Chapter 12: Understanding Responses to Stress

Question 1

The adult child of a patient diagnosed with major depression asks, “Do you think depression and physical illness are connected? Since my father’s death, my mother has had shingles and the flu, but she’s usually not one who gets sick.” Which answer by the nurse best reflects current knowledge about psychoneuroimmunology?

a. “It is probably a coincidence. Emotions and physical responses travel on different tracts of the nervous system.”
b. “You may be paying more attention to your mother since your father died and noticing more things such as minor illnesses.”
c. “So far, research on emotions or stress and becoming ill more easily is unclear. We do not know for sure if there is a link.”
d. “Negative emotions and stress may interfere with the body’s ability to protect itself and can increase the likelihood of infection.”

Answer 1

ANS: D
The correct answer best explains the research. Research supports a link between negative emotions and/or prolonged stress and impaired immune system functioning. Activation of the immune system sends proinflammatory cytokines to the brain, and the brain in turn releases its own cytokines that signal the central nervous system to initiate myriad responses to stress. Prolonged stress suppresses the immune system and lowers resistance to infections. Although the adult child may be more aware of issues involving the mother, the pattern of illnesses described may be an increase from the mother’s baseline.

Question 2

A patient diagnosed with emphysema has severe shortness of breath and needs portable oxygen when leaving home. Recently, the patient has reduced activity because of fear that breathing difficulty will occur. A nurse suggests using guided imagery. Which image should the patient be encouraged to visualize?

a. Engaging in activity without using any supplemental oxygen
b. Sleeping comfortably and soundly, without respiratory distress
c. Feeling relaxed and taking regular deep breaths when leaving home
d. Having a younger, healthier body that knows no exercise limitations

Answer 2

ANS: C
The patient has dysfunctional images of dyspnea. Guided imagery can help replace the dysfunctional image with a positive coping image. Athletes have found that picturing successful images can enhance performance. Encouraging the patient to imagine a regular breathing depth and rate will help improve oxygen–carbon dioxide exchange and help achieve further relaxation. Other options focus on unrealistic goals (being younger, not needing supplemental oxygen) or restrict her quality of life.

Question 3

A nurse leads a psychoeducational group for depressed patients. The nurse plans to implement an exercise regime for each patient. Which of the following rationales should the nurse use when presenting this plan to the treatment team?

a. Exercise can lead to protection from the harmful effects of stress.
b. Exercise prevents damage from overstimulation of the sympathetic nervous system.
c. Exercise detoxifies the body by removing metabolic wastes and other toxins.
d. Exercise improves mood stability for patients with bipolar disorders.

Answer 3

ANS: A
Physical exercise can lead to protection from the harmful effects of stress on both physical and mental states. Regular physical activity was associated with lower incidence of all psychiatric disorders except bipolar disorder. The other options are not accurate.

Question 4

A recent immigrant from Honduras comes to the clinic with a family member who has been a Canadian resident for 10 years. The family member says, “The immigration to Canada has been very difficult.” Considering cultural background, which expression of stress by this patient would the nurse expect?

a. Motor restlessness
b. Somatic complaints
c. Memory deficiencies
d. Sensory perceptual alterations

Answer 4

ANS: B
Honduras is in Central America. Many people from Asia, Africa and Central America express distress in somatic terms. The other options are not specific to this patient’s cultural background and are less likely to be observed in people from Central America.

Question 5

A patient nervously says, “Financial problems are stressing my marriage. I’ve heard rumours about cutbacks at work; I am afraid I might get laid off.” The patient’s pulse is 112 per minute; respirations are 26 per minute; and blood pressure is 166/88. Which nursing intervention will the nurse implement?

a. Advise the patient, “Go to sleep 30 to 60 minutes earlier each night to increase rest.”
b. Direct the patient in slow and deep breathing via use of a positive, repeated word.
c. Suggest the patient consider that a new job might be better than the present one.
d. Tell the patient, “Relax by spending more time playing with your pet.”

Answer 5

ANS: B
The patient is responding to stress with increased arousal of the sympathetic nervous system, as evidenced by elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system will counter the sympathetic nervous system’s arousal, normalizing these vital-sign changes and reducing the physiological demands stress is placing on his body. Other options do not address his physiological response pattern as directly or immediately.

Question 6

According to the Recent Life Changes Questionnaire, which situation would most necessitate a complete assessment of a person’s stress status and coping abilities?

a. A person who has been assigned more responsibility at work
b. A parent whose job required relocation to a different city
c. A person returning to college after an employer ceased operations
d. A man who recently separated from his wife because of marital problems

Answer 6

ANS: C
A person returning to college after losing a job is dealing with two significant stressors simultaneously. Together, these stressors total more life change units than any of the single stressors cited in the other options.

Question 7

A patient newly diagnosed as HIV-positive seeks the nurse’s advice on how to reduce the risk of infections. The patient says, “I used to go to church and I was in my best health then. Maybe I should start going to church again.” Which response will the nurse offer?

a. “Religion does not usually affect health, but you were younger and stronger then.”
b. “Contact with supportive people at church might help, but religion itself is not especially helpful.”
c. “Studies show that spiritual practices can enhance immune system function and coping abilities.”
d. “Going to church would expose you to many potential infections. Let’s think about some other options.”

Answer 7

ANS: C
Studies have shown a positive correlation between spiritual practices and enhanced immune system function and sense of well-being. The other options wrongly suggest that spiritual practices have little effect on the immune system or reject the patient’s preferences regarding health management.

Question 8

When a nurse asks a newly admitted patient to describe social supports, the patient says, “My parents died last year and I have no family. I am newly divorced, and my former in-laws blame me. I don’t have many friends because most people my age just want to go out drinking.” Which action will the nurse apply?

a. Advise the patient that being so particular about potential friends reduces social contact.
b. Suggest using the Internet as a way to find supportive others with similar values.
c. Encourage the patient to begin dating again, perhaps with members of the church.
d. Discuss how divorce support groups could increase coping and social support.

Answer 8

ANS: D
High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships affect a person’s coping negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than help her cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose her to predators misrepresenting themselves to take advantage of vulnerable people.

Question 9

A patient experiencing significant stress associated with a disturbing new medical diagnosis asks the nurse, “Do you think saying a prayer would help?” Select the nurse’s best answer.

a. “It could be that prayer is your only hope.”
b. “You may find prayer gives comfort and lowers your stress.”
c. “I can help you feel calmer by teaching you meditation exercises.”

Answer 9

ANS: B
Many patients find that spiritual measures, including prayer, are helpful in mediating stress. Studies have shown that spiritual practices can enhance the sense of well-being. When a patient suggests a viable means of reducing stress, it should be supported by the nurse. Indicating that prayer is the patient’s only hope is pessimistic and would cause further distress. Suggesting meditation or other alternatives to prayer implies that the nurse does not think prayer would be effective.

Question 10

A patient is brought to the emergency department after a motorcycle accident. The patient is alert and responsive and is diagnosed with a broken leg. The patient’s vital signs are pulse (P) 72 and respiration (R) 16. After being informed surgery is required for the broken leg, which vital sign readings would be expected?

a. P 64, R 14
b. P 68, R 12
c. P 72, R 16
d. P 80, R 20

Answer 10

ANS: D
The patient would experience stress associated with anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight-or-flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs.

Question 11

A patient tells the nurse, “I know that I should reduce the stress in my life, but I have no idea where to start.” What would be the best initial nursing response?

a. “Physical exercise works to elevate mood and reduce anxiety.”
b. “Reading about stress and how to manage it might be a good place to start.”
c. “Why not start by learning to meditate? That technique will cover everything.”
d. “Let’s talk about what is going on in your life and then look at possible options.”

Answer 11

ANS: D
In this case, the nurse lacks information about what stressors the patient is coping with and what coping skills the patient already possesses. Further assessment is indicated before potential solutions can be explored. Suggesting exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

Question 12

A patient tells the nurse, “My doctor thinks my problems with stress relate to the negative way I think about things and suggested I learn new ways of thinking.” Which response by the nurse would support the recommendation?

a. Encourage the patient to imagine being in calm circumstances.
b. Provide the patient with a blank journal and guidance about journaling.
c. Teach the patient to recognize, reconsider, and reframe irrational thoughts.
d. Teach the patient to use instruments that give feedback about bodily functions.

Answer 12

ANS: C
Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient’s manner of thinking.

Question 13

A patient who had been experiencing significant stress learned to use progressive muscle relaxation and deep breathing exercises. When the patient returns to the clinic 2 weeks later, which finding most clearly shows the patient is coping more effectively with stress?

a. The patient’s systolic blood pressure has changed from the 140s to the 120s mm Hg.
b. The patient reports, “I feel better, and things are not bothering me as much.”
c. The patient reports, “I spend more time napping or sitting quietly at home.”
d. The patient’s weight decreased by 3 pounds.

Answer 13

ANS: A
Objective measures tend to be the most reliable means of gauging progress. In this case, the patient’s elevated blood pressure, an indication of the body’s physiological response to stress, has diminished. The patient’s report regarding activity level is subjective; sitting quietly could reflect depression rather than improvement. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiological changes from stress and may not reflect improved coping with stress. The patient’s weight change could be a positive or negative indicator; the blood pressure change is the best answer.

Question 14

A patient tells the nurse, “I will never be happy until I’m as successful as my older sister.” The nurse asks the patient to reassess this statement and reframe it. Which reframed statement by the patient is most likely to promote coping?

a. “People should treat me as well as they treat my sister.”
b. “I can find contentment in succeeding at my own job level.”
c. “I won’t be happy until I make as much money as my sister.”
d. “Being as smart or clever as my sister isn’t really important.”

Answer 14

ANS: B
Finding contentment within one’s own work, even when it does not involve success as others might define it, is likely to lead to a reduced sense of distress about achievement level. It speaks to finding satisfaction and happiness without measuring the self against another person. Focusing on salary is simply a more specific way of being as successful as the sister, which would not promote coping. Expecting others to treat her as they do her sister is beyond her control. Dismissing the sister’s cleverness as unimportant indicates that the patient continues to feel inferior to the sibling.

Question 15

A patient says, “One result of my chronic stress is that I feel so tired. I usually sleep from 11 p.m. to 6:30 a.m. I started setting my alarm to give me an extra 30 minutes of sleep each morning, but I don’t feel any better and I’m rushed for work.” Which nursing response would best address the patient’s concerns?

a. “You may need to speak to your doctor about taking a sedative to help you sleep.”
b. “Perhaps going to bed a half-hour earlier would work better than sleeping later.”
c. “A glass of wine in the evening might take the edge off and help you to rest.”
d. “Exercising just before retiring for the night may help you to sleep better.”

Answer 15

ANS: B
Sleeping later in the morning may disturb circadian rhythms and in this case is adding, rather than reducing, stress. Going to bed earlier and arising at the usual time alleviates fatigue more effectively. Sedatives may offer some benefit but are a short-term intervention with potential side effects, and other nonpharmacological interventions might work as well or better. Exercise earlier in the evening could induce tiredness and ease the process of falling asleep, but doing so right before bedtime would stimulate and interfere with sleep. Alcohol is sedating but potentially addictive; encouraging its use could increase the risk of using alcohol maladaptively as a response to stress in general

Question 16

A patient reports, “I am overwhelmed by stress.” Which question by the nurse would be most important to use in the initial assessment of this the patient?

a. “Tell me about your family history. Do you have any relatives who have problems with stress?”
b. “Tell me about your exercise. How much activity do you typically get in a day?”
c. “Tell me about the kinds of things you do to reduce or cope with your stress.”
d. “Stress can interfere with sleep. How much did you sleep last night?”

Answer 16

ANS: C
The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether or not his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses, such as drinking) and would help the nurse understand how he copes and how well his coping strategies and resources serve him. Of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful information but provide data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

Question 17

Which scenario best demonstrates an example of eustress?

a. An individual loses a beloved family pet.
b. An individual prepares to take a one-week vacation to a tropical island with a group of close friends.
c. An individual receives a bank notice that there were insufficient funds in his or her account for a recent rent payment.
d. An individual receives notification that his or her current employer is experiencing financial problems and some workers will be terminated.

Answer 17

ANS: B
Eustress is beneficial stress; it motivates people to develop skills they need to solve problems and meet personal goals. Positive life experiences produce eustress. Going on a tropical vacation is an exciting, relaxing experience and is an example of eustress. Losing the family pet, worrying about employment security, and having financial problems are examples of distress, a negative experience that drains energy and can lead to significant emotional problems. See related audience response question.

Question 18

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?

a. Thalamus
b. Parietal lobe
c. Hypothalamus
d. Pituitary gland

Answer 18

ANS: C
The individual will find this experience stressful. The hypothalamus functions as the command-and-control centre when receiving stressful signals. The hypothalamus responds to signals of stress by engaging the autonomic nervous system. The parietal lobe is responsible for interpretation of other sensations. The thalamus processes messages associated with pain and wakefulness. The pituitary gland may be involved in other aspects of the person’s response but would not stimulate the autonomic nervous system.

Question 19

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system will be stimulated in response to this experience?

a. Limbic system
b. Peripheral nervous system
c. Sympathetic nervous system
d. Parasympathetic nervous system

Answer 19

ANS: C
The autonomic nervous system is comprised of the sympathetic (fight-or-flight response) and parasympathetic (relaxation response) nervous system. In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

Question 20

Which changes reflect short-term physiological responses to stress? Select all that apply.

a. Muscular tension, blood pressure, and triglycerides increase.
b. Epinephrine is released, increasing heart and respiratory rates.
c. Corticosteroid release increases stamina and impedes digestion.
d. Cortisol is released, increasing glucogenesis and reducing fluid loss.
e. Immune system functioning decreases, and risk of cancer increases.
f. Risk for depression, autoimmune disorders, and heart disease increases.

Answer 20

ANS: A, B, C, D
The correct answers are all short-term physiological responses to stress. Increased risk for immune system dysfunction, cancer, cardiovascular disease, depression, and autoimmune disease are all long-term (chronic) effects of stress.

Question 21

Which nursing comments are likely to help a patient to cope, by addressing the mediators of stress? Select all that apply.

a. “A divorce, while stressful, can be the beginning of a new, better phase of life.”
b. “You said you used to jog; getting back to aerobic exercise could be helpful.”
c. “Journaling often promotes awareness of how experiences have affected people.”
d. “Slowing your breathing by counting to three between breaths will calm you.”
e. “Would a short-term loan make your finances less stressful?”
f. “There is a support group for newly divorced persons in your neighborhood.”

Answer 21

ANS: A, C, E, F
Stress mediators are factors that can help people cope by influencing how they perceive and respond to stressors; they include personality, social support, perceptions, and culture. Suggesting that a divorce may have positive as well as negative aspects helps the patient to alter perceptions of the stressor. Journaling increases self-awareness regarding how life experiences may have shaped how we perceive and respond to stress (or how our personality affects how we respond to stressors). A loan could help the patient by reducing the financial pressures. Participation in support groups is an excellent way to expand one’s support network relative to specific issues. However, neither aerobic exercise nor breathing-control exercises, while helpful in other ways, affect stress mediators.

Question 22

The nurse wishes to use guided imagery to help a patient relax. Which comments would be appropriate to include in the guided imagery script? Select all that apply.

a. “Imagine others treating you the way they should, the way you want to be treated . . .”
b. “With each breath, you feel calmer, more relaxed, almost as if you are floating . . .”
c. “You are alone on a beach, the sun is warm, and you hear only the sound of the surf . . .”
d. “You have taken control; nothing can hurt you now. Everything is going your way . . .”
e. “You have grown calm; your mind is still; there is nothing to disturb your well-being . . .”
f. “You will feel better as work calms down, as your boss becomes more understanding . . .”

Answer 22

ANS: B, C, E
The intent of guided imagery to help patients manage stress is to lead the patient to envision images that are calming and health-enhancing. Statements that involve the patient calming progressively with breathing, feeling increasingly relaxed, being in a calm and pleasant location, being away from stressors, and having a peaceful and calm mind are therapeutic and should be included in the script. However, items that raise stressful images or memories or that involve unrealistic expectations or elements beyond the patient’s control (e.g., that others will treat the patient as he desires, that everything is going the patient’s way, that bosses are understanding) interfere with relaxation or do not promote effective coping (or both). Thus these are not health-promoting and should not be included in the script.

Question 23

An individual says to the nurse, “I feel so stressed out lately. I think the stress is affecting my body, also.” Which somatic complaints are most likely to accompany this feeling? Select all that apply.

a. Headache
b. Muscle flaccidity
c. Ulcer
d. Arthritis
e. Myopia

Answer 23

ANS: A, C, D
When individuals feel “stressed-out,” they often have accompanying somatic complaints, including headache, ulcers, and arthritis, to name a few. Changes in vision, such as myopia, would not be expected.