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Site Title: Erb's Fundamentals of Nursing

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Berman
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Unit 4 > Chapter 16: Health
Location on Promotion > NCLEX Review
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Date/Time May 6, 2015 at 12:06 PM


Submitted: (UTC/GMT)

1.

A nurse and a primary care provider inform a client that chemotherapy is


recommended for a diagnosis of cancer. Which nursing action is most
representative of the concept of holism?
Inquire how this will affect other aspects of the clients
Your Answer: life.

Your Results for "NCLEX Review"

2.

A nurse is planning a workshop on health promotion for older adults.


Which topic will be included?
Adequate sleep.
Your Answer:

Rationale: Learning about sleep will increase the older adults well-being,
which is the focus of health promotion. Prevention of falls (option 1) is

health protection because the focus is avoiding injury. Learning about


cardiovascular risk factors (option 2) relates to health protection/disease
prevention. How to stop smoking (option 4) focuses on health protection
and avoiding illness.
Cognitive Level: Applying.
Client Need: Health Promotion/ Maintenance and Psychosocial Integrity.
Nursing Process: Planning.

3.

While hospitalized, a client is very worried about business activities. The


client spends a great deal of time on the phone and with colleagues
instead of resting. Which principle of need therapy applies to this client?
His lower level physiological needs are being deferred
Your Answer: while higher needs are addressed.

Rationale: Choices are often related to learned experiences, lifestyle, and


values. The client obviously values the business more than physical health.
When a person feels strongly enough, a lower level need (rest) can be
postponed until a higher level need (success, safety) is met. It is very
likely that no one else can meet that need for him and the lower need
must still be met eventually.
Cognitive Level: Applying.
Client Need: Health Promotion and Maintenance.
Nursing Process: Assessment.

4.

Which statement by the client best represents the contemplation stage of


the stages of behavior change?
I currently do not exercise 30 minutes three times a
Your Answer: week, but I am thinking about starting to do so within the
next 6 months.

Rationale: A person in this stage recognizes there is a problem, is


seriously considering changing, actively gathers information, and
verbalizes plans to change in the near future. Option 1 reflects the
precontemplation stage in which the person denies there is a problem.
Option 2 reflects the planning stage in which the person makes final plans
to accomplish the change, and option 4 is the maintenance stage in which
the person made the change and demonstrates the appropriate behavioral
change.
Cognitive Level: Analyzing.
Client Need: Health Promotion and Maintenance.
Nursing Process: Assessment.

5.

A client who is 46 pounds overweight tells you, I was just born to be fat. I
dont have the willpower. Although weight loss occurred while attending
two previous programs that guaranteed weight loss, the weight returned
along with extra pounds after each program. According to the Health
Promotion Model, the nurse is most likely to focus on which behaviorspecific cognition and affect variable for this client?
Perceived self-efficacy.
Your Answer:

Rationale: Perceived self-efficacy is the confidence the person has for


achieving the desired outcome. Option 1 is a persons perceptions about
available time, inconvenience, expense, and difficulty performing the
activity. Option 3 is the persons perceptions concerning the behaviors,
beliefs, or attitudes of others. Option 4 refers to the persons perception of
the environment and how it assists or detracts from the healthy behavior.
Cognitive Level: Applying.
Client Need: Health Promotion and Maintenance.
Nursing Process: Planning.

6.

Based on the Life-Change Index, which individual would have an increased


possibility of illness in the near future?
A 50-year-old woman whose husband died a month ago.
Your Answer:

Rationale: See Box 167. The death of a spouse is a score of 100 on the
Life-Change Index by Holmes and Rahe (1967). Option 1 is a score of 50,
option 2 is a score of 47, and option 3 is a score of 26.
Cognitive Level: Analyzing.
Client Need: Health Promotion and Maintenance.
Nursing Process: Assessment.

7.

The nurse who is assisting a client in the action stage of change would use
which strategy?
Reinforce the importance of providing rewards for positive
Your Answer: behavior.

Rationale: Option 2 is a strategy for the contemplation stage, option 3 is

a strategy for the preparation stage, and option 4 is a strategy for the
maintenance stage.
Cognitive Level: Applying.
Client Need: Health Promotion and Maintenance.
Nursing Process: Implementation.

8.

Which is the best response by the nurse if a client fails to follow the
information or teaching provided?
Reassess the clients importance given to the behavior and
Your Answer: readiness to change it.

Rationale: Change is a complex process and a nurse should not give up


or assume that the client doesnt want to change (option 1). People often
resist a tough approach because it can make them feel cornered. This
approach may work for some people but not for everyone (option 2). The
goal of teaching is to try to help the client become the expert as well
(option 3).
Cognitive Level: Applying.
Client Need: Health Promotion and Maintenance.
Nursing Process: Implementation.

9.

A client is admitted for heart failure. The nurse assesses that the clients
blood pressure is below normal range and the apical pulse is 110. The
nurse knows that the increase in the clients pulse illustrates which aspect
of the clients homeostatic mechanism?
Compensation
Your Answer:

Rationale: The compensatory mechanism of increasing the heart rate is


the bodys way of trying to balance an ineffective cardiac output since the
BP has decreased. Decompensation (option 2) occurs when the
compensatory mechanism is ineffective. Self-regulation (option 3) refers to
the homeostatic mechanisms that come into play automatically in the
healthy person. Equilibrium (option 4) is balance through adaptation to the
environment.
Cognitive Level: Applying.
Client Need: Health Promotion and Maintenance.
Nursing Process: Assessment.

10
.

Using Maslows framework, which statement characterizes the highest level


of need?
Im very proud of receiving the Employee of the Month
Your Answer: award.

Rationale: Option 1 is a physiological need. Option 2 is a love and


belonging need, and option 4 is a safety and security need.
Cognitive Level: Analyzing.
Client Need: Health Promotion and Maintenance.
Nursing Process: Assessment.