Question 1

A patient is in crisis.After assessing the situation,what should the nurse do first?

Accepted Answer

The goals of crisis intervention are to assess the situation first.Then ensure safety of self and patient,defuse the situation,decrease the person's anxiety,determine the problem (cause of the crisis),and decide on the type of help needed.Safety is always foremost.

Question 2

Before entering the room of a patient who is angry and yelling,the nurse removes her stethoscope from around her neck.The best rationale for doing so is that the stethoscope:

Accepted Answer

When dealing with an angry patient,the nurse must be alert to her own safety needs.A stethoscope,dangling jewelry,or anything else the patient might use as a weapon to harm the nurse should be removed before entering the patient's room.It is unlikely a stethoscope would cause the patient not to trust the nurse,nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope.For the same reason,it would not likely distract the nurse.Nurses carry stethoscopes so routinely that they likely don't even notice their presence.

Question 3

A nurse identifies a patient's nursing diagnosis as "Diarrhea related to stress." Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?

Accepted Answer

(Answer to specific patient scenario is not directly stated in text.) The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress,which is the cause of the patient's diarrhea.Monitoring stool frequency is an assessment,not a nursing intervention.The other interventions may be necessary to treat diarrhea,but they do not alleviate the cause of the diarrhea.

Question 4

At the end of a guided imagery session,which physical assessment finding would suggest that the relaxation technique was successful?

Accepted Answer

Reassessment findings that suggest relaxation has been effective include decreased blood pressures,increased peripheral skin temperature,decreased heart rate,and decreased respiratory rate.

Question 5

A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis.Assuming the cancer diagnosis represents a crisis,this patient is most likely experiencing which phase of crisis?

Accepted Answer

When a patient begins to think rationally and attempt to solve problems,she is most likely experiencing the adaptive phase of crisis.During the precrisis phase,the patient finds success using her previous coping strategies.Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective.The patient may use new coping strategies,such as withdrawal,during the crisis phase.

Question 6

An 18-year-old female has just been accepted to nursing school in another state.She says to her parents,"I know I am going away to college,but I am nervous about going." What type of stressor is this student most likely experiencing?

Accepted Answer

Developmental stressors are those that can be predicted to occur at various stages of a person's life.For example,most young adults face the stress of leaving home for college or beginning a new career.In this item,the young adult is expressing concern over a normal developmental stressor.Situational stressors are unpredictable.Biophysical stressors affect body function or structures,and external stressors are usually something external to a person,for example,death of a family member.

Question 7

A patient complains of a vague,uneasy feeling of dread,and his heart rate is elevated.Which of the following nursing diagnoses is most appropriate for this patient?

Accepted Answer

NANDA International defines Anxiety as a vague,uneasy feeling of discomfort or dread accompanied by an autonomic response.This patient is most likely experiencing anxiety.Anger is not a nursing diagnosis.Fear,which is also a nursing diagnosis,is an emotion or feeling of apprehension from an identified danger,threat,or pain.Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.

Question 8

You are caring for a patient who suddenly experiences a cardiac arrest.As you respond to this emergency,which substance will your body secrete in large amounts to help prepare you to react in this situation?

Accepted Answer

During the shock phase of the general adaptation syndrome,epinephrine prepares the body to react in an emergency situation by increasing heart rate and blood pressure.In response to the epinephrine release,the endocrine system releases corticotrophin-releasing hormone,aldosterone,and antidiuretic hormone.

Question 9

After a patient has an argument with her husband,she becomes verbally abusive to the nurse who is caring for her.Which coping mechanism is this patient exhibiting?

Accepted Answer

This patient is using displacement.She is transferring the emotions she feels toward her husband to the nurse.When a patient uses the coping mechanism of reaction formation,the patient is aware of her feelings but acts in an opposite manner to what she is really feeling.With the coping mechanism of denial,the patient transforms reality by refusing to acknowledge thoughts,feelings,desires,or impulses.With conversion,emotional conflict is changed into physical symptoms that have no physical basis.

Question 10

When released in response to alarm,which of the following substances promotes a sense of well-being?

Accepted Answer

Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm.Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules.Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs.Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralcorticoids.

Question 11

The nursing student asks his instructor,"Why do some of my patients get a headache when they have stress and others cry?" The most appropriate response by the instructor is which of the following?

Accepted Answer

Responses to stress are holistic.This means they can be physical,psychological,mental,behavioral,spiritual,and social.It is important for a nurse to understand these responses to assist patients to develop healthy and adaptive coping skills.The most appropriate response is to cite the holistic responses to stress and not merely respond that "all patients react to stress differently." All patients do react to stress differently; however,this is not the most comprehensive and explanatory response the instructor could make.

Question 12

The nurse caring for a patient with unresolved anger.For which associated complication should the nurse assess?

Accepted Answer

Depression is sometimes associated with unresolved anger and may result from stress.A person with hypochondriasis is preoccupied with feelings that he will become seriously ill.In somatization,anxiety and emotional turmoil are expressed in physical symptoms,loss of physical function,pain that changes location often,and depression.Malingering is a conscious effort to avoid unpleasant situations.Hypochondriasis,somatization,and malingering are not associated with unresolved anger.

Question 13

After sustaining injuries in a motor vehicle accident,a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation.Which stage of the general adaptation syndrome is the patient most likely experiencing?

Accepted Answer

Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates.During the alarm stage,heart rate and blood pressure both increase.In the resistance stage,the body tries to maintain homeostasis; blood pressure and heart rate normalize.If adaptation is successful,recovery takes place.

Question 14

What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?

Accepted Answer

Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules.Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle.Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain.Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.

Question 15

A client approaches the nurse in the health clinic and states,"I have been dealing with my husband's illnesses for years.Now my children want me to start babysitting for my grandchildren.I don't know whether I can handle all this." What is the nurse's interpretation of this woman's statements?

Accepted Answer

When there are many stressors or when stressors continue for a long period of time,adaptation is more likely to fail.In this item,the client is verbalizing both a concern in caring for a family member over a long period of time and the possibility of dealing with a new stressor: babysitting grandchildren.Some events produce more stress than others.However,a person with good coping skills can usually adapt to a single stressful event,even a demanding one.This client has been managing one stressful event.It is the addition of another that is concerning her.In this item,we are unable to determine that coping strategies are no longer successful because we do not have any information on past coping strategies.Additionally,we cannot determine that she is unable to cope because she states,"I don't know whether I can handle all this."

Question 16

A patient sustains a laceration of the thigh in an industrial accident.Which step in the inflammatory process will the patient experience first?

Accepted Answer

Immediately after the injury,the vascular response occurs.Blood vessels at the site constrict to control bleeding.After the injured cells release histamine,the vessels dilate,causing increased blood flow to the area.During the next phase,known as the cellular response phase,white blood cells migrate to the site of injury.In the exudate formation phase,the fluid and white blood cells move from circulation to the site of injury,forming an exudate.Tissue regeneration occurs in the healing phase.

Question 17

A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him,"I hate this place; nobody knows how to take care of me or I'd be home by now." Which response by the nurse is best in this situation?

Accepted Answer

"You seem angry; what's going on ..." encourages the patient to express his feelings and may provide you with more information.The nurse should not take responsibility for the patient's anger by apologizing ("I'm sorry ...").Advising the patient "don't be angry" or "you shouldn't be angry" diminishes the patient's right to be angry.

Question 18

When counseling a patient about behaviors to reduce stress,which of the following goals should the nurse put on the care plan?

Accepted Answer

The nurse should advise the client to limit the intake of sugar (to avoid sugar highs and crashes)and salt (to avoid increasing blood pressure); limit the intake of fat to no more than 30% (not 15%)of daily calories (to prevent cardiovascular disease); eat smaller,more frequent meals (rather than three meals a day)to aid in digestion; and consume no more than two alcoholic beverages per day but not necessarily every day.

Question 19

You are caring for a patient with numerous physiological complaints.A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work.Which somatoform disorder is this patient most likely experiencing?

Accepted Answer

Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder.With hypochondriasis,the patient is preoccupied with the idea that he is or will become seriously ill.In somatization,anxiety and emotional turmoil are expressed in physical symptoms.With somatoform pain disorder,emotional pain manifests physically.

Question 20

The nurse is presenting a workshop on stress and adaptation to a group of teenagers at the local high school.A teenager approaches the nurse and says,"Sometimes I feel stressed when I have to take a test.I feel my heart is going a little faster but I do focus better.What do you think?" What is the most appropriate response by the nurse?

Accepted Answer

Stress is not necessarily bad.It can keep one alert and motivate one to function at a higher performance level.For example,when preparing for an examination the desire to succeed can create just enough anxiety to motivate the student to study.Conversely,if a person becomes too anxious he may be unable to focus on the task or think clearly.In this item,the student identifies that he feels some anxiety but is able to focus.The nurse's response,"as long as you are focusing and getting through the test" is an acceptable one; however,this is not the best response as it will not assist the student in learning about and understanding mild stress and the motivating aspect of mild stress.

Quiz 12: Stress Adaptation