L2-10-E5 Flashcards
The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient’s discharge planning?
a. The mechanisms of the inflammatory response
b. Basic infection control techniques
c. The importance of wearing a face mask in public
d. Limiting contact with the general population
b. Basic infection control techniques
The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition?
a. Primary immunodeficiency
b. Secondary immunodeficiency
c. Cancer
d. Autoimmunity
a. Primary immunodeficiency
Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.
The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition?
a. His immune system is functioning properly.
b. He is properly vaccinated.
c. He has an infection.
d. The suppressor T-cells in his body are activated.
a. His immune system is functioning properly.
Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement?
a. “My body will treat the new kidney like my original kidney.”
b. “I will have to make sure that I avoid being around people.”
c. “The medications that I take will help prevent my body from attacking my new kidney.”
d. “My body will only have a problem with my new kidney if the donor is not directly related to me.”
c. “The medications that I take will help prevent my body from attacking my new kidney.”
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition?
a. Suppressed immune response
b. Hyperimmune response
c. Allergic reaction
d. Anaphylactic reaction
d. Anaphylactic reaction
The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?
a. Eradicate the disease
b. Enhance immune response
c. Control inflammation
d. Manage pain
c. Control inflammation
Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.
The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)
a. Are only required for infants
b. Are part of primary prevention for system disorders
c. Prevent the child from getting childhood diseases
d. Help protect individuals and communities
e. Are risk free
f. Are recommended by the Centers for Disease Control and Prevention (CDC)
b. Are part of primary prevention for system disorders
d. Help protect individuals and communities
f. Are recommended by the Centers for Disease Control and Prevention (CDC)
Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.
What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?
a. Plasmapheresis eliminates eosinophils and basophils from blood.
b. Plasmapheresis decreases the damage to organs from T lymphocytes.
c. Plasmapheresis removes antibody-antigen complexes from circulation.
d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.
c. Plasmapheresis removes antibody-antigen complexes from circulation.
Plasmapheresis is used in SLE to remove antibodies, antibody–antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.
The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation?
a. Shortness of breath
b. High blood pressure
c. Transfusion reaction
d. Extremity numbness
d. Extremity numbness
Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.
Which patient should the nurse assess first?
a. Patient with urticaria after receiving an IV antibiotic
b. Patient who is sneezing after subcutaneous immunotherapy
c. Patient who has graft-versus-host disease and severe diarrhea
d. Patient with multiple chemical sensitivities who has muscle stiffness
b. Patient who is sneezing after subcutaneous immunotherapy
Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash?
a. The donor T cells are attacking the patient’s skin cells.
b. The patient needs treatment to prevent hyperacute rejection.
c. The patient’s antibodies are rejecting the donor bone marrow.
d. The patient is experiencing a delayed hypersensitivity reaction.
a. The donor T cells are attacking the patient’s skin cells.
The patient’s history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient’s tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.
A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
a. Take this medication on an empty stomach.
b. Take this medication with a full glass of water.
c. You may have vivid and bizarre dreams as a side effect.
d. Continue to use contraception while taking this medication.
d. Continue to use contraception while taking this medication.
To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
a. CD4+ cell count trajectory
b. HIV genotype and phenotype
c. Patient’s tolerance for potential medication side effects
d. Patient’s ability to follow a complex medication regimen
d. Patient’s ability to follow a complex medication regimen
Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?
a. Patient who is currently HIV negative but has unprotected sex with multiple partners
b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/μL
c. HIV-positive patient with a CD4+ count of 160/μL who drinks a fifth of whiskey daily
d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?
a. Instruct the patient to apply ice to the neck.
b. Explain to the patient that this is an expected finding.
c. Request that an antibiotic be prescribed for the patient.
d. Advise the patient that this indicates influenza infection.
b. Explain to the patient that this is an expected finding.
Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy
Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?
a. Age
b. Lifestyle
c. Symptoms
d. Sexual orientation
a. Age
The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?
a. “Clean drug injection equipment before each use.”
b. “Ask those who share equipment to be tested for HIV.”
c. “Consider participating in a needle-exchange program.”
d. “Avoid sexual intercourse when using injectable drugs.”
c. “Consider participating in a needle-exchange program.”
Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
a. Give the patient detailed information about possible medication side effects.
b. Remind the patient of the importance of taking the medications as scheduled.
c. Encourage the patient to join a support group for students who are HIV positive.
d. Check the patient’s class schedule to help decide when the drugs should be taken.
d. Check the patient’s class schedule to help decide when the drugs should be taken.
The best approach to improve adherence is to learn about important activities in the patient’s life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient’s schedule.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?
a. The patient will be free from injury.
b. The patient will receive immunizations.
c. The patient will have adequate oxygenation.
d. The patient will maintain intact perineal skin.
d. The patient will maintain intact perineal skin.
The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?
a. Review foods that are higher in protein.
b. Teach about the benefits of daily exercise.
c. Discuss a change in antiretroviral therapy.
d. Talk about treatment with antifungal agents.
c. Discuss a change in antiretroviral therapy.
A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?
a. Nystatin tablet
b. Oral acyclovir (Zovirax)
c. Oral saquinavir (Invirase)
d. Aerosolized pentamidine (NebuPent)
c. Oral saquinavir (Invirase)
It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
a. Viral loading test
b. Enzyme immunoassay
c. Rapid HIV antibody testing
d. Immunofluorescence assay
a. Viral loading test
The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.
The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
a. The patient complains of feeling “constantly tired.”
b. The patient can’t explain the effects of indinavir (Crixivan).
c. The patient reports missing some doses of zidovudine (AZT).
d. The patient reports having no side effects from the medications.
c. The patient reports missing some doses of zidovudine (AZT).
Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time?
a. Encourage adequate nutrition, exercise, and sleep.
b. Teach about the side effects of antiretroviral agents.
c. Explain opportunistic infections and antibiotic prophylaxis.
d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).
a. Encourage adequate nutrition, exercise, and sleep.
The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.
Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
a. Patient whose rapid HIV-antibody test is positive
b. Patient whose latest CD4+ count has dropped to 250/μL
c. Patient who has had 10 liquid stools in the last 24 hours
d. Patient who has nausea from prescribed antiretroviral drugs
c. Patient who has had 10 liquid stools in the last 24 hours
The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.
An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?
a. Many drugs interact with antiretroviral medications.
b. HIV infections progress more rapidly in older adults.
c. Less frequent CD4+ level monitoring is needed in older adults.
d. Hospice care is available for patients with terminal HIV infection.
a. Many drugs interact with antiretroviral medications.
The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
a. Teach the patient how to dispose of tissues with respiratory secretions.
b. Stock the patient’s room with the necessary personal protective equipment.
c. Interview the patient to obtain the names of family members and close contacts.
d. Tell the patient’s family members the reason for the use of airborne precautions.
b. Stock the patient’s room with the necessary personal protective equipment.
A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
a. Methods to prevent perinatal HIV transmission
b. Ways to sterilize needles used by injectable drug users
c. Prevention of HIV transmission between sexual partners
d. Means to prevent transmission through blood transfusions
c. Prevention of HIV transmission between sexual partners
Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.
The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
d. Trimethoprim-sulfamethoxazole
e. Varicella zoster immune globulin
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.
A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor
a. blood glucose.
b. blood pressure.
c. erythrocyte count.
d. lymphocyte count.
b. blood pressure.
Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.
Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse’s teaching about the condition?
a. “I will exercise even if I am tired.”
b. “I will use sunscreen when I am outside.”
c. “I should avoid nonsteroidal antiinflammatory drugs.”
d. “I should take birth control pills to avoid getting pregnant.”
b. “I will use sunscreen when I am outside.”
Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.
A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I never leave my house because I hate the way I look.” The nurse will plan interventions with the patient to address the nursing diagnosis of
a. social isolation.
b. activity intolerance.
c. impaired skin integrity.
d. impaired social interaction.
a. social isolation.
The patient’s statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.
A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review?
a. Rheumatoid factor (RF)
b. Antinuclear antibody (ANA)
c. Anti-Smith antibody (Anti-Sm)
d. Lupus erythematosus (LE) cell prep
c. Anti-Smith antibody (Anti-Sm)
The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.
The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?
a. Draw anti-DNA blood titer.
b. Administer varicella vaccine.
c. Naproxen (Aleve) 200 mg BID.
d. Famotidine (Pepcid) 20 mg daily.
b. Administer varicella vaccine.
Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.
Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider?
a. Decreased C-reactive protein (CRP)
b. Elevated blood urea nitrogen (BUN)
c. Positive antinuclear antibodies (ANA)
d. Positive lupus erythematosus cell prep
b. Elevated blood urea nitrogen (BUN)
Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.
A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the
a. acute pain.
b. risk for aspiration.
c. disturbed visual perception.
d. risk for impaired skin integrity.
b. risk for aspiration.
The patient’s vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient’s airway.
A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider?
a. The patient has painful hematuria.
b. Acne is noted on the patient’s face.
c. Fasting blood glucose is 112 mg/dL.
d. The patient has an increased appetite.
a. The patient has painful hematuria.
Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.
After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management?
a. “I will need to stop drinking so much coffee and soda.”
b. “I am going to join a soccer team to get more exercise.”
c. “I will call the doctor every time my symptoms get worse.”
d. “I should avoid using over-the-counter medications for pain.”
a. “I will need to stop drinking so much coffee and soda.”
ANS: A
Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.
Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management?
a. Symptoms usually progress as patients become older.
b. A gradual increase in daily exercise may help decrease fatigue.
c. Avoid use of over-the-counter antihistamines or decongestants.
d. A low-residue, low-fiber diet will reduce any abdominal distention.
b. A gradual increase in daily exercise may help decrease fatigue.
A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
a. Sleep disturbances
b. Multiple tender points
c. Cardiac palpitations and dizziness
d. Multijoint inflammation and swelling
e. Widespread bilateral, burning musculoskeletal pain
a. Sleep disturbances
b. Multiple tender points
e. Widespread bilateral, burning musculoskeletal pain
These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.
An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient’s chief complaint?
a. The patient is responsible for caring for two school-age grandchildren.
b. The patient’s daughter works to support the family.
c. The patient is being treated for hypertension and is overweight.
d. The patient has recently lost her spouse and needed to move in with her daughter.
d. The patient has recently lost her spouse and needed to move in with her daughter.
The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient’s sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient’s daughter may have added stress due to working, but this should not directly affect the patient.
A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take?
a. Ask the health care provider for a psychiatric referral.
b. Administer the PRN sedative medication every 4 hours.
c. Suggest the use of a home caregiver to the patient’s family.
d. Plan to reinforce and repeat teaching about diabetes management.
d. Plan to reinforce and repeat teaching about diabetes management.
Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient’s ability to learn the necessary information for self-management.
A diabetic patient who is hospitalized tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate?
a. “It is probably just coincidental that your blood sugar is high when you are ill.”
b. “Stressors such as illness cause the release of hormones that increase blood sugar.”
c. “Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.”
d. “Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level.”
b. “Stressors such as illness cause the release of hormones that increase blood sugar.”
The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.
A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient’s vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first?
a. Go to sleep 30 to 60 minutes earlier each night to increase rest.
b. Relax by spending more time playing with his pet dog.
c. Slow and deepen breathing via use of a positive, repeated word.
d. Consider that a new job might be better than his present one.
c. Slow and deepen breathing via use of a positive, repeated word.
The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson’s relaxation response) will counter the sympathetic nervous system’s arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.
The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function?
a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.
b. Alter the internal state by modifying electronic signals related to physiologic processes.
c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities.
d. Reduce catecholamine production and promote the production of additional beta-endorphins.
a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.
When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery’s effectiveness.
A patient tells the nurse, “I’m told that I should reduce the stress in my life, but I have no idea where to start.” Which would be the best initial nursing response?
a. “Why not start by learning to meditate? That technique will cover everything.”
b. “In cases like yours, physical exercise works to elevate mood and reduce anxiety.”
c. “Reading about stress and how to manage it might be a good place to start.”
d. “Let’s talk about what is going on in your life and then look at possible options.”
d. “Let’s talk about what is going on in your life and then look at possible options.”
In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.
A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor’s recommendations?
a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts
b. Encouraging the patient to imagine being in calming circumstances
c. Teaching the patient to use instruments that give feedback about bodily functions
d. Provide the patient with a blank journal and guidance about journaling
a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts
Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient’s manner of thinking.
A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress?
a. The patient’s wife reports that he spends more time sitting quietly at home.
b. He reports that his appetite, mood, and energy levels are all good.
c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
d. He reports that he feels better and that things are not bothering him as much.
c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
Objective measures tend to be the most reliable means of gauging progress. In this case, the patient’s elevated blood pressure, an indication of the body’s physiologic response to stress, has diminished. The wife’s observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient’s report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.
Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.)
a. Assess for bradycardia.
b. Ask about epigastric pain.
c. Observe for increased appetite.
d. Check for elevated blood glucose levels.
e. Monitor for a decrease in respiratory rate.
b. Ask about epigastric pain.
c. Observe for increased appetite.
d. Check for elevated blood glucose levels.
The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.
The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.)
a. Notify the provider to evaluate for antidepressant therapy.
b. Suggest that the patient consider a support group for widows.
c. Suggest that the patient learn stress reduction breathing exercises.
d. Suggest that the patient take prescribed anti-anxiety medications.
e. Assist the patient in identifying support systems.
f. Notify the provider to evaluate the need for anti-anxiety medications.
b. Suggest that the patient consider a support group for widows.
c. Suggest that the patient learn stress reduction breathing exercises.
e. Assist the patient in identifying support systems.
Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.
The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as which of the following?
a. Identifying the cause of fear
b. Accessing a community support group
c. Identifying relaxation methods
d. Reviewing an educational pamphlet
a. Identifying the cause of fear
Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance
coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.
The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy?
a. Scheduling a regular exercise program
b. Attending a seminar on treatment options
c. Identifying a confidant to share feelings
d. Attending a support group for families
c. Identifying a confidant to share feelings
Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.
The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population?
a. Altered vital sign readings
b. Inaccurate perceptions of stressors
c. Increased risk for suicide
d. Decreased access to alcoholic beverages
c. Increased risk for suicide
Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.
A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?
a. Ask if there is another family member who can help at home while the patient is in the hospital.
b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover.
c. Coordinate an ambulance transfer of the family member to an alternate family member’s home.
d. Ask social services to assess what the patient’s needs will be after discharge to home.
a. Ask if there is another family member who can help at home while the patient is in the hospital.
The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person’s needs, availability to provide the care by another, and distance of the transfer. Assessing the patient’s needs after discharge does not address the immediate need to provide care for the disabled family person.
After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff?
a. Ask administration to require staff to meditate daily for at least 30 minutes.
b. Have a staff psychologist available on the unit once a week for required counseling.
c. Have training sessions to help the staff understand their new responsibilities.
d. Ask support staff from other disciplines to complete some nursing tasks to provide help.
c. Have training sessions to help the staff understand their new responsibilities.
Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.
The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool?
a. “This tool will let us compare your stress to other patients in the hospital.”
b. “This tool is short because it only measures the negative stressors you are experiencing.”
c. “You will need to ask your parents about stressors you had as a child to complete this tool.”
d. “This tool will help assess recent positive and negative events you are experiencing.”
d. “This tool will help assess recent positive and negative events you are experiencing.”
Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.
The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.)
a. Current stressors as perceived by the patient
b. Use of drugs or alcohol
c. Recent weight changes
d. Age and height
e. Temperature
a. Current stressors as perceived by the patient
b. Use of drugs or alcohol
c. Recent weight changes
Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age, height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be affected.
An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate?
a. Start an IV line to administer antihypertensive medications.
b. Recheck the blood pressure after the patient has been assessed.
c. Discuss the need for hospital admission to control blood pressure.
d. Teach the patient about the stroke risk associated with uncontrolled hypertension.
b. Recheck the blood pressure after the patient has been assessed.
When a patient experiences an acute stressor, the BP increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient’s usual blood pressure. Elevated BP that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.
A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take?
a. Ask the health care provider for a psychiatric referral.
b. Focus teaching on preventing postoperative complications.
c. Try to calm the patient before repeating any information about the surgery.
d. Encourage the patient to combine the hysterectomy with surgery for bladder repair.
c. Try to calm the patient before repeating any information about the surgery.
Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.
An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care?
a. Anxiety
b. Defensive coping
c. Ineffective denial
d. Risk prone health behavior
a. Anxiety
The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.
A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure?
a. Yoga stretching
b. Guided imagery
c. Relaxation breathing
d. Mindfulness meditation
c. Relaxation breathing
Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn.
A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially?
a. “Regular exercise may get your mind off the pain.”
b. “Guided imagery can be helpful in regaining control.”
c. “Tell me more about how your life has been recently.”
d. “Your previous coping resources can be helpful to you now.”
c. “Tell me more about how your life has been recently.”
The nurse’s initial strategy should be further assessment of the stressors in the patient’s life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this.
A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take?
a. Use music composed by Mozart.
b. Play music that does not have words.
c. Ask the patient about music preferences.
d. Select music that has 60 to 80 beats/minute.
c. Ask the patient about music preferences.
Although music with 60 to 80 beats/min, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.
The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be appropriate?
a. “Think of a place where you feel peaceful and comfortable.”
b. “Place the stress in your life into an image that you can destroy.”
c. “Repeatedly visualize yourself experiencing the distress in your workplace.”
d. “Bring what you hear and sense in your work environment into your image.”
a. “Think of a place where you feel peaceful and comfortable.”
Imagery is the use of one’s mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery that is not intended for relaxation purposes can target a disease, problem, or stressor.
An obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will best assist the patient to cope with this situation?
a. Have the patient practice frequent relaxation breathing.
b. Ask the patient what outdoor activities she misses the most.
c. Teach the patient to use imagery for reducing pain and stress.
d. Encourage the patient to consider weight loss to improve symptoms.
d. Encourage the patient to consider weight loss to improve symptoms.
For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.
A hospitalized patient with diabetes tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating.” Which response by the nurse is accurate?
a. “The liver is not able to metabolize glucose as well during stressful times.”
b. “Your diet at the hospital is the most likely cause of the increased glucose.”
c. “The stress of illness causes release of hormones that increase blood glucose.”
d. “It is probably coincidental that your blood glucose is higher when you are ill.”
c. “The stress of illness causes release of hormones that increase blood glucose.”
The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A patient with diabetes who is hospitalized will be on an appropriate diet to help control blood glucose.
A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed?
a. The patient states that he takes his prescribed antihypertensive medications daily.
b. The patient states that both of his parents have high blood pressure and diabetes.
c. The patient indicates that he does blood glucose monitoring several times each day.
d. The patient reports that he and his wife are disputing custody of their 8-yr-old son.
d. The patient reports that he and his wife are disputing custody of their 8-yr-old son.
The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels.
A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mildly depressed and anxious. Which additional information about the patient is most important to communicate to the health care provider?
a. The patient takes vitamin supplements and St. John’s wort.
b. The patient recently experienced the death of a close friend.
c. The patient’s blood pressure has increased to 152/88 mm Hg.
d. The patient expresses anxiety about whether the drugs are effective.
a. The patient takes vitamin supplements and St. John’s wort.
St. John’s wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient’s health.
A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)?
a. Assess for bradycardia.
b. Observe for decreased appetite.
c. Ask about epigastric discomfort.
d. Monitor for decreased respiratory rate.
e. Check for elevated blood glucose levels.
b. Observe for decreased appetite.
c. Ask about epigastric discomfort.
e. Check for elevated blood glucose levels.
The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.
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
c. Maturational and situational factors
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.
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
b. Post-traumatic stress disorder
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.
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
c. Tertiary
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.
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
d. Using sensory peaceful words
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.
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.”
b. “Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.”
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 pre-crisis level of functioning; family therapy will focus on helping families communicate better.
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
b. Self-esteem issues
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.
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.
d. Reassess patient’s stress-related symptoms and compare with expected outcomes.
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.
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.
c. Obtain history of any recent life stressors.
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.
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.”
b. “Give the freshman student this list of university and community resources.”
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.
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.
b. Strengthen friendships outside the workplace.
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.
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.
d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.
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 non-therapeutic, it may cause communication problems.
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?”
a. “Are you reliving your trauma?”
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.
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
a. Denial
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.
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?
- Resistance
- Exhaustion
- Alarm
a. 3, 1, 2
b. 3, 2, 1
c. 1, 3, 2
d. 1, 2, 3
a. 3, 1, 2
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.
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.
c. Ask about the patient’s priority needs.
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.
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
c. Neuman Systems Model
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.
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
d. Epinephrine and norepinephrine
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.
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.
c. This protects against feelings of worthlessness and anxiety.
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.
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
c. Prolonged poverty
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.
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
a. Time-management skills
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.
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
a. Cancer
b. Diabetes
c. Infections
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.
A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?
a. Normal in the older adult
b. A need for the patient to be evaluated for cognitive impairment
c. A side effect of anti-hypertensive medication
d. Pathologic impairment of sensory responses
d. Pathologic impairment of sensory responses
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.
The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?
a. “This will help us to identify your baby’s risk for ear infections the first year of life.”
b. “Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.”
c. “Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child.”
d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.”
d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.”
Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.
An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response?
a. “Your wife should increase the spices in your food, as the pneumonia changes your sense of smell.”
b. “Notify your doctor immediately, because this is a concerning reaction to the medication.”
c. “You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.”
d. “You should see an improvement in the next week or so. Call if this continues.”
d. “You should see an improvement in the next week or so. Call if this continues.”
Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.
An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following?
a. “I will make sure that Dad always wears warm socks.”
b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.”
c. “I will ask the home health aide to carefully inspect Dad’s feet every day when she helps him bathe.”
d. “We will give him only warm foods, so that he doesn’t burn his mouth.”
c. “I will ask the home health aide to carefully inspect Dad’s feet every day when she helps him bathe.”
Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one’s own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.
The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase?
a. Place the television to the left or right of patient’s visual field.
b. Encourage the patient to learn braille.
c. Suggest use of talking books.
d. Provide headphones for listening to music.
c. Suggest use of talking books.
Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.
The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?
a. Notify the physician.
b. Document the finding in the records.
c. Recheck the reflex after several hours.
d. Monitor the eye movements and pupil reactions closely.
a. Notify the physician.
The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.
The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?
a. “I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.”
b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.”
c. “Making my child wear ear plugs when she goes to a rock concert may save her hearing!”
d. “I see now why when my child has a cold, he complains about everything tasting blah!”
b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.”
Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.
During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure?
a. Tympanoplasty
b. Irrigation of the ear
c. Pure tone test
d. Otoscopic exam by a specialist
b. Irrigation of the ear
The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.
A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, “Ow, that was sharp!” How will the nurse interpret the finding when the child said that it was sharp?
a. The child’s sensation is intact.
b. The child’s reception is intact.
c. The child’s perception is intact.
d. The child’s reaction is intact.
c. The child’s perception is intact.
When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person’s experiences. Sensation is a general term that refers to awareness of sensory stimuli through the body’s sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. Reaction is how a person responds to a perceived stimulus.
A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure?
- Eardrum
- Perilymph
- Oval window
- Bony ossicles
- Eighth cranial nerve
a. 1, 5, 2, 4, 3
b. 1, 3, 4, 2, 5
c. 1, 2, 4, 5, 3
d. 1, 4, 3, 2, 5
d. 1, 4, 3, 2, 5
Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval window transmit in perilymph within the inner ear to stimulate hair cells that send impulses along the eighth cranial nerve to the brain.
A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
a. The patient frequently cleans out eyes with saline washes.
b. The patient applies different spices during mealtime to food.
c. The patient turns one ear toward the nurse during conversation.
d. The patient isolates self from social situations with groups of people.
c. The patient turns one ear toward the nurse during conversation.
Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive.
The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
a. Xerostomia
b. Dysequilibrium
c. Diabetic retinopathy
d. Peripheral neuropathy
a. Xerostomia
Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. Peripheral neuropathy includes numbness and tingling of the affected areas and stumbling gait.
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
a. Impaired night vision
b. Difficulty hearing low pitch
c. Heightened sense of smell
d. Increased taste discrimination
a. Impaired night vision
Night vision becomes impaired as physiological changes in the aging eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.
A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse “Should Istop driving?” Which response by the nurse is most therapeutic?
a. “Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk.”
b. “Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can’t avoid an accident.”
c. “No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.”
d. “No, instead you should see your ophthalmologist and get some glasses to help you see better.”
c. “No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.”
Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient’s accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.
A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient’s plan of care?
a. Teach the patient about special assistive devices.
b. Make the patient talk as much as possible.
c. Obtain an order for antidepressant medications.
d. Place a consult for a home health nurse.
a. Teach the patient about special assistive devices.
Because a stroke often causes partial or complete paralysis of one side of a patient’s body, the patient needs special assistive devices. The nurse should include interventions that help the patient adapt to this deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for him- or herself. Making the patient talk can be inappropriate and demeaning. A home health nurse is not necessary as long as the patient is able to care for him- or herself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.
A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
a. Risk for falls
b. Self-care deficit
c. Social isolation
d. Impaired physical mobility
c. Social isolation
In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall risk are physiological risks for the patient.
