Deck 0 Chapter 37

Question 1

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following?

1. Restorative care
2. Strong financial resources
3. Maturational and sociocultural factors
4. Immaturity and intelligence factors

Answer 1

3. Maturational and sociocultural factors

Rationale:

Maturational factors and sociocultural factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

Question 2

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem?

1. General adaptation syndrome
2. Posttraumatic stress disorder
3. Developmental crisis
4. Alarm reaction

Answer 2

2. Posttraumatic stress disorder

Rationale:

Posttraumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional numbing and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Developmental crisis occurs as a person moves through life stages rather than in response to a trauma. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

Question 3

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention?

1. Primary
2. Secondary
3. Tertiary
4. Quad level

Answer 3

3. Tertiary

Rationale:

Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. Tertiary prevention focuses on the person who already has the disease and is recovering or rehabilitating. Tertiary prevention goals are to slow down the disease process, prevent further damage or pain from the disease, and prevent the current disease from creating other health problems. Primary level consists of stress prevention, promotion of wellness, and risk factor reduction before illness occurs. Secondary level occurs after symptoms appear and assists the person to develop resources to manage illness and stress. Quad level does not exist.

Question 4

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below.

1. Singing
2. Back massage
3. Sensory peaceful words
4. Listening to music

Answer 4

3. Sensory peaceful words

Rationale:

Guided imagery is used as a means to create a relaxed state through the person’s imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

Question 5

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating “No way, I’m not crazy.” The best response the nurse can give is which of the following?

1. “Many times disasters can create mental health problems, so you really should participate with your family.”
2. “Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness.”
3. “Don’t worry now. The psychiatrists are well trained to help.”
4. “Crisis intervention will help your family communicate better.”

Answer 5

2. “Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness.”

Rationale:

Crisis intervention is a type of brief therapy that is more directive than typical psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The goal of crisis intervention is to create stability for the person involved in the crisis while promoting self-reliance. The other options do not properly reassure the patient and build trust.

Question 6

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category?

1. Elementary school age
2. Preadolescence
3. Adolescence
4. Early adulthood

Answer 6

2. Preadolescence

Rationale:

The preadolescent age category experiences stress related to self-esteem issues, changing family structure due to divorce or death of a parent, or hospitalization. Adolescent stressors include identity issues with peer groups and separation from parents. Elementary school age stressors include friends, family, and school relations. Adult stressors centralize around life events.

Question 7

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will

1. Select nursing interventions to promote the patient’s adaptation to stress.
2. Establish short- and long-term goals with the patient experiencing stress.
3. Identify stress management interventions for achieving expected outcomes.
4. Reassess patient’s stress-related symptoms and compare with expected outcomes.

Answer 7

4. Reassess patient’s stress-related symptoms and compare with expected outcomes.

Rationale:

During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

Question 8

An adult male reports new-onset seizurelike activity. An EEG and a neurology consultant’s report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurse’s next best action would be to

1. Recommend acupuncture.
2. Confront the patient on malingering.
3. Obtain history of any recent life stressors.
4. Recommend a regular exercise program.

Answer 8

3. Obtain history of any recent life stressors.

Rationale:

The purpose of an ego defense mechanism is to help regulate emotional stress. By regulating emotional stress, the individual gains some protection from anxiety and stress. A conversion reaction involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, appetite loss, or sudden blindness without medical cause. The nurse must assess the patient fully before implementing any nursing interventions. Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.

Question 9

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be

1. “I’d better call 911 because your friend is suicidal.”
2. “Give her this list of university and community resources.”
3. “You must make an appointment for the student to obtain medications.”
4. “I’d recommend you help the student pack her bags to go home.”

Answer 9

2. “Give her this list of university and community resources.”

Rationale:

A health care provider can help to reduce situational stress factors for individuals. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college.

Question 10

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to

1. Identify limits and scope of work responsibilities.
2. Write for 10 minutes in a journal every day.
3. Use progressive muscle relaxation.
4. Delegate complex nursing tasks to licensed professional nurses.

Answer 10

1. Identify limits and scope of work responsibilities.

Rationale:

An important step in preventing burnout is acknowledging one’s own limitations, as well as what one’s scope of work is while on the job. By doing this, the person will help to prevent emotional exhaustion and will limit the effects of chronic stress. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating if not applicable is an inappropriate coping mechanism.

Question 11

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to

1. Teach the patient about the food pyramid.
2. Administer antidiarrheal medications with meals.
3. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.
4. Admonish the teen and her parents regarding her consistently poor diet choices.

Answer 11

3. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

Rationale:

Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent emotional needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a “typical and normal” teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill. Administering antidiarrheal medications may help but is not a tertiary level intervention. Admonishing the teen and parents is not a tertiary level intervention, and because this approach is nontherapeutic, it may cause communication problems.

Question 12

A trauma survivor is requesting sleep medication because of “bad dreams.” Concerned about posttraumatic stress disorder, the nurse asks

1. “Are you reliving your trauma?”
2. “Are you having chest pain?”
3. “Can you describe your phobias?”
4. “Can you tell me when you wake up?”

Answer 12

1. “Are you reliving your trauma?”

Rationale:

People who have PTSD often have flashbacks, reexperiencing the trauma. The other answers involve assessment of problems not specific to PTSD.

Question 13

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism?

1. Dissociation
2. Conversion
3. Denial
4. Compensation

Answer 13

3. Denial

Rationale:

Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into a physiological problem. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

Question 14

An assessment finding example for caregiver strain would be which of the following?

1. Caregiver routinely creates a weekly menu plan.
2. Caregiver has not received medical care when ill.
3. Caregiver can identify respite care provider.
4. Caregiver attends religious service.

Answer 14

2. Caregiver has not received medical care when ill.

Rationale:

A nurse will identify a caregiver’s lack of self-care as a potential example of caregiver role strain. Sacrificing their own health to care for the identified patient places caregivers at risk for becoming ill themselves. If caregivers jeopardize their own health, they may not be able to care for the actual patient. In all of the other options, the caregiver is handling caregiver stress appropriately.

Question 15

A young adult’s chief complaint is “seizure fits.” A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young man’s pseudo-seizures most likely are an example of which unconscious coping mechanism?

1. Compensation
2. Conversion
3. Dissociation
4. Denial

Answer 15

2. Conversion

Rationale:

A conversion reaction is an ego defense mechanism that involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, loss of appetite, or sudden blindness without medical cause. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Dissociation involves experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings. Denial is seen as avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain.

Question 16

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory?

1. Ego defense model
2. Situational model
3. Evidence-based practice model
4. Neuman systems model

Answer 16

4. Neuman systems model

Rationale:

The Neuman systems model is based on an individual’s/family’s/community’s relationship to stress and the reaction to stress. This model promotes wellness on primary, secondary, and tertiary levels. The other items listed as models are not nursing theories. Ego defense mechanisms are unconscious coping mechanisms. Situational refers to factors such as relocation or family job changes that are stressors. Evidence-based practice consists of relying on data or other reputable information sources to guide nursing care.

Question 17

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs:
Oral temperature: 99.0° F
Pulse: 102 beats per minute
Respiratory rate: 26 breaths per minute
Blood pressure: 140/106
The nurse can identify that which hormones are the likely causes of the abnormal vital signs?
1.	ADH and ACTH
2.	ACTH and epinephrine
3.	ADH and norepinephrine
4.	Epinephrine and norepinephrine

Answer 17

4. Epinephrine and norepinephrine

Rationale:

Epinephrine and norepinephrine are catecholamine hormones secreted by the adrenal medulla that rapidly elevate heart rate and blood pressure. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate.

Question 18

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual?

1. Protect against feelings of worthlessness and anxiety.
2. Facilitate the use of problem-focused coping.
3. Evaluate an event for its personal meaning.
4. Trigger the stress control functions of the medulla oblongata.

Answer 18

1. Protect against feelings of worthlessness and anxiety.

Rationale:

Ego defense mechanisms offer the individual psychological protection from emotional stress. They are used unconsciously to protect against worthlessness and feelings of anxiety. Problem-focused coping is a coping strategy rather than an ego defense mechanism. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

Question 19

Identify a sociocultural factor that can lead to developmental problems.

1. Family relocation
2. Childhood obesity
3. Prolonged poverty
4. Loss of stamina

Answer 19

3. Prolonged poverty

Rationale:

Environmental and social stressors are believed to lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

Question 20

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce children’s stress regarding homework assignments?

1. Time management skills
2. Prevention of iron deficiency anemia
3. Routine preventative health visits
4. Speech articulation skills

Answer 20

1. Time management skills

Rationale:

Time management skills are most related to homework assignment completion. Anemia prevention will improve energy levels but not stress. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress..