Exam 2 aids/hgd/communication/stress/fluids&electrolyte Flashcards
1
Q
HIV
A
Human Immunodifficiency Virus
2
Q
what specific immune cells does HIV attack? What does it use it for?
A
CD4+ T-cells
high-jacks the host cell to produce more of itself
HIV binds to CD4+ cells in the host, also known as helper T cells. These cells are responsible for regulating the normal immune response. When the HIV DNA inserts itself into the CD4+ cell, it will cause cell death. This causes the number of CD4+ cells to decrease, therefore weakening the immune system.
3
Q
AIDS
A
Acquired Immuno Deficiency Syndrome
4
Q
When is AIDS diagnosed?
A
When CD4+ T-cells are less than or equal to 200 cells per uL or when opportunistic infection is diagnosed
5
Q
AHI
A
Acute HIV Infection refers to the initial period after infection
at this moment EIA will be negative
6
Q
After about how many weeks will symptoms appear after infection? And what symptoms appears?
A
1-4 weeks after infection
Symptoms include fatigue, fever, malaise, headache, muscle aches, rash, sore throat, swollen lymph glands
7
Q
Whats the normal count for CD4+?
A
500-1500
8
Q
How long may take for HIV to appear in tests?
A
3 - 6 mo
9
Q
Name the steps for HIV life cycle
A
- HIV binds the T-cells
- Viral RNA is released into the host cell
- The viral RNA is converted into the viral DNA through a process called reverse transcriptase. During reverse transcriptase, an enzyme reads the sequence of viral DNA nucleic acids that have entered the host cell and transcribes the sequence into a complementary DNA sequence.
- Viral DNA enter the T-call’s nucleus and inserts itself into the T-cell’s DNA
- The T cell starts to make copies of HIV components
- Protease an enzyme helps create new virus particles.
- The new virion ( virus particle) is released from the T cell.
10
Q
Opportunistic Infections examples
A
Tuberculosis Recurrent pneumonia Pneumocystis jirovecii pneumonia (aka PCP) Wasting syndrome Candidiasis of trachea, bronchi or lungs
11
Q
Most common modes of transmission for HIV
A
Sexual Contact Male-to-male (MSM) Heterosexual Blood Exposure Injecting drug use (IDU) Occupational exposure Organ transplant Blood/blood products transfusion Perinatal Before or during birth Breastfeeding
12
Q
What are the testings for HIV?
A
Screening tests
Orasure: detects HIV antibodies in oral fluid
Rapid test: detects HIV antibodies in blood from finger prick
Confirmatory tests
IFA: highly accurate detection of HIV antibodies from venous blood
Western blot: very specific detection of HIV antibodies from venous blood
13
Q
What is HAART?
A
Highly Active Anti-Retroviral Treatment (HAART) includes at least 3 drugs. This is to reduce the likelihood of development of drug resistance.
There can be many, tough side effects to the drugs.
Drugs aim to keep the viral load at a minimum.
Stopping treatment often results in a quick jump in viral load.
14
Q
A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-lb weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child’s edema?
- Weighing daily
- Observing body changes
- Measuring intake and output
- Monitoring electrolyte values
A
Correct 1. Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb.
2. Visual inspection is subjective and generally inaccurate. 3. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. 4. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.
15
Q
In an interview with a pregnant patient, the nurse discussed the three risk factors that have been cited as having a possible effect on prenatal development. They are:
- Nutrition, stress, and mother’s age.
- Prematurity, stress, and mother’s age.
- Nutrition, mother’s age, and fetal infections.
- Fetal infections, prematurity, and placenta previa.
A
Answer: 1.
The woman’s diet before and during pregnancy has a significant effect on fetal development; the mother’s age may contribute to a risk for chromosomal defects (older mothers) or the lack of prenatal care (adolescent mothers); pregnancy is often accompanied by stress because of all of the developmental changes, and it is important to know whether or not the mother has an effective support system.
16
Q
A parent has brought her 6-month-old infant in for a wellchild check. Which of her statements indicates a need for further teaching?
1. “I can start giving her whole milk at about 12 months.”
2. “I can continue to breastfeed for another 6 months.”
3. “I’ve started giving her plenty of fruit juice as a way to
increase her vitamin intake.”
4. “I can start giving her solid food now.”
A
Answer: 3.
Breast milk or formula is recommended at this time; fruit juice is not considered a nutritive addition.
17
Q
The type of injury a child is most vulnerable to at a specific age is most closely related to which of the following?
- Provision of adult supervision.
- Educational level of the parent
- Physical health of the child
- Developmental level of the child
A
Answer: 4.
The child’s cognitive and physical development need to be considered initially when assessing the potential risk for injury.
18
Q
Which approach would be best for the nurse to use with a hospitalized toddler?
- Always give several choices.
- Set few limits to allow for open expression.
- Use noninvasive methods when possible.
- Gain cooperation before attempting treatment
A
Answer: 4.
Toddlers are learning to become independent and frequently display negative behavior if an effort to gain their trust is not provided initially. Providing too many choices does not support their efforts to gain control.
19
Q
The nurse is providing information on prevention of sudden infant death syndrome (SIDS) to the mother of a young infant. Which of the following statements indicates that the mother has a good understanding? (Select all that apply.)
- “I won’t use a pacifier to help my baby sleep.”
- “I’ll be sure my baby does not spend any time on her
abdomen. ” - “I’ll place my baby on her back for sleep.”
- “I’ll be sure to keep my baby’s room cold.”
A
Answer: 3, 4.
The American Academy of Pediatrics has clearly recommended that infants be placed on their backs for sleep to help prevent SIDS. Keeping the room cool is also important.
20
Q
In evaluating the gross-motor development of a 5-month-old infant, which of the following would the nurse expect the infant to do?
- Roll from abdomen to back
- Move from prone to sitting unassisted
- Sit upright without support
- Turn completely over
A
Answer: 1.
The 5-month-old infant should be able to turn from abdomen to back.
21
Q
Parents are concerned about their toddler’s negativism and ask the nurse for guidance. Which is the most appropriate recommendation?
- Provide more attention.
- Reduce opportunities for a “no” answer.
- Be consistent with punishment.
- Provide opportunities for the toddler to make decisions.
A
Answer: 2. Giving toddlers realistic choices reduces the opportunity for a negative response and helps support their need for control.
22
Q
When nurses are communicating with adolescents, they
should:
1. Be alert to clues to their emotional state.
2. Ask closed-ended questions to get straight answers.
3. Avoid looking for meaning behind adolescents’ words or actions.
4. Avoid discussing sensitive issues such sex and drugs.
A
Answer: 1.
Adolescents are searching for their identity and trying to become emotionally independent from parents while maintaining family ties. Depression, substance abuse, and violence are all real concerns during this period; thus the nurse must be aware of the adolescent’s emotional state.
23
Q
Which of the following statements is most descriptive of the psychosocial development of school-age children?
- Boys and girls play equally with each other.
- Peer influence is not yet an important factor to the child.
- They like to play games with rigid rules.
- Children frequently have “best friends.”
A
Answer: 4.
Peer relationships become very important to school-age children, and they usually develop close friendships.
24
Q
You are caring for a 4-year-old child who is hospitalized for an infection. He tells you that he is sick because he was “bad.” Which is the most correct interpretation of his comment?
- Indicative of extreme stress
- Representative of his cognitive development
- Suggestive of excessive discipline at home
- Indicative of his developing sense of inferiority
A
Answer: 2.
Preschoolers exhibit “egocentric” thought, meaning that they truly believe that their thinking is shared by others and that they can control their environment by their thoughts.
25
At a well-child examination, the mother comments that her toddler eats little at mealtime, will only sit briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend?
1. Provide nutritious snacks.
2. Offer rewards for eating at mealtimes.
3. Avoid snacks so she is hungry at mealtime.
4. Explain to her firmly why eating at mealtime is important
Answer: 1.
Toddlers are not growing as quickly as they did during infancy and thus eat smaller meals; nutritious snacks can help to ensure that they gain the nutrients they need.
26
An 8-year-old child is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which of the following will most help her adjust to the hospital?
1. Explain hospital routines such as meal times to her.
2. Use terms such as “honey” and “dear” to show a caring
attitude.
3. Explain when her parents can visit and why siblings cannot
come to see her.
4. Since she is young, orient her parents to her room and
hospital facility.
Answer: 1.
School-age children are able to think logically and can classify objects or routines; having an understanding of what to expect can help them cope with a new experience.
27
The school nurse is counseling an obese 10-year-old child. What factor would be important to consider when planning an intervention to support the child’s health?
1. Concentrate on the child only rather than the family since
it is the child’s responsibility.
2. Consider the use of medications to suppress the appetite.
3. First plan for weight loss through dieting and then add
activity as tolerated.
4. Plan food intake to allow for growth
Answer: 4.
Although growth slows down during the school-age years, it is still important that appropriate nutrients be provided to promote growth. Children need adequate caloric intake along with activity for gross-motor development. Dieting might not provide the intake necessary.
28
You are working in an adolescent health center when a 15-yearold patient shares with you that she thinks she is pregnant and is worried that she may now have a sexually transmitted infection (STI). Her pregnancy test is negative. What is your next priority of care?
1. Contact her parents to alert them of her need for birth
control.
2. Refer her to a primary health care provider to obtain a
prescription for birth control.
3. Counsel her on safe sex practices.
4. Ask her to have her partner come to the clinic for STI
testing.
Answer: 3.
| Adolescent pregnancy and STIs are concerns that should be addressed by the nurse to support health care.
29
While working in the high-school clinic, one of the students tells you that she is worried about her friend who has started to refuse to participate in group activities, no longer cares about how she looks at school, and is not going to all of her classes. Your assessment of these symptoms may indicate that:
1. She has just broken up with her boyfriend and time will
heal all.
2. You will need to observe her over time to see if symptoms
persist.
3. School may be too difficult for her right now.
4. She may be at increased risk for suicide.
Answer: 4.
Depression is a major health concern for adolescents and can be triggered by many factors; the symptoms that are listed indicate increased risk.
30
Ms. X is diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse caring for this patient is aware that for a patient to be diagnosed with HIV she should have which condition?
a. Infection of HIV, have a CD4+ T-cell count of 500 cells/microliter, history of acute HIV infection
b. Infection with Tuberculosis, HIV and cytomegalovirus
c. Infection of HIV, have a CD4+ T-cell count of >200 cells/microliter, history of acute HIV infection
d. Infection with HIV, history of HIV infection and T-cell count below 200 cells/microliter
Answer C. The three criteria for a client to be diagnosed with AIDS are the following:
• HIV positive
• CD4+ T-cell count below 200 cells/microliter
• Have one or more specific conditions that include acute infection of HIV
31
The nurse observes precaution in caring for Mr. X as HIV is most easily transmitted in:
a. Vaginal secretions and urine
b. Breast milk and tears
c. Feces and saliva
d. Blood and semen
Answer D. Keyword: MOST EASILY. Rationale: HIV is MOST EASILY transmitted in blood, semen and vaginal secretions. However, it has been noted to be found in fecal materials, urine, saliva, tears and breast milk.
32
Nurse Jaja is giving an injection to Ms. X. After giving an injection, the nurse accidentally stuck her finger with the needle when the client became very agitated. To determine if the nurse became infected with HIV when is the best time to test her for HIV antibodies?
a. Immediately and repeat the test after 12 weeks
b. Immediately and repeat the test after 4 weeks
c. After a week and repeat the test in 4 months
d. After a weeks and repeat the test in 6 months
Answer A. Keyword: BEST TIME. Rationale: To determine if a preexisting infection is present a test should be done immediately and is repeated again in 3 months time (12 weeks) to detect seroconversion as a result of the needle stick.
33
The blood test first used to identify a response to HIV infection is:
a. Western blot
b. ELISA test
c. CD4+ T-cell count
d. CBC
Answer B. Keyword: FIRST. Rationale: The ELISA test is the first screening test for HIV. A Western blot test confirms a positive ELISA test. Other blood tests that support the diagnosis of HIV include CD4+ and CD8 + counts, CBC, immunoglobulin levels, p24 antigen assay, and quantitative ribonucleic acid assays.
34
What is the main reason why it is difficult to develop a vaccine against HIV?
a. HIV is still unknown to human
b. HIV mutates easily
c. HIV spreads rapidly throughout the body
d. HIV matures easily
Answer B. Keyword: MAIN REASON. Rationale: HIV was identified in 1983, thus, A is incorrect. By 1988 two strains of HIV existed, HIV-1 and HIV-2. Viruses spread rapidly and mature easily but these factors don’t affect the potential for development against HIV. Mutating too easily makes it hard to create a vaccine against it.
35
Human Immunodeficiency virus belongs to which classifications?
a. Rhabdovirus
b. Rhinovirus
c. Retrovirus
d. Rotavirus
Answer C. Rationale: HIV is a retrovirus that has a ribonucleic acid dependent reverse transcriptase.
36
B-cells are involved in which of the following types of immunity?
a. Humoral immunity
b. Cell-mediated immunity
c. Antigen-mediated immunity
d. All of these
Answer A. Keyword: B-CELLS. Rationale: B-Cells are responsible for humoral or immunoglobulin mediated immunity. T-cells are responsible for cell-mediated immunity. There is such thing as antigen-mediated immunity.
37
The average length of time from HIV infection to the development of AIDS is?
a. Less than 3 years
b. 5-7 years
c. 10 years
d. More than 10 years
Answer C. Keyword: AVERAGE LENGTH OF TIME. Rationale: epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
38
A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client?
a) consume foods and beverages that are high in glucose
b) plan large menus and cook meals in advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout the day
D
- The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.
39
A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living?
a) provide supportive care with hygiene needs
b) provide meals and snacks with high-protein, high calorie, and high-nutritional value
c) provide small, frequent meals
d) offer low microbial foods
A
- Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.
40
A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?
a) the test should be repeated in 6 months
b) this ensures that the client is not infected with the HIV virus
c) the client no longer needs to protect himself from sexual partners
d) the client probably has immunity to the acquired immunodeficiency virus
A
- A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options B, C, and D are incorrect.
41
A client is diagnosed with late stage human immunodeficiency virus (HIV), and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to:
a) tell the client and family to stop smoking because it will predispose the client to respiratory infections
b) tell the client and family that raw or improperly washed foods can produce microbes
c) encourage the client and family to discuss their feelings about the disease
d) advise the client to avoid becoming pregnant because of the risk of transmission of the infection
C
- The priority psychosocial nursing intervention for the client and family is to encourage the client and family to discuss their feelings about the disease. Options A, B, and D identify physiological not psychosocial concerns.
42
A client is diagnosed with human immunodeficiency virus (HIV) infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which:
a) immunosuppression occurs and is indicated by a T4 lymphocyte count of less than 200/mm3
b) bacterial infection occurs, causing weakness
c) fungal infection occurs, causing a rash and pruritus
d) protozoan infection occurs, causing a fever and nonproductive cough
A
- HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoal infection can occur, these occur as opportunistic infections as a result of the immunosuppression.
43
Which of the following nursing actions is essential before an EIA test is performed?
a) Performing a Western blot test
b) Obtaining a written consent from the patient
c) Performing a polymerase chain reaction test
d) Obtaining a general consent for medical care from the patient
D
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. The Western blot test is performed if the results of the EIA test are positive. A polymerase chain reaction test, which measures viral loads, is used if diagnosis is confirmed as positive.
44
A patient is administered foscarnet to treat a case of cytomegalovirus (CMV) retinitis. Which of the following adverse effects should the nurse closely monitor in the patient?
a) Hypotension
b) Peripheral neuropathy
c) Electrolyte imbalances
d) Anemia
C
Alterations in renal function, fever, nausea, electrolyte imbalances, and diarrhea are the most common adverse effects of foscarnet and should be closely monitored. The drug does not cause hypotension. On the other hand, peripheral neuropathy is an adverse effect of administering drugs such as didanosine and zalcitabine. Anemia is an adverse effect of administering zidovudine
45
What intervention is a priority when treating a patient with HIV /AIDS?
a) Monitoring skin integrity
b) Assessing neurologic status
c) Monitoring psychological status
d) Assessing fluid and electrolyte balance
D
Fluid and electrolyte deficits are a priority in monitoring patients with HIV/AIDS. Assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored, but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.
46
Which of the following microorganisms is known to cause retinitis in people with HIV/AIDS?
a) Pneumocystis carinii
b) Cytomegalovirus
c) Mycobacterium avium
d) Cryptococcus neoformans
B
Cytomegalovirus is a species-specific herpes virus. Cryptococcus neoformans is a fungus that causes an opportunistic infection in patients with HIV/AIDS. Mycobacterium avium is an acid-fast bacillus that commonly causes a respiratory illness. Pneumocystis carinii is an organism that is thought to be protozoan, but believed to be a fungus based on its structure.
47
Which blood test confirms the presence of antibodies to HIV?
a) p24 antigen
b) Reverse transcriptase
c) Enzyme-linked immunosorbent assay (ELISA)
d) Erythrocyte sedimentation rate (ESR)
C
ELISA, as well as Western blot assay, identifies and confirms the presence of antibodies to HIV. The ESR is an indicator of the presence of inflammation in the body. The p24 antigen is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into a double-stranded DNA.
48
When assisting the patient to interpret a negative HIV test result, what does the nurse tell the patient this result means?
a) Antibodies to the AIDS virus are in his blood.
b) He is immune to the AIDS virus.
c) His body has not produced antibodies to the AIDS virus.
d) He has not been infected with HIV.
C
A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that, if infected, the body has not produced antibodies (which takes from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.
49
Which stage of HIV infection is indicated when the results are more than 500 CD4+ lymphocytes/mm?
a) Stage 2
b) Stage 1
c) Stage 3
d) Primary infection (acute HIV infection or acute HIV syndrome)
D
| More than 500 CD4+ T lymphocytes/mm indicates CDC stage 1.
50
The term used to define the balance between the amount of HIV in the body and the immune response is which of the following?
a) Primary infection stage
b) Viral clearance rate
c) Window period
d) Viral set point
D
The viral set point is the balance between the amount of HIV in the body and the immune response. During the primary infection period, the window period occurs since a person is infected with HIV but negative on the HIV antibody blood test. The period from infection with HIV to the development of antibodies to HIV is known as the primary infection stage. The amount of virus in circulation and the number of infected cells equals the rate of viral clearance.
51
Which of the following statements reflects the treatment of HIV infection?
a) Treatment should be offered to individuals with plasma HIV RNA levels less than 55,000 copies/mL (RT-PCR assay).
b) Treatment of HIV infection for an individual patient is based on the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).
c) Treatment should be offered to only select patients once they reach CDC category B: HIV symptomatic.
d) Treatment should be offered to all patients once they reach CDC category B: HIV symptomatic.
B
Although specific therapies vary, treatment of HIV infection for an individual patient is based on three factors: the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).Treatment should be offered to all patients with the primary infection (acute HIV syndrome). In general, treatment should be offered to individuals with fewer than 350 CD4+ T cells/mm or plasma HIV RNA levels exceeding 55,000 copies/mL (RT-PCR assay).
52
When do most perinatal HIV infections occur?
a) Through casual contact
b) In utero
c) Through breastfeeding
d) After exposure during delivery
D
Mother-to-child transmission of HIV-1 may occur in utero or through breastfeeding, but most perinatal infections are thought to occur after exposure during delivery.
53
Other than abstinence, what is the only proven method of decreasing the risk for sexual transmission of HIV infection?
a) Spermicides
b) Consistent and correct use of condoms
c) Vaginal lubricants
d) Birth control pills
B
Other than abstinence, consistent and correct use of condoms is the only method proven to decrease the risk for sexual transmission of HIV infection. Vaginal lubricants, birth control pills, and spermicides do not decrease the risk for sexual transmission of HIV infection.
54
Which diagnostic test measures HIV RNA in the plasma?
a) ELISA
b) Viral load
c) Enzyme immunoassay
d) Western blot assay
B
A viral load test measures the quantity of HIV RNA in the blood. Enzyme immunoassay is a blood test that can determine the presence of antibodies to HIV in the blood or saliva that is also referred to as an ELISA. A Western blot assay is a blood test that identifies antibodies to HIV and is used to confirm the results of an EIA (ELISA) test.
55
The nurse teaches the patient that lowering his or her viral load will have what effect?
a) A longer survival time
b) A shorter survival time
c) A longer immunity
d) A shorter time to AIDS diagnosis
A
| The lower the patient's viral load, the longer the survival time.
56
Which of the following is usually the most important consideration in decisions to initiate antiretroviral therapy?
a) HIV RNA
b) CD4 counts
c) Western blot assay
d) ELISA
B
| The most important consideration in decisions to initiate antiretroviral therapy is CD4 counts
57
Which assessment finding is not likely to cause noncompliance with antiretroviral treatment?
a) Past substance abuse
b) Active substance abuse
c) Lack of social support
d) Depression
A
Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment. Factors associated with nonadherence include active substance abuse, depression, and lack of social support.
58
A patient taking amprenavir (APV, Agenerase) complains of “getting fat.” What is the nurse’s best action?
a) Assess the patient’s diet.
b) Arrange for a psychological counseling.
c) Teach the patient about medication side effects.
d) Have the patient increase exercise.
C
The patient needs to be aware of the potential for fat redistribution. Exercise, diet, and counseling will not change the outcome of this side effect.
59
A client receiving atazanavir (ATV, Reyataz) requires what priority intervention?
a) Cardiac assessment
b) Renal function tests
c) Increased fluids
d) Diet modification
A
This medication may cause prolongation of the PR interval and first degree AV block. Patients with underlying conduction deficits may develop problems. A cardiac assessment will assist in determining if the patient has underlying problems that could be exacerbated by this drug therapy. The other interventions are not necessary.
60
What test will the nurse assess to determine the patient’s response to antiretroviral therapy?
a) Western blot
b) CBC
c) EIA enzyme immunoassay
d) Viral load
D
| Viral load is used to assess response to treatment of HIV infection. The other tests are not used in this way.
61
The nurse is teaching the patient with HIV about therapy. What is essential for the nurse to include in the teaching plan? Select all that apply.
a) Medication therapy is rarely effective.
b) Patients rarely respond to medication therapy.
c) The goal of antiretroviral therapy is to prevent opportunistic infections.
d) The CD4 count is the major indicator of immune function and guides therapy.
e) Antiretroviral therapy targets different stages of the HIV life cycle.
D, E
The CD4 count is the major indicator of immune function. Antiretroviral therapy in HIV targets different stages of the HIV life cycle. Therapy does not prevent opportunistic infections. Medication therapy is effective and most patients respond well to therapy.
62
A patient being treated for HIV/AIDS has a decreased appetite, almost to the point of anorexia. What is the nurse’s best action?
a) Talk to the patient about his unwillingness to eat.
b) Ask his family to bring in food that he enjoys.
c) Ask the dietician to prepare his favorite meals.
d) Administer megestrol acetate (Megace).
D
Appetite stimulants are successfully used in patients with AIDS-related anorexia. The anorexia is compounded by medications that cause nausea and vomiting. The anorexia has a physiologic cause, and this must be addressed. Bringing in favorite foods or making favorite foods may have little or no effect on the patient’s appetite; it is physiologically rather than psychologically based
63
For stress what is the contributor/ aggravator of medical conditions
```
Cardiovascular disease
Immune disorders
Asthma
Diabetes
Digestive disorders
Skin disorders
Psychological disorders
```
64
Stress
Condition in which the human system responds to changes in its normal balanced state
Tensions that threaten equilibrium
65
Stressor
Anything that a person perceives as challenging, threatening, or demanding.
(positive or negative)
66
Types of External Stressors
Environment (temp, noise, space…)
Social interaction (rudeness, bossiness…)
Major life events (birth, death, divorce…)
Daily hassles (commuting, misplaced keys…)
67
Type of Internal Stressors
Life choices: (overloaded schedule, caffeine…)
Negative self talk: (self-criticism, pessimistic…)
Mind trap:(unrealistic expectation, taking things personally)
Personality traits: (perfectionist, workaholics)
68
What is LAS? And give an Example
Local Adaptation Syndrome
A. Response of body tissue, an organ, or a part of the body to the stress of trauma, illness, or other physiological change
B. Examples
1. reflex pain response=localized response of CNS to stimulus of pain ( remove hand from hot surface)
2. inflammatory response
69
How does LAS take affect on the vascular system?
| What examples for each affect on how the patient is affected?
Brief constriction -> pallor and numb
Increase blood flow -> redness & heat
Inc Histamine -> Swelling
Cell permeability -> Loss of function
70
What happens with LAS in the exudative stage?...
- Fluids released from a type of wound
| - Nerve irritation and Pain
71
LAS in Regeneration
Cells replaced
same type of cells
scar formation
72
What is GAS? What are the stages?
```
General Adaptation Syndrome
An immediate physiological response of the whole body to stress; involves several body systems, especially the autonomic nervous and endocrine systems, and includes immunological changes
A three-stage reaction to stress:
Alarm reaction
Resistance stage
Exhaustion stage
```
73
What is the first stage of GAS and what happens?
1. Alarm Reaction (AR) - mobilization of the defense
mechanisms of the body or the mind to cope with the stress
- Fight or Flight Response
- Inc. blood vol—prepare to act
- Inc. blood sugar—needed energy
- Inc. H.R./O2—Mental alertness
If not resolved it moves on to the next stage
74
What is the second stage of GAS and what happens?
2. Resistance Stage (SR) - stabilization, person attempts to adapt to the stressor
Body stabilizes ** ? Adaptation
a) hormone levels, heart rate, BP, and cardiac output
return to normal
b) if stage successful body repairs damage
c) if however stressor remains and person unable to
adapt person moves on to the third stage
75
What is the third stage of GAS and what happens?
3. Exhaustion Stage (SE) - body cannot resist the stress, and energy necessary to maintain adaptation is depleted
?? Death may occur
a) physiological response is intensified but the person's
energy level is compromised and adaptation to the
stressor diminishes
b) physiological regulation diminishes
c) if stress continues, death may result
76
Hypothalamus secretes which hormones in stress mode?
ADH = vasopressin
| Oxytocin
77
Adrenal cortex release
Glucocorticoid (cortisol) which releases glucose
| Mineralcorticoids (Aldosterone, which increases BP)
78
Adrenal medulla releases
Epinephrine (adrenaline)
79
Physiological changes with epinephrine release
Increase v/s (Heart rate, pulse, resp)
Increases blood sugar
Increases contractility
Bronchial dilation
80
Sympathetic nervous system activates
Norepinephrine
81
Physiological changes in norepinephrine
Vasoconstriction
Increase in BP
Pale skin
82
Which three structures control the response of the body to a stressor
Medulla oblongata
Reticular formation
Pituitary gland
83
Primary appraisal
Evaluating an even or circumstance for its personal meaning
84
Secondary appraisal
Stress is present, focuses on possible coping strategies
85
Factors influencing stress and coping
Situational (job changes, promotions, obesity, asthma)
Maturational (milestones)
Sociocultural (poverty, homelessness, violence)
86
Health Promotions
Exercise
Time management
Support systems
87
Types of crises
Developmental
Adventious
Maturational
88
Examples of developmental crises
Marriage
Birth of a child
Retirement
89
Examples of situational crises
Job change
MVA
Death
Severe illness
90
Examples of adventitous crises
Major natural disaster
Man made disaster
Crime of violence
91
Types of stress
Chronic (stable condition)
| Acute (time limited)
92
Post traumatic stress disorder
An acute stress disorder that begins when a person experiences, witnesses, or is confronted with a traumatic event
93
What is RAAS?
Renin - Angiotensin - Aldesterone System
94
What releases renin?
The kidneys during norepinephrine
95
What creates and releases angiotensinogen during norepinephrine?
the Liver `
96
How is angiotensin I produced?`
The renin enzyme produced in the kidneys during norepinephrine breaks angiotensinogen into angiotensin I.
97
How is angiotensin II produced?
Angiotensin I is further metabolised by the action of angiotensin-converting enzyme to produce angiotensin II
98
Physiological changes with Angiotensin II
Vasoconstriction -> Inc. BP
Effects on Adrenal Glands by stimulating aldosterone production resulting in retaining Na+.
In turn affecting the Kidneys Inc. retention of Na+ which Inc. water re-absorption.
99
What is ACE inhibitors?
Its a pharmaceutical drug that relaxes blood vessels. It prevents production of of Angiotensin II.
100
What happens during stress to posterior pituitary?
Releases hormones that are synthesized in the hypothalamus. Such as
oxytocin: uterine contraction and lacting milk
ADH (anti-diuretic hormone) aka Vasopressin: inhibits urine production which Inc. water in our body
101
What happens when aldosterone is released?
Na retention and inc in water
102
What produces glucocorticoids?
Adrenal Cortex
103
What happens when glucocorticoids is produced?
Protein catabolism
Gluconeogenesis (how can you obtain glucose? Out of proteins not carbohydrates)
Altered immune response
104
What is compensation? Can it be negative or positive?
P. Refusing to acknowledge the presence of something disturbing.
105
What is Denial? Can it be positive or negative?
D. Overcoming a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area.
106
What is displacement? Can it be positive or negative?
Transfers an emotional reaction from one object to another.
107
What is introjection? Negative or positive?
N. Incorporating qualities or values of another into one’s own.
108
What is projection? Negative or positive?
Thoughts or impulses are attributed to another, allowing intolerable feeling or motivation to be attributed to someone else.
109
What is rationalization? Negative or positive?
Giving questionable behavior a logical or socially acceptable explanation.
110
What is reaction formation? Negative or positive?
Negative. Developing conscious attitudes and behaviors that are opposite to what one really feels or would like to do.
111
What is regression? Negative or positive?
Negative. Returning to an earlier method of behaving.
112
What is repression? Negative or positive?
Involuntarily excluding and anxiety-producing event from conscious awareness.
113
What is sublimation? Negative or positive?
P. Substituting a socially acceptable activities for strong impulses that are not acceptable in their original form.
114
What is undoing? Negative or positive?
An act or communication that is used to negate a previous act or communication.
115
PTSD is chronic or acute?
Both
116
A client expresses to the nurse that she constantly feels irritated and loses her temper. During the course of the interview, the nurse finds that the client takes care of her mother who was confined to bed following a stroke. The client struggles to balance caring for her family and her mother. Which nrusing diagnosis would the nurse most likely identify for this client?
a) Compromised family adjustment
b) Caregiver role strain
c) Ineffective coping
d) Anxiety
b) Caregiver role strain
Explanation: The most appropriate nursing diagnosis is caregiver role strain because the client feels tired and fatigued by struggling to care for her mother and fulfilling family needs. Ineffective coping, compromised family adjustment, and anxiety would be inappropriate nursing diagnoses based on the information provided.
117
A middle-aged woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are
a) Stressors
b) Demands
c) Illnesses
d) Stimuli
Stressors
Explanation: Stress is defined as any event or set of events, a stressor, that causes a response. Everyday triggers associated with work or social relationships, and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors.
118
An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of
a) Valuation
b) Adaptation
c) Evaluation
d) Reaction
Adaptation
Explanation: Adaptation is generally considered a person's capacity to flourish and survive, even with diversity.
119
You are the nurse caring for a 72-year-old female who is recovering from abdominal surgery on the Medical Surgical unit. The surgery was very stressful and prolonged and you note on the chart that her blood sugars are elevated yet she in not been diagnosed with diabetes. To what do you attribute this elevation in blood sugars?
a) It is a result of antidiuretic hormone.
b) She must have had diabetes prior to surgery.
c) She has become a diabetic from the abdominal surgery.
d) The blood sugars are probably a result of the;fight-or-flight" reaction.
The blood sugars are probably a result of the "fight-or-flight" reaction.
Explanation: During stressful situations, ACTH stimulates the release of cortisol from the adrenal gland, which creates protein catabolism releasing amino acids and stimulating the liver to convert amino acids to glucose, the result is elevated blood sugars. Option A is incorrect, antidiuretic hormone is released during stressful situations and stimulates reabsorption of water in the distal and collecting tubules of the kidney. Option B is incorrect; assuming the patient had diabetes prior to surgery demonstrates a lack of understanding of stress induced hyperglycemia. Option C is incorrect, there is no evidence presented in the question other than are elevated blood sugars that would support a diagnosis of diabetes.
120
A nurse is assessing an obese teenager who is unhappy and stressed out because she has not lost weight despite working out at the gym. The physician asks the nurse to try the modeling intervention for stress management for the client. Which of the following actions should the nurse perform when adhering to the modeling intervention?
a) Ask the client to undergo liposuction surgery.
b) Ask the client to change her exercise regimen.
c) Ask the client to cut down on her food intake.
d) Introduce the client to someone with a positive attitude.
Introduce the client to someone with a positive attitude.
Explanation: The nurse should introduce the client to a person who demonstrates a positive attitude or behavior as this promotes the ability to learn an adaptive response. The nurse should not ask the client to change her exercise regime, cut down on her food intake, or undergo liposuction surgery as that could lead to further medical complications.
121
Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome?
a) Increased mental alertness
b) Vasoconstriction
c) The initiation of neuroendocrine activity
d) Decreased blood pressure
Decreased blood pressure
Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS.
122
You walk into your patients' room and find her sobbing uncontrollably. When you ask what the problem is your patient responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a nursing diagnosis of "Ineffective coping related to stress". What is the best outcome you can expect for this patient?
a) Patient will avoid stressful situations.
b) Patient will start anti-anxiety agent.
c) Patient will adapt relaxation techniques to reduce stress.
d) Patient will be stress free.
Patient will adapt relaxation techniques to reduce stress.
Explanation: Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the patient needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. The other options are incorrect because it is unrealistic to expect a patient to be stress free; avoiding stressful situations and starting an anti-anxiety agent are not the best answers as outcomes for ineffective coping.
123
The nurse would recognize that short-term pharmacological treatment may be appropriate if an anxious patient's nursing diagnoses includes which of the following?
a) Social isolation
b) Decisional conflict
c) Disturbed sleep pattern
d) Defensive coping
Disturbed sleep pattern
Explanation: The nurse should recognize that diagnoses relating to conflict, coping, and decisional conflict are less amenable to pharmacologic treatment. Disturbances in sleep patterns, however, are often addressed by the appropriate use of hypnotic medications.
124
When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?
a) Avoid doing petty jobs.
b) Take control of the situation.
c) Change jobs.
d) Avoid people who dump tasks on him.
Take control of the situation.
Explanation: A behavioral technique for modifying stress is to take control rather than become immobilized. This is also known as alternative behavior. Another behavioral approach to reduce stress is to sometimes say "no," in order to avoid becoming overwhelmed and more stressed. Changing jobs or avoiding the person or the petty jobs would not help.
125
The children of a 60-year-old woman are distraught at her apparent lack of recovery following a stroke several weeks earlier. The patient's daughter has frequently directed harsh criticism toward the nurses, accusing them of a substandard effort in rehabilitating her mother despite their best efforts. What defense mechanism may the patient's daughter be exhibiting?
a) Sublimation
b) Regression
c) Displacement
d) Denial
Displacement
Explanation: The daughter may be transferring her feelings about her mother's health status to the care providers, an act that involves the displacement of the emotional reaction to another person. Denial about her mother's potential for recovery may underlie her response, but this is not demonstrated as clearly as displacement.
126
The nurse is interviewing a client with complaints of chronic fatigue. The nurse understands that the client has a sedentary lifestyle and suggests that the client start low-intensity exercise. Which of the following exercises would be appropriate for the nurse to suggest the client engage in initially?
a) Brisk walking
b) Running
c) Cycling
d) Gardening
Gardening
Explanation: The nurse should suggest that the client start with gardening, which is a low-intensity exercise and is particularly good preparation for sedentary persons before they progress to more vigorous aerobic exercise. Running, cycling, and brisk walking are vigorous aerobic exercises.
127
The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?
a) Secondary stage
b) Exhaustion stage
c) Alarm stage
d) Resistance stage
Exhaustion stage
Explanation: The client is in the exhaustion stage when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.
128
A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?
a) Stress-reduction strategy
b) Therapeutic coping strategy
c) Antidepressant strategy
d) Non-therapeutic coping strategy
Non-therapeutic coping strategy
Explanation: The client has used non-therapeutic coping strategies such as mind- and mood-altering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy.
129
A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which of the following stress-reduction techniques should the nurse use with this client?
a) Discourage family from interacting with the client.
b) Advocate on behalf of the client to others.
c) Avoid referring the client to other organizations.
d) Avoid discussing the client's condition with client's family.
Advocate on behalf of the client to others.
Explanation: The nurse should advocate on behalf of the client to others. If need be, the nurse should refer the client and his family to organizations or people who provide post-discharge assistance. The nurse should keep the client and the client's family informed about the client's condition and encourage the family members to interact with the client.
130
A nurse is trying to assess a client's stress type; however, the client is very depressed and quiet and does not reply to the nurse's questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client?
a) The nurse should demonstrate confidence and expertise.
b) The nurse should take help from the senior physician.
c) The nurse should not assess the client's stress type.
d) The nurse should calm him first by giving him a sedative.
The nurse should demonstrate confidence and expertise.
Explanation: Some general interventions appropriate during the care of the client who is suffering from stress include remaining calm during the discussions with the client, being available to the client, responding promptly to the client's signal for assistance, and encouraging family interaction. However, taking the help of a senior physician or giving the client a sedative would not help in assessing the client. The nurse has to assess the client's type of stress.
131
Upon arrival to the emergency room, the mother of a patient involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing?
a) Severe anxiety
b) A panic attack
c) Mild anxiety
d) Moderate anxiety
A panic attack
Explanation: Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living, and it increases alertness and perceptual fields.
132
As an occupational health nurse at an oil refinery on the Gulf coast of Texas you are doing patient education with a man in his mid-forties. The patient is being seen after having been exposed to a chemical spill at the refinery. What type of stressor has this patient been exposed to?
a) Psychiatric
b) Psychosocial
c) Physiologic
d) Physical
Physical
Explanation: Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. These facts make the other options incorrect.
133
A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an)
a) Adjustment
b) Concern
c) Threat
d) Stressor
Stressor
Explanation: Stress, coping, and adaptation are interrelated. Survival depends upon successful coping responses to ordinary and sometimes extraordinary circumstances and challenges.
134
The client is a 5-year-old child hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of
a) displacement.
b) reaction formation.
c) compensation.
d) regression.
regression.
Explanation: Regression is a maladaptive behavior in which the client returns to an earlier method of behaving as seen in the child who is now bedwetting. Compensation is overcoming a perceived weakness by emphasizing a more desirable trait. Displacement is transferring an emotional reaction from one object or person to another. Reaction formation is exhibiting behaviors that are the opposite of what the client would really like to do.
135
Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse?
a) A graduate nurse working on a telemetry unit
b) A nurse with 1 year of experience working on an oncology unit
c) A nurse who is an editor of a nursing journal
d) A nurse with 10 years of experience working as a nurse educator
A graduate nurse working on a telemetry unit
Explanation: Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care.
136
1. When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response?
1. Results in neurophysiological response.
2. Reduces body temperature
3. Causes a person to be hypervigilant
4. Reduces level of consciousness to conserve energy.
1. Answer: 1.
Negative feedback senses an abnormal state such as lowered body temperature and makes an adaptive response such as shivering to generate body heat to return the body to hormonal homeostasis.
137
2. A nurse observes that a patient whose home life is chaotic with intermittent homelessness, a child with spina bifida, and an abusive spouse appears to be experiencing an allostatic load. As a result, the nurse expects to detect which of the following while assessing the patient?
1. Posttraumatic stress disorder
2. Rising hormone levels
3. Chronic illness
4. Return of vital signs to normal
2. Answer: 3.
An increased allopathic load can result in long-term physiological problems and chronic illness. Posttraumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage. Vital signs return to normal in the resistance stage.
138
3. A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, “The hemoglobin A1C is wrong. My blood sugar levels
have been excellent for the last 6 months.” The patient is using the defense mechanism:
1. Denial.
2. Conversion.
3. Dissociation.
4. Displacement.
3. Answer: 1.
Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient’s statements reflect denial about poorly controlled blood sugars.
139
4. When doing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as ____________.
4. Answer: Posttraumatic stress disorder (PTSD).
PTSD originates with a person’s experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The car accident is the traumatic event that is causing intense fear or helplessness in this patient.
140
5. A grandfather living in Japan worries about his two
young grandsons who disappeared after a tsunami. This is an example of:
1. A situational crisis.
2. A maturational crisis.
3. An adventitious crisis.
4. A developmental crisis.
5. Answer: 3.
| An adventitious crisis is a type of crisis resulting from a natural disaster such as a tsunami.
141
6. During the assessment interview of an older woman experiencing a developmental crisis, the nurse asks which of the following questions?
1. How is this flood affecting your life?
2. Since your husband has died, what have you been doing in
the evening when you feel lonely?
3. How is having diabetes affecting your life?
4. I know this must be hard for you. Let me tell you what
might help.
6. Answer: 2.
| A developmental crisis occurs as a person moves through life’s stages, including widowhood.
142
7. The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following?
1. Loss of autonomy caused by health problems
2. Physical appearance, family, friends, and school
3. Self-esteem issues, changing family structure
4. Search for identity with peer groups and separating from family
7. Answer: 4.
| Answer 1 applies to the older adult. Answer 2 applies to children. Answer 3 applies to preadolescents.
143
8. A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse’s first assessment for stress the nurse says:
1. “Tell me who I can call to help you.”
2. “Tell me what bothers you the most about this experience.”
3. “I’ll contact someone who can help get you temporary
housing.”
4. “I’ll sit with you until other family members can come help
you get settled.”
8. Answer: 2.
| The patients’ appraisal of the crisis is the most important area to address first.
144
9. When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following?
1. The amount of family support
2. A 3-day diet recall
3. A thorough physical assessment
4. Threats to safety in her home
9. Answer: 3.
| Physical causes for problems need to be discovered before treatment for psychosocial problems can be initiated.
145
10. After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse’s first response is which of the following?
1. “Don’t be sad. People live with cancer every day.”
2. “Have you thought about how you are going to tell your family?”
3. “Would you like for me to sit down with you for a few
minutes so you can talk about this?”
4. “I know another patient whose colon cancer was cured by surgery.”
10. Answer: 3.
Ask the patient if he would like you to sit down for a few minutes so he can talk. Providing an open-ended question and an opportunity for the patient to talk allows the nurse to assess the patient’s perception of the situation, which is of utmost importance.
146
11. A 34-year-old man who is anxious, tearful, and tired from caring for his three young children tells you that he feels depressed and doesn’t see how he can go on much longer. Your best response would be which of the following?
1. “Are you thinking of suicide?”
2. “You’ve been doing a good job raising your children. You
can do it!”
3. “Is there someone who can help you?”
4. “You have so much to live for.”
11. Answer: 1.
Although this sounds abrupt, the patient usually is relieved that you’ve broached this issue. For safety reasons it is very important to discuss his suicidal thoughts with the patient.
147
12. The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the patient is coping successfully when the patient says:
1. “I’m going to learn to drive a car so I can be more
independent.”
2. “My sister says she feels better when she goes shopping, so
I’ll go shopping.”
3. “I’ve always felt better when I go for a long walk. I’ll do that
when I get home.”
4. “I’m going to attend a support group to learn more about multiple sclerosis.”
12. Answer: 4.
| Support groups often benefit people experiencing stress.
148
13. A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:
1. “Let’s talk about something cheerful.”
2. “Do other members of your family have diabetes?”
3. “I can tell that you feel stressed to learn that you have
diabetes. ”
4. With silence.
13. Answer: 4.
The nurse understands that denial is a defense mechanism that assists in coping with a shock. Therapeutic use of silence gives patients time to process their thoughts.
149
14. A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. The supervising nurse recognizes that:
1. Nurses who feel stress usually pass the stress along to their patients.
2. A nurse who feels stress is ineffective as a nurse and should not be working.
3. Nurses who talk about feeling stress are unprofessional and should calm down.
4. Nurses frequently experience stress with the rapid
changes in health care technology and organizational
restructuring.
14. Answer: 4.
Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring and when the situation seems out of their personal control.
150
15. A crisis intervention nurse working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her entitlement check while the child is hospitalized can expect the mother to regain stability after how long?
1. After 2 weeks when the child’s pneumonia begins to
improve
2. After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks
3. After 1 month when the child goes home and the mother gets help from a food pantry
4. After 6 months when the child is back in school
15. Answer: 2.
| Generally a person resolves the crisis and reaches psychological equilibrium in about 6 weeks
151
Describe Freud's Stage 1
| Age?
Oral (birth to 12 to 18 mo)
Initially sucking and oral satisfaction are not only vital to life but also extremely pleasurable in their own rights.
Gratification by crying
Gradually modified to finding ways to achieve fulfillment
152
Describe Erikson's Stage 1
| Age?
Trust vs Mistrust ( Birth to 1 yr)
Develops sense of self from the development of a trust relationship with a consistent primary caregiver. Basic need are for warmth, food and comfort.
153
Describe Piaget's Stage 1
| Age?
Sensorimotor (Birth to 2 yrs)
Learning through all his/her senses and motor activities.
Future cognitive laid down.
Egocentric.
Everything is perceived in relation to self.
Object permanence.
154
Describe Kohlberg's moral stage for infancy: Birth to 1 year?
Level 1: Preconventional
Egocentric Orientation Stage
Good is what one like and wants.
Judgments made no the basis of liking that which helps and disliking that which hurts.
155
Birth weight doubles in how much time?
4 - 6 mo
156
Birth weight triples in how much time?
1 yr
157
Posterior fontanel closes by how much time?
2 - 3 mo
158
Height inc. by how much percent in 1 yr?
50%
159
Head circumference is less than or greater than chest circumference?
greater than
Head is bigger than chest up until 2 yrs of age
160
3 mo Psychosocial
Social smile
Responds to stimuli with whole body
Knows primary caregiver
161
3 mo Motor
Lifts head and chest in prone position
Follows objects with eyes
Move arms and legs simultaneously
162
3 mo Toys
Music box
Mobile
Mirror
163
6 mo Psychosocial
Apprehensive of strangers
Babbles and coos
Observes environments
164
6 mo Motor
Rolls from side to side well
Sits with assitance
transfers objects from hand to hand
165
6 mo Toys
Rattle
Soft toys
Bright colors
166
9 mo Psychosocial
Waves "bye-bye"
Mama, Dada indiscriminately
Stranger anxiety
Exhibits object permanence
167
9 mo Motor
Sits well without assistance
Uses pincer grasp
Crawls
stands with assistance
168
9 mo Toys
Rattle
Soft toys
Bright colors
>greater than fist
169
12 mo Psychosocial
Imitates behaviors
Cooperates with dressing
Mama, Dada has meaning
Shows jealousy
170
12 mo Motor
Walks with assistance
Turns pages in a book
Stands without assistance
attempts to stack blocks
171
12 mo Toys
Push and pull
cloth books
surprise toys
ball
172
Infancy: Birth to 1 year
| Issues related to hospitalization and nursing interventions
Issue: Separation
Intervention: Encourage caregiver to room in
Primary nursing
Hold for feedings
173
Infancy: Birth to 1 year
| Food intriduction
Breast milk/iron fortified formula for 1st year
grains: 4 - 6 mo
Fruits/veggies
Meat/eggs
174
Infancy: Birth to 1 yrs
| Instructions for feeding
Feed all solids with spoons
Introduce at 3 -4 day intervals
common reaction: eczema
do not dilute formula
