NUR 130 Exam 4

Correct Answer: A. Development of an eating disorder

Explanation:

A negative body image refers to a person’s dissatisfaction or distorted perception of their physical appearance, which can lead to significant psychological and behavioral consequences. One of the most well-documented adverse effects of negative body image is the development of eating disorders, such as anorexia nervosa, bulimia nervosa, or binge eating disorder. These conditions often stem from an intense fear of gaining weight or a persistent desire to alter one’s body, driven by dissatisfaction with appearance. Negative body image can lead to unhealthy eating habits, obsessive behavior around food and exercise, and impaired mental health, including anxiety and depression.

Why the Other Options Are Incorrect:

B. Self-absorption

Self-absorption refers to excessive self-focus or egocentrism, which is not directly linked to negative body image. While a person with poor body image may be preoccupied with their appearance, this is not the same as self-absorption, which lacks the emotional distress and self-critical nature associated with body image issues.

C. Mistrust

Mistrust refers to difficulty trusting others, which can stem from many causes (e.g., trauma or relationship problems) but is not a primary or direct effect of negative body image. While interpersonal relationships may be affected by self-esteem issues, mistrust is not the defining outcome.

D. Role performance overload

Role performance overload occurs when a person is overwhelmed by multiple demands or responsibilities, such as work, parenting, or caregiving roles. This condition is related to stress and time management, not body image concerns.

Summary:

The correct answer is A. Development of an eating disorder, as this is a well-established psychological consequence of negative body image, often resulting from dissatisfaction and preoccupation with body shape and weight. The other options are unrelated or not directly tied to the effects of negative body image.

Correct Answer is C. The client reports dizziness when ambulating to the bathroom.

Explanation:

When administering antihypertensive medications, it is crucial to consider the client's current health status and any potential side effects or complications that could arise from the medication. Antihypertensive medications can lower blood pressure, and dizziness, particularly when changing positions, is a common side effect of these medications, especially if the blood pressure drops too low. The dizziness upon ambulating reported by the client could indicate orthostatic hypotension, which is a sudden drop in blood pressure upon standing up or changing positions. This is a concern, as it may suggest that the client’s blood pressure is already lower than desired or that they are at risk of a fall. Therefore, the nurse should further assess the client’s blood pressure and evaluate whether it is safe to administer the antihypertensive medication at this time.

Why the Other Options Are Incorrect:

A. The client has a urine output of 400 mL for the past 8 hr.

This finding may indicate a decreased urine output, but it is not directly related to the administration of antihypertensive medication. It would be important to assess kidney function and fluid status, but this is not an immediate concern that would require postponing the antihypertensive medication. However, if the client is on a diuretic (which is often used alongside antihypertensives), further evaluation of renal function would be necessary.

B. The client ate 60% of their breakfast.

While the client did not eat the entire meal, this finding does not immediately raise a concern for administering antihypertensive medication. Antihypertensive medications can generally be taken with food, and eating a reduced amount of food typically would not interfere with the medication’s effectiveness or safety. However, if the client were on other medications that require food intake (e.g., certain diabetes medications), this might require attention, but it is not the most pressing issue in this case.

D. The client reports having trouble sleeping the previous night.

Difficulty sleeping, while potentially important for overall health, is not typically a concern when administering antihypertensive medication unless it is related to an acute condition such as anxiety or pain, which could elevate blood pressure. While insomnia may be a side effect of some medications, it is not directly relevant in the context of assessing the safety of administering antihypertensive medications at this moment.

Summary:

The correct answer is C. The client reports dizziness when ambulating to the bathroom, as dizziness could be a sign of low blood pressure or a side effect of antihypertensive medication. The nurse should further assess the client’s blood pressure and overall condition before administering the medication to ensure safety. The other findings, while noteworthy, are less directly related to the safe administration of the antihypertensive medication.

The correct answer is D. Rationalization.

Explanation:

Rationalization is a defense mechanism where a person offers a logical or plausible explanation for their behavior or actions, often to make them seem more acceptable or justified, even if these explanations are not the true underlying reasons. In this case, the client states that they did not take their medication because their partner forgot to remind them. This is an example of rationalization because the client is providing an external, seemingly reasonable explanation for why they failed to take the medication, rather than taking personal responsibility for their actions. This behavior is common when someone wants to avoid the guilt or shame of not following through on their responsibilities. By blaming the partner, the client is attempting to make their failure to take the medication seem less like a personal shortcoming and more like something beyond their control. This is a way to protect their self-image and avoid confronting the real reason they didn't take the medication, such as forgetfulness or lack of motivation.

Why the other options are incorrect:

A. Repression:

Repression is a defense mechanism where an individual unconsciously blocks out distressing thoughts, feelings, or memories from their conscious awareness. In this situation, the client is not forgetting or unconsciously blocking out the fact that they didn't take the medication. Instead, they are offering an explanation, which shows they are fully aware of their actions. Repression would involve the client not consciously recalling or acknowledging the reason they missed their medication, which is not the case here.

B. Regression:

Regression refers to reverting to behavior characteristic of an earlier developmental stage, typically in response to stress or anxiety. For instance, a person might start behaving in a childlike manner, such as throwing a tantrum or seeking excessive comfort. In this scenario, the client is not displaying any behavior typical of an earlier developmental stage. Instead, they are providing a reason for their actions, which is not an example of regression.

C. Projection:

Projection is a defense mechanism where a person attributes their own unacceptable feelings, thoughts, or impulses to someone else. For example, someone who is angry might accuse others of being angry. In this case, the client is not projecting any of their own feelings onto their partner. Instead, they are explaining their own actions by blaming their partner for forgetting to remind them. Projection would involve the client accusing the partner of something related to their own feelings or behavior, which is not happening here.

Summary

The client is demonstrating rationalization by providing an external justification for why they didn't take their medication. They are avoiding personal responsibility by attributing their failure to an external factor— their partner's forgetfulness. This is a common way people protect themselves from feelings of guilt or shame.

Correct Answer is D. Disenfranchised grief.

Explanation:

Disenfranchised grief occurs when an individual experiences grief but is unable to openly mourn or is not recognized as having a valid reason to grieve. In this case, the client is grieving the loss of a pet and feels alone in their grief, which often happens when the grief is not socially acknowledged or considered significant by others. Pets are often seen as family members, but society may not fully recognize the depth of the emotional bond, leading the person to feel isolated in their mourning process.

Why the Other Options are Incorrect:

A. Uncomplicated grief:

Uncomplicated grief refers to the normal grieving process that most people experience after a loss, without prolonged or excessive symptoms. The client’s experience of feeling alone in their grief may indicate disenfranchised grief, where the grief is not recognized or supported by society, rather than a typical uncomplicated process.

B. Prolonged grief:

Prolonged grief is characterized by grief that lasts longer than expected (typically over six months) and interferes significantly with the individual’s functioning. The client in this scenario is not describing an unusually long duration of grief, only that they feel isolated in the process, which points more to disenfranchised grief.

C. Anticipatory grief:

Anticipatory grief occurs before the actual loss, typically when someone is aware that a loss is imminent, such as in the case of a terminal illness. The client is grieving after the loss has occurred, which makes anticipatory grief an incorrect option in this case.

Summary:

The client is experiencing disenfranchised grief, as they are grieving the loss of a pet and feeling alone in their grief, suggesting that their grief is not fully acknowledged or supported by others. This type of grief is often not openly expressed or socially recognized, making the individual feel isolated.

Correct Answer is C. Hospice care is restricted to clients who are terminally ill.

Explanation:

Hospice care is a specialized form of care designed for clients who are terminally ill, typically with a life expectancy of six months or less if the disease follows its usual course. The focus is on comfort, dignity, and quality of life, rather than curative treatment. This care may be provided in a variety of settings, including the client's home, hospice centers, long-term care facilities, or hospitals.

Why the Other Options are Incorrect:

A. The goal of hospice care is to prolong life:

The goal of hospice care is not to prolong life, but to enhance the quality of the remaining life by relieving pain and managing symptoms. It emphasizes comfort rather than aggressive or life-prolonging interventions.

B. Hospice care is limited to clients who are in a health care facility:

Hospice care is not limited to healthcare facilities. In fact, a large portion of hospice services are provided in the client’s home, allowing them to remain in a familiar and comfortable environment surrounded by loved ones.

D. Hospice care cannot be discontinued once it is initiated:

Hospice care can be discontinued at any time. If a client’s condition improves or if they decide to pursue curative treatments again, they can revoke hospice services. It is a flexible form of care based on the client’s needs and choices.

Summary:

The correct action is C. Hospice care is restricted to clients who are terminally ill. Hospice is comfort-focused care for those nearing the end of life and is not limited by setting or permanently binding once started. Its purpose is to support both the client and their family during this final stage of life.

Correct Answer is A. Social worker.

Explanation:

When a client is being discharged and requires home health care for wound management, the nurse needs to assess the patient's social and emotional needs as part of the discharge plan. A social worker is an essential team member to consult in this case. The social worker can help with arranging resources for home care, such as coordinating home health visits, ensuring that the patient has adequate support at home (like family or caregiver assistance), and addressing financial concerns or community resources (e.g., access to transportation, home modifications, or support services). The social worker may also assist with mental health needs or helping the client cope with the stress of managing a wound at home.

Why the Other Options Are Incorrect:

B. Occupational therapist

An occupational therapist (OT) would typically be consulted if the patient requires help with activities of daily living (ADLs) due to functional impairments (e.g., difficulty dressing, bathing, or eating). While an OT could help with adaptation strategies for activities like dressing or managing daily tasks, their role is not directly related to wound care management or home health care coordination for a wound.

C. Dietician

A dietician may be consulted if the wound care requires nutritional support, particularly if there are concerns about wound healing that could be affected by nutrition (e.g., protein deficiency, vitamin deficiencies). However, based on the scenario provided, there is no specific indication that the client’s wound care requires dietary intervention. A dietician's role is not primarily related to wound management unless there are nutritional concerns that could impact healing.

D. Respiratory therapist

A respiratory therapist would be consulted if there were issues related to the client’s breathing or respiratory function, such as if the client had respiratory diseases or complications. In this case, the client requires home health care for a wound, and there is no indication of respiratory issues. Therefore, the respiratory therapist would not be the most appropriate team member to contact for consultation regarding wound care.

Summary:

The correct answer is A. Social worker, as they can help with coordinating home health care, ensuring adequate support for the client at home, and addressing any social or emotional needs related to the discharge process. The other team members (occupational therapist, dietician, and respiratory therapist) may play important roles in different situations but are not the primary resources for wound care or home health coordination.

Correct Answer is C. "Information about a client can be disclosed to family members at any time."

Explanation:

The Health Insurance Portability and Accountability Act (HIPAA) is designed to protect the privacy and security of an individual’s health information. It establishes strict regulations regarding the use and disclosure of protected health information (PHI). Under HIPAA, information about a client cannot be disclosed to family members or others without the client’s explicit consent unless the disclosure is necessary for treatment, payment, or healthcare operations, or if there is a legal requirement. The statement "Information about a client can be disclosed to family members at any time" is incorrect because it overlooks the important aspect of client consent. Information about a client can only be disclosed to family members in specific circumstances, such as when the client has authorized the release, or if the client is incapacitated and the information is necessary for their care or safety.

Why the Other Options are Correct:

A. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form."

This statement is correct. HIPAA regulates the protection of PHI in all forms—verbal, electronic, or written—and ensures that health information is kept private and secure across all channels.

B. "A client's address would be an example of personally identifiable information."

This is correct. According to HIPAA, personally identifiable information (PII) includes any data that can be used to identify a person, such as a client's address, name, phone number, social security number, and other demographic details.

D. "HIPAA is federal law, not a state law."

This is correct. HIPAA is federal law, established by the U.S. Department of Health and Human Services. However, states may have their own laws that provide additional privacy protections, but HIPAA sets the minimum standards for health information privacy and security.

Summary:

The statement C. "Information about a client can be disclosed to family members at any time" is incorrect. Information can only be disclosed to family members under specific conditions, such as client consent or when required for the client’s care.

Correct Answer: C. Obtaining a blood pressure for a client who is to be discharged later in the day

Explanation:

Assistive personnel (AP), which may include nursing assistants, certified nursing assistants (CNAs), or other unlicensed staff, are typically responsible for tasks that are routine, non-invasive, and do not require clinical judgment or complex decision-making. Obtaining vital signs, such as measuring blood pressure, is a task that can be delegated to an AP, especially when the client is stable and in a routine setting, such as being prepared for discharge.

Why the Other Options Are Incorrect:

A. Providing tracheostomy care for a client

Tracheostomy care is an invasive procedure that requires specialized knowledge and skill. It involves managing the airway, suctioning, and cleaning the tracheostomy site, which requires a licensed nurse's clinical judgment and training. This task should not be delegated to an AP.

B. Teaching a client who is preoperative how to use an incentive spirometer

Patient education is a nursing responsibility, as it involves assessing the client’s understanding, addressing questions, and ensuring they are properly prepared for the procedure. Teaching a client about medical equipment or procedures is a nursing task that requires knowledge of both the equipment and the client's condition, which an AP cannot provide.

D. Assessing a client who just returned from surgery

Postoperative assessments require clinical judgment to detect complications and assess the client's recovery, including monitoring vital signs, oxygenation, and neurological status. An AP is not qualified to perform comprehensive assessments or make clinical decisions regarding a newly postoperative client.

Summary:

The correct answer is C. Obtaining a blood pressure for a client who is to be discharged later in the day, as this task is routine and involves no clinical decision-making, making it suitable for delegation to an AP. The other tasks require clinical skills, judgment, and knowledge that should be performed by a licensed nurse.

Correct Answer is B. Spirituality can increase the quality of life.

Explanation:

At the end of life, spirituality can be a significant factor in enhancing quality of life. Many clients find comfort, peace, and meaning through spiritual beliefs or practices, which can help them cope with the emotional, physical, and psychological challenges they face. Spirituality often provides clients with a sense of hope, purpose, and connection, even during the dying process. It can also help clients manage pain and suffering by offering comfort and strength through faith, rituals, or a sense of community.

Why the Other Options are Incorrect:

A. Spirituality can increase the desire to hasten death:

This is generally not true. Spirituality often encourages life-affirming beliefs, offering clients hope and a sense of peace even in the face of death. Spirituality might guide individuals to find meaning and acceptance in their circumstances rather than to hasten death. Many spiritual beliefs support a natural process of death and promote life quality rather than an urge to end it prematurely.

C. Spirituality can increase feelings of hopelessness:

In fact, spirituality often helps clients combat feelings of hopelessness. Through spiritual practices, clients may experience reassurance, comfort, and a sense of connection that counters feelings of despair. Spirituality provides a framework for understanding suffering, making it less likely to increase hopelessness, especially for those nearing the end of life.

D. Spirituality can increase depression:

Spirituality itself is generally not associated with increasing depression. On the contrary, it can be a source of emotional support and resilience during difficult times. For many clients, spirituality can reduce feelings of isolation and help them cope with emotions, including sadness, fear, or grief, that may arise during the dying process. Spiritual well-being has been linked to improved mental health and emotional resilience, even in the face of death.

Summary:

The correct answer is B. Spirituality can increase the quality of life. This reflects the potential for spirituality to provide comfort, meaning, and a sense of peace, which are important for clients near the end of life. Spirituality often helps to enhance the emotional, psychological, and existential aspects of well-being during this time.