Deck 3 Module 31 Flashcards
After a mammogram, a client is told that she needs a fine needle aspirate of a breast mass. Which action by the client demonstrates engagement in a primary appraisal of the stressful situation?
A) Holding her breath while the nurse is talking
B) Sitting in the dressing room crying
C) Asking the nurse if she has cancer
D) Scheduling the procedure in 6 weeks, which is the earliest possible appointment
C) Asking the nurse if she has cancer
Rationale:
In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.
A client states to the nurse that learning how to use the blood glucose machine will have to wait until holiday events are planned. Which cognitive indication of stress is the client demonstrating? A) Problem solving B) Suppression C) Self-control D) Cognitive structuring
B) Suppression
Rationale:
The client is demonstrating suppression, which is the conscious process of denying unacceptable thoughts or emotions. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through a challenging situation, using specific steps to arrive at a solution. Cognitive structuring uses mental processes to make sense of environmental stimuli. Self-control is the ability to restrain oneself from acting on impulse or to act in such a way as to delay gratification.
) A client worries every day about personal health and states, "I may not have enough medication if the weather takes a turn for the worse." This client is exhibiting a sign of which alteration in stress and coping? A) Generalized anxiety disorder B) Phobia C) Obsessive-compulsive disorder D) Panic disorder
A) Generalized anxiety disorder
Rationale:
Generalized anxiety disorder is excessive worry about everyday problems, with the anxiety being more intense than the situation warrants. The client is demonstrating signs of generalized anxiety disorder. A phobia is an intense, persistent, irrational fear of a simple thing or social situation that compels the individual to avoid the stressor that elicits the fear. Panic disorder is a sudden attack of terror, accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive repetitive behaviors formed in response to the obsessive thoughts to lower the level of anxiety experienced.
Which assessment findings indicate to the nurse that a client is experiencing stress? Select all that apply. A) Chewing on a fingernail B) Checking cellular phone C) Reading a magazine D) Talking with others E) Tapping foot
A) Chewing on a fingernail
E) Tapping foot
Rationale:
The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.
A client complains about the stress of having to work long hours and missing daily exercise routines. Which response by the nurse is appropriate?
A) “There are other ways to reduce stress, such as meditation.”
B) “Exercise helps reduce the impact of stress on the body and would be a good thing.”
C) “Drinking a small glass of wine each day does help reduce stress.”
D) “Maybe exercising, with all of the work, would be too much for your body anyway.”
B) “Exercise helps reduce the impact of stress on the body and would be a good thing.”
Rationale:
The client had been exercising but has not been recently because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client’s not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client’s needs. The nurse should not suggest using alcohol to deal with stress.
Which intervention would help a client who is demonstrating stress about being hospitalized who is concerned about the needs of the children at home?
A) Ask the client if there is anything that is needed once discharged to home.
B) Ask the client if there is anyone who would be able to help with the family needs at home during recuperation.
C) Find out if the children can be sent to a grandparent’s home until the client fully recovers.
D) Suggest the client be transferred to a long-term care facility to ensure a full recovery.
B) Ask the client if there is anyone who would be able to help with the family needs at home during recuperation.
Rationale:
The nurse needs to focus on what can be done right away to help the client. The best way that the nurse can help this client is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent’s home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.
Which instruction by the nurse to a client prescribed diazepam (Valium) for anxiety and stress is appropriate?
A) “This medication will be good to take for a long time.”
B) “Take this medication every time feelings of stress become overwhelming.”
C) “This medication works best if taken with a meal.”
D) “This medication is good to use for the short term only.”
D) “This medication is good to use for the short term only.”
Rationale:
Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client’s anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.
A client is recently prescribed risperidone (Risperdal) by the healthcare provider. Which would be a priority nursing consideration for this client?
A) Assess blood pressure and heart rate.
B) Monitor for increased agitation.
C) Assess for drowsiness.
D) Monitor for neuroleptic malignant syndrome.
D) Monitor for neuroleptic malignant syndrome.
Rationale:
Monitoring for neuroleptic malignant syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.
A nurse on the behavioral health unit is caring for a client diagnosed with depression who just lost a spouse in a motor vehicle crash. The client states to the nurse, "My wife would not have wanted to live if she were disabled." Based on this statement, which defense mechanism is the client using? A) Identification B) Denial C) Intellectualization D) Displacement
C) Intellectualization
Rationale:
Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.
Which hormone is one of the primary mediators of stress? A) Glucagon B) Cortisol C) Serotonin D) Somatostatin
B) Cortisol
Rationale:
The two primary stress mediators are glucocorticoids (e.g., cortisol) and catecholamines (e.g., epinephrine). Serotonin is a neurotransmitter that is involved in some mood and anxiety disorders, but it is not a primary mediator of stress. Somatostatin is a hormone released by the pituitary gland. It is not involved in the stress response. Glucagon is secreted by the pancreas to increase blood glucose levels.
Occupation-specific stressors that are ongoing and unmanaged can lead to what extreme form of stress? A) Distress B) Eustress C) Allostasis D) Burnout
D) Burnout
Rationale:
Eustress is good stress that leads to accomplishment and victory. Distress is bad stress that is associated with inadequacy, insecurity, and loss. Although occupation-specific stressors can be a type of distress, distress is not the specific term for the extreme form of stress caused by ongoing and unmanaged stress. The term used for that form of extreme stress is burnout. Burnout in nurses can lead to reduced quality of care and decreased patient satisfaction. Allostasis refers to the changes necessary to achieve homeostasis.
Which intervention can the nurse implement independently when caring for a client with alterations in stress and coping? A) Therapeutic communication B) Cognitive-behavioral therapy C) Psychotherapy D) Administration of medications
A) Therapeutic communication
Rationale:
Using therapeutic communication is an essential intervention that the nurse can implement independently when caring for a client with an alteration in stress and coping. Cognitive-behavioral therapy, psychotherapy, and administration of medications are all collaborative interventions.
Which child would the nurse recognize as being at the highest risk of experiencing toxic stress?
A) A 15-year-old adolescent who is slightly overweight and didn’t make the football team; he regularly gets teased for his weight at school.
B) A 2-week-old infant who was born at 31 weeks’ gestation and has been in the neonatal intensive care unit (NICU) for the entire 2 weeks; the child’s parents are at the hospital as often as possible.
C) A 12-year-old child whose father recently died and whose mother works three part-time jobs; this child is expected to care for two younger siblings after school.
D) A 4-year-old child who attends preschool or daycare each day while the parents work; the child displays signs of mild separation anxiety.
C) A 12-year-old child whose father recently died and whose mother works three part-time jobs; this child is expected to care for two younger siblings after school.
Rationale:
The 4-year-old child and 15-year-old adolescent are experiencing normative stressors, which do not usually lead to toxic stress. The 2-week-old infant may be experiencing non-normative stress, but the infant is receiving appropriate adult support and is likely too young to be cognitively aware of stressors. The 12-year-old child has experienced a non-normative stressor in the death of the father, and the child does not have adequate adult support. This places the child at high risk for toxic stress.
The nurse is assessing a 68-year-old client who appears disheveled. At previous appointments, the client was well kept with good hygiene practices. Today, the client’s clothes do not match, the client’s hair is unkempt, and the client has intense body odor. The nurse is concerned about this change in self-care. When conducting the assessment, what is the primary factor the nurse should consider?
A) Whether the changes are due to a lack of understanding of technology
B) Whether the changes are due to stress or dementia
C) Whether the client is taking all medications as prescribed
D) Whether the client is living independently
B) Whether the changes are due to stress or dementia
Rationale:
In older clients, changes in self-care habits are frequently in response to stress, but they could also be related to dementia and an inability to remember how to use basic grooming tools. The nurse needs to determine the cause of the self-care changes. A lack of understanding of technology and living independently could be causes of stress, and forgetting to take medications could be a sign of dementia, so these are secondary considerations after determining whether the changes are due to stress or dementia.
A client, who is experiencing anxiety, is trembling and complaining of dizziness and palpitations. The client is having a hard time following the nurse's instructions. Based on this data, which level of anxiety is the client likely experiencing? A) Panic B) Severe C) Moderate D) Mild
B) Severe
Rationale:
Severe anxiety can be associated with trembling, dizziness, palpitations, and difficulty following directions, among other signs and symptoms. Mild anxiety causes an increase in alertness and sensory perception. Moderate anxiety results in a reduction in awareness and increased restlessness and irritability. Panic is associated with dilated pupils, pallor, diaphoresis, and bizarre behavior.
A client, who was recently laid off from work, is scheduled for a biopsy to evaluate a site for malignancy. When planning this client’s care, which does the nurse include?
A) Reasons to delay the biopsy
B) Medicate around the clock for pain
C) Interventions to address anxiety
D) Social services to aid with financial planning
C) Interventions to address anxiety
Rationale:
Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client’s financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.
The nurse is evaluating medication teaching for a client who recently started taking fluoxetine (Prozac) for anxiety. Which statement by the client indicates appropriate understanding of the information presented?
A) “My medication will take 1 week to become effective.”
B) “My medication will take 4 weeks to become effective.”
C) “My medication will become effective immediately after I start taking it.”
D) “My medication will not begin to work for 12 weeks.”
B) “My medication will take 4 weeks to become effective.”
Rationale:
Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Although these drugs begin to alter brain chemistry after the first dose, their full effect requires a few weeks because a series of neurobiological changes must take place before SSRIs achieve efficacy.
The nurse is instructing a client with an anxiety disorder on behavioral tools to help with coping. Which tools to help with coping should the nurse include in the teaching session? Select all that apply. A) Relaxation techniques B) Thought stopping C) Journaling D) Distraction E) Practicing yoga
A) Relaxation techniques
C) Journaling
E) Practicing yoga
Rationale:
Behavioral tools to help with coping include relaxation techniques, yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.
Which is the priority nursing action when providing care to a client who demonstrates signs of escalating anxiety?
A) Isolate the client in a safe, quiet, and protective environment.
B) Leave the client alone in a room.
C) Provide a benzodiazepine.
D) Phone the physician.
A) Isolate the client in a safe, quiet, and protective environment.
Rationale:
The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.
The nurse is admitting a client suffering a panic attack to the behavioral health unit. Which clinical manifestations would indicate that the client's anxiety is at a panic level of severity? Select all that apply. A) Inability to focus B) Dilated pupils C) Feelings of doom D) Self-absorption E) Rapid speech
A) Inability to focus
B) Dilated pupils
C) Feelings of doom
Rationale:
An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.
A nurse on the behavioral health unit is leading a group regarding risk factors for anxiety. At the completion of group work, which comment made by a client would indicate the need for further teaching?
A) “A lack of social interaction places me at risk for anxiety.”
B) “My personality could place me at risk for anxiety because I am shy.”
C) “Chronic illness is not a risk factor unless I am also unemployed.”
D) “I experienced a traumatic event that placed me at risk for having this anxiety disorder.”
C) “Chronic illness is not a risk factor unless I am also unemployed.”
Rationale:
Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.
The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client would indicate to the nurse a need for further education?
A) “This medicine could make me feel like I have the jitters.”
B) “I may experience some nausea while on this medication.”
C) “My doctor will start me off on a high dose and then decrease the dose.”
D) “This medicine alters the levels of the neurotransmitter serotonin in the brain.”
C) “My doctor will start me off on a high dose and then decrease the dose.”
Rationale:
SSRIs are generally started at low doses and then increased as their effectiveness becomes apparent; therefore, this statement made by the client is inaccurate and indicates a lack of understanding and the need for further teaching. The other statements are accurate so do not require further teaching.
