
the patient that there is no cause for anxiety, and devalues the patient’s feelings. It would have
been better for the nurse to ask the patient to “discuss that a bit further.” The nurse is not
agreeing with the patient’s idea, is not giving the patient advice, nor is the nurse probing for
more information.
10. The nurse is planning to instruct a patient on the anatomy of the heart so that he will
understand what type of surgery he needs. The best teaching strategy for the nurse to use
would be:
1. Discussion with printed materials.
2. Role modeling.
3. Demonstration.
4. Self-discovery.
Answer: Discussion with printed materials.
Rationale:
The patient is in need of cognitive knowledge about the anatomy of the heart. The teaching
strategy that supports cognitive learning is discussion with printed materials. Role modeling
is a strategy for affective learning. Demonstration and self-discovery are strategies to support
psychomotor learning.
11. A patient tells the nurse that he will not learn how to give himself insulin injections
because he gave his father insulin injections and “he died anyway.” To facilitate this patient’s
learning, the nurse’s best action would be to:
1. Talk with the patient about his father’s illness and how the insulin injections will help him
control his own illness.
2. Ask the patient if he prefers to read about how to provide the injections.
3. Leave a needleless syringe at the patient’s bedside for him to practice with.
4. Provide a diagram of body areas where insulin injections should be given.
Answer: Talk with the patient about his father’s illness and how the insulin injections will
help him control his own illness.
Rationale:
The nurse should talk with the patient about his father’s illness and how the injections will
help with the control of his own illness. The patient has experience with providing injections
but has an attitude or belief about insulin and the role it plays in diabetes management. The
patient needs affective learning, or learning that involves changing an attitude, value, or
feeling. The nurse should not ignore the patient’s statement by asking if he prefers written
instructions on how to provide injections. Leaving a needleless syringe at the bedside for the
patient to practice or providing a diagram of body areas where insulin injections should be
given would not support the patient’s need for affective learning.
12. The nurse has instructed a patient on the home use of a machine to treat sleep apnea.
Which of the following would indicate that the patient understands the instructions?
1. Patient demonstrates the use of the machine and the application of the mask.
2. Patient points to the instructions.
3. Patient says, “I know how to do it.”
4. Patient looks to her husband and says, “Do you have any questions?”
Answer: Patient demonstrates the use of the machine and the application of the mask.
Rationale:
The nurse is attempting to evaluate the success of instruction. The best way for the nurse to
assess the patient’s learning is to have the patient demonstrate the use of the machine and the
application of the mask. Pointing to the instructions does not ensure learning of the process or
materials. Stating, “I know how to do it” may or may not be sufficient to assess that learning
has taken place. Asking her husband if he has any questions would indicate that the patient is
not clear on the use of the equipment.
13. A patient undergoing chemotherapy tells the nurse that his wife lost her job and now they
do not have any health insurance. The patient has no way of paying for the treatments and
tells the nurse that he is going home to die. Which of the following can the nurse do to help
with this patient’s crisis?
1. Ask the patient if the wife has been offered a continuation of health care benefits from her
previous employer that would cover the costs of chemotherapy.
2. Find out if the chemotherapy can be billed at a later time, once the wife has other
employment.
3. Contact the health care provider and document that the patient is unable to pay for ongoing
treatment.
4. Suggest that the patient visit an emergency room for care because they cannot deny him
treatment.
Answer: Ask the patient if the wife has been offered a continuation of health care benefits
from her previous employer that would cover the costs of chemotherapy.
Rationale:
The problem of lack of health insurance has initiated a crisis for the patient. Since the
problem is already identified, the nurse and patient can move quickly into developing an
initial plan of care that, in this case, would be for the patient to find out if his wife has been
offered continuation of health care benefits from the previous employer. Postbilling for the
chemotherapy is not an option. The nurse should not contact the health care provider and
document that the patient is unable to pay for ongoing treatment. It would be inappropriate
for the nurse to suggest that the patient go to an emergency room for care.
14. The daughter of a patient tells the nurse that her mother was sitting at the kitchen table
and then went totally limp and was disoriented. Currently, the daughter is pacing in the
emergency room cubicle and continues to try to arouse her mother. Which of the following
should the nurse do?
1. Explain to the daughter that her mother is in the best place to figure out what has happened
to cause her to become disoriented.
2. Ask the daughter to have a seat in the waiting room until the doctor has finished examining
her mother.
3. Encourage the daughter to return home to wait for information.
4. Tell the daughter that being obviously stressed out will not help her mother.
Answer: Explain to the daughter that her mother is in the best place to figure out what has
happened to cause her to become disoriented.
Rationale:
The daughter is reacting to the sudden change in her mother’s health status. The daughter’s
reaction to the event is creating a crisis. The nurse needs to explain to the daughter that the
mother is in the best possible place to determine the cause for the change in her health status.
The nurse should not ask the daughter to leave her mother by going to the waiting room or
returning home. The nurse should also not threaten the daughter by stating that being stressed
out will not help her mother.
15. After being hit by an automobile, a patient tells the nurse that he lay on the pavement until
the ambulance arrived and was thinking about how his wife would continue to survive
without him. Which of the following is the best action by the nurse to help this patient with
the crisis?
1. Offer to contact his wife to explain where he is and what his condition is.
2. Provide the patient with a telephone so he can contact his wife.
3. Tell the patient that once his injuries are stabilized, someone will contact his wife.
4. Suggest that the patient should not worry about anything.
Answer: Offer to contact his wife to explain where he is and what his condition is.
Rationale:
The patient was a victim of a pedestrian-automobile accident and is concerned about his wife.
At the onset of a crisis, the nurse might have to intervene and do some things for the patient
that, under different circumstances, the patient could do for himself. While the nurse could
provide the patient with a phone for him to call his wife, he may not be in a condition to
make the call, and will not be able to provide factual answers to the wife about his condition.
The nurse should not make the patient wait to contact his wife by telling him that once he is
stabilized, someone will call her. Telling the patient not to worry is dismissive of his
concerns.
16. A patient tells the nurse that he is sick and will do whatever he is told to do. The nurse
realizes this patient is demonstrating:
1. Sick role behavior.
2. Internal locus of control.
3. Crisis response.
4. Denial.
Answer: Sick role behavior.
Rationale:
When individuals become ill and must be hospitalized, they are expected to behave in certain
ways and assume a sick role. A sick role is a set of expectations that people who are ill should
meet and that society, including caregivers, expects of them. When a person enters the
hospital, that person is immediately oriented to hospital rules, regulations, policies, and
procedures. It is expected that patients and their families will adhere to these rules. The
patient is expected to be cooperative, dependent, and nondemanding. Internal locus of control
is the perception that people have control over events that happen in their lives. This patient is
not demonstrating denial or a response to a crisis.
17. A male patient, newly diagnosed with prostate cancer, tells the nurse that his wife died a
few weeks ago and he does not know how he is going to deal with this new health problem.
Which of the following can the nurse do to help this patient?
1. Talk with the patient about his support systems and what he can do to maintain stability.
2. Suggest that the patient talk with a spiritual counselor.
3. Listen quietly while the patient talks.
4. Tell the patient that it seems overwhelming now, but everything is going to work out all
right.
Answer: Talk with the patient about his support systems and what he can do to maintain
stability.
Rationale:
The best approach would be for the nurse to talk with the patient about his support systems
and what he can do to maintain autonomy and stability. The patient is experiencing two
losses: the loss of his wife and the perceived loss of his health. The patient is still working
through the stages of grief and mourning for his wife when he is confronted with a new crisis.
Suggesting that the patient talk with a spiritual counselor may or not be appropriate, but it
does not immediately address the patient’s concerns. The nurse needs to do more than listen
quietly while the patient talks. The nurse should not minimize the patient’s losses by saying
that although it is overwhelming now; everything is going to work out all right. The nurse has
no way of knowing if this will occur.
18. The wife of a patient tells the nurse that she realizes that her husband’s cancer is in
remission but she can’t stop thinking about when he will eventually die and that she can’t
seem to be motivated to do anything anymore. The nurse realizes the wife is demonstrating
which of the following stages of grief and mourning?
1. Depression
2. Denial
3. Anger
4. Acceptance
Rationale:
The patient’s wife has accepted the patient’s diagnosis and inevitable outcome but is having
difficulty continuing with life, which is demonstrative of depression. Denial is not accepting
the diagnosis and outcome. Anger is asking “why me” and voicing hostility over the
diagnosis and outcome. Acceptance is peacefully accepting the inevitable outcome.
19. A patient who is waiting for a diagnostic test tells the nurse that she is nervous because
this test has been “on her mind” for weeks. The nurse realizes that the result of this patient’s
ongoing anxiety can lead to:
1. Wear and tear on the body.
2. Improved decision-making ability.
3. A variety of coping skills.
4. Nausea, headache, and dizziness.
Answer: Wear and tear on the body.
Rationale:
The patient has been experiencing anxiety for several weeks. The anxiety can become
chronic, which leads to dangerous wear and tear on the body. Improved decision-making
ability is seen in mild anxiety. A variety of coping skills is also seen in mild anxiety. Nausea,
headache, and dizziness are symptoms of severe anxiety.
20. A patient tells the nurse that “she is worthless” and to send in someone “who knows what
they are doing.” Which of the following should the nurse do in this situation?
1. Realize the patient is anxious and attempt to calm the patient and find out what the patient
needs.
2. Tell the patient that there is no one else available and he has to work with her today.
3. Leave the room and find someone else to work with the patient.
4. Tell the patient that he is not the easiest person in the world to work with, either.
Answer: Realize the patient is anxious and attempt to calm the patient and find out what the
patient needs.
Rationale:
This patient’s anger should be conceptualized as anxiety. Once the nurse realizes the patient
is anxious, she can attempt to calm the patient and find out what the patient needs. The nurse
should not respond with feelings of anger or anxiety. Telling the patient there is no one else
available, leaving the room, or scolding the patient are not approaches that address the
patient’s underlying anxiety.
21. A patient is found sitting on the side of the bed crying and repeating “I can’t take one
more thing.” The nurse realizes this patient is most likely demonstrating:
1. Depression.
2. Anxiety.
3. Frustration.
4. Anger.
Answer: Depression.
Rationale:
The crying patient is demonstrating depression. Depression is a predictable response to
illness and hospitalization and often accompanies loss and grief. Anxiety is an uncomfortable
feeling of discomfort, dread, apprehension, and unease; crying is not usually seen with
anxiety. Frustration is an emotion that is often seen with anxiety and accompanies the feeling
of helplessness and powerlessness. Anger develops as a response to the feelings of
powerlessness and helplessness and helps the person feel more in control.
22. A patient who is waiting to go for a diagnostic test that will determine the presence of
cancer tells the nurse that she is having difficulty breathing and feels like her heart is
pounding out of her chest. To best help this patient, the nurse should:
1. Stay with the patient and provide emotional support.
2. Darken the room and let the patient rest quietly alone.
3. Encourage the patient to walk around in the room.
4. Offer the patient a light snack to eat.
Answer: Stay with the patient and provide emotional support.
Rationale:
The patient is demonstrating a panic level of anxiety. In this situation, the nurse should not
leave the patient but should provide emotional support. Leaving the patient alone in a
darkened room, or encouraging the patient to ambulate or eat, does not provide supportive
care to the patient.
23. A patient tells the nurse that he has been having trouble sleeping and it has gotten worse
over the last several weeks. The nurse realizes sleep deprivation is most closely associated
with which of the following behavioral responses?
1. Anxiety
2. Frustration
3. Anger
4. Loss
Answer: Anxiety
Rationale:
Nursing diagnoses for the patient with anxiety include Sleep Deprivation. Sleep deprivation
is not typically associated with frustration, anger, or loss.
24. A patient tells the nurse that she has been losing weight and has no appetite or energy to
do anything. The nurse believes this patient is demonstrating signs of which of the following
behavioral health problems?
1. Depression
2. Anxiety
3. Frustration
4. Anger
Answer: Depression
Rationale:
Physical changes seen in depression include weight loss, loss of appetite, and low energy
levels. Weight loss, appetite change, and low energy and not typically associated with
anxiety, frustration, and anger.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
