Deck 1 Chapter 38

Question 1

In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions?

a. Restorative care factors
b. Strong financial resource factors
c. Maturational and situational factors
d. Immaturity and intelligence factors

Answer 1

c. Maturational and situational factors

Rationale:

Maturational factors and situational 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 reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart?

a. General adaptation syndrome
b. Post-traumatic stress disorder
c. Acute stress disorder
d. Alarm reaction

Answer 2

b. Post-traumatic stress disorder

Rationale:

Post-traumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional detachment and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Acute stress disorder is a similar diagnosis that differs from PTSD in duration of symptoms. 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. Which level of intervention is the nurse using?

a. Primary
b. Secondary
c. Tertiary
d. Quad

Answer 3

c. Tertiary

Rationale:

Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. At the primary level of prevention, you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Quad level does not exist.

Question 4

A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe?

a. Singing
b. Massaging back
c. Listening to music
d. Using sensory peaceful words

Answer 4

d. Using 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.” What is the nurse’s best response?

a. “Many times disasters can create mental health problems, so you really should participate with your family.”
b. “Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.”
c. “Don’t worry now. The psychiatrists are well trained to help.”
d. “This will help your family communicate better.”

Answer 5

b. “Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.”

Rationale:

Crisis intervention is a type of brief therapy that is more directive than traditional psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The other options do not properly reassure the patient and build trust. Giving advice in the form of “you really should participate” is inappropriate. “Don’t worry now” is false reassurance. While crisis intervention may help families communicate better, the goal is to return to precrisis level of functioning; family therapy will focus on helping families communicate better.

Question 6

A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care?

a. Identity issues
b. Self-esteem issues
c. Physical appearance
d. Major changing life events

Answer 6

b. Self-esteem issues

Rationale:

Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances.

Question 7

A nurse is caring for a patient with stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take?

a. Select nursing interventions and promote patient’s adaptation to stress.
b. Establish short- and long-term goals with the patient experiencing stress.
c. Identify stress management interventions and achieve expected outcomes.
d. Reassess patient’s stress-related symptoms and compare with expected outcomes.

Answer 7

d. 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, seizure-like activity. An EEG and a neurology consultant’s report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next?

a. Suggest acupuncture.
b. Confront the patient on malingering.
c. Obtain history of any recent life stressors.
d. Recommend a regular exercise program.

Answer 8

c. Obtain history of any recent life stressors.

Rationale:

Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite) describes conversion. The nurse must assess the patient fully for emotional conflict and stress before implementing any nursing interventions (acupuncture or exercise program). 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 visits 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. Which is the best response by the nurse?

a. “Let’s call 911 because this freshman student is suicidal.”
b. “Give the freshman student this list of university and community resources.”
c. “I recommend that you help the freshman student start packing bags to go home.”
d. “You must make an appointment for the freshman student to obtain medications.”

Answer 9

b. “Give the freshman student this list of university and community resources.”

Rationale:

A nurse can help reduce situational stress factors for individuals. Inform the patient about potential resources. 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 nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use?

a. Delegate complex nursing tasks to nursing assistive personnel.
b. Strengthen friendships outside the workplace.
c. Write for 10 minutes in a journal every day.
d. Use progressive muscle relaxation.

Answer 10

b. Strengthen friendships outside the workplace.

Rationale:

Strengthening friendships outside of the workplace, arranging for temporary social isolation for personal “recharging” of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating complex nursing tasks to nursing assistive personnel is an inappropriate.

Question 11

A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan?

a. Teach the teen about the food pyramid.
b. Administer antidiarrheal medications with meals.
c. Gently admonish the teen and her parents regarding the consistently poor diet choices.
d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

Answer 11

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

Rationale:

Tertiary-level interventions assist the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent maturational 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 and the food pyramid is usually a primary intervention. Administering antidiarrheal medications may help but is not a tertiary-level or maturational 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.” The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient?

a. “Are you reliving your trauma?”
b. “Are you having chest pain?”
c. “Can you describe your phobias?”
d. “Can you tell me when you wake up?”

Answer 12

a. “Are you reliving your trauma?”

Rationale:

People who have PTSD often have flashbacks, recurrent and intrusive recollections of the event. The other answers involve assessment of problems not specific to PTSD.

Question 13

A patient in a motor vehicle accident states, “I did not run the red light,” despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using?

a. Denial
b. Conversion
c. Dissociation
d. Compensation

Answer 13

a. 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 nonorganic symptoms. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

Question 14

A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage?

1. Resistance
2. Exhaustion
3. Alarm
   a. 3, 1, 2
   b. 3, 2, 1
   c. 1, 3, 2
   d. 1, 2, 3

Answer 14

a. 3, 1, 2

Rationale:

The general adaptation syndrome (GAS), a three-stage reaction to stress, describes how the body responds physiologically to stressors through stages of alarm, resistance, and exhaustion.

Question 15

A young male patient is diagnosed with testicular cancer. Which action will the nurse take first?

a. Provide information to the patient.
b. Allow time for the patient’s friends.
c. Ask about the patient’s priority needs.
d. Find support for the family and patient.

Answer 15

c. Ask about the patient’s priority needs.

Rationale:

Take time to understand a patient’s meaning of the precipitating event and the ways in which stress is affecting his life. For example, in the case of a woman who has just been told that a breast mass was identified on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and finding support may be implemented after finding out what the patient wants or needs.

Question 16

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing?

a. Ego defense model
b. Immunity model
c. Neuman Systems Model
d. Pender’s Health Promotion Model

Answer 16

c. Neuman Systems Model

Rationale:

The Neuman Systems Model uses a systems approach, and it helps you understand your patients’ individual responses to stressors and also families’ and communities’ responses. Every person develops a set of responses to stress that constitute the “normal line of defense.” This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body’s natural protection mechanism. Pender’s Health Promotion Model focuses on promoting health and managing stress.

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/min
Respiratory rate: 26 breaths/min
Blood pressure: 140/106
Which hormones should the nurse consider as the most likely causes of the abnormal vital signs?
a.	ADH and ACTH
b.	ACTH and epinephrine
c.	ADH and norepinephrine
d.	Epinephrine and norepinephrine

Answer 17

d. Epinephrine and norepinephrine

Rationale:

During the alarm stage, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. 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

A nurse is planning care for a patient that uses displacement. Which information should the nurse consider when planning interventions?

a. This copes with stress directly.
b. This evaluates an event for its personal meaning.
c. This protects against feelings of worthlessness and anxiety.
d. This triggers the stress control functions of the medulla oblongata.

Answer 18

c. This protects against feelings of worthlessness and anxiety.

Rationale:

Ego-defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and offer psychological protection from a stressful event. 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

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem?

a. Family relocation
b. Childhood obesity
c. Prolonged poverty
d. Loss of stamina

Answer 19

c. Prolonged poverty

Rationale:

Environmental and social stressors often 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

A nurse is helping parents who have a child with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments?

a. Time-management skills
b. Speech articulation skills
c. Routine preventative health visits
d. Assertiveness training for the family

Answer 20

a. Time-management skills

Rationale:

Time-management skills are most related to homework assignment completion. Time-management techniques include developing lists of prioritized tasks. 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. Assertiveness includes skills for helping individuals communicate effectively regarding their needs and desires, but it does not help with homework assignments.

Question 21

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.)

a. Cancer
b. Diabetes
c. Infections
d. Allostasis
e. Low blood pressure

Answer 21

a. Cancer
b. Diabetes
c. Infections

Rationale:

Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person’s susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress..