Practice Questions Flashcards
A client is told that the computed tomography scan she has just undergone has revealed a pancreatic mass that is most likely cancer. The client becomes upset and anxious on hearing this news and tells the nurse that she feels nauseated. Checking the client’s vital signs, the nurse notes that the client’s heart rate, respiratory rate, and blood pressure are increased compared with previous readings. The nurse plans interventions to correspond with which stage of Selye’s general adaptation syndrome that the client is experiencing?
A) Eustress
B) Alarm reaction
C) Stage of resistance
D) Stage of exhaustion
B) Alarm reaction
The nurse plans care for a client experiencing stress. Which characteristics are associated with the stage of resistance in Selye’s description of general adaptation syndrome? Select all that apply.
A) All energy for adaptation has been expended.
B) The body makes some effort to resist the stressor.
C) When resources are adequate, the person may successfully recover from a stressor.
D) Successful adaptation depends on the adequacy of the person’s internal and external resources.
E) The person in this stage may become ill and die if assistance from an outside source is not available.
B) The body makes some effort to resist the stressor.
C) When resources are adequate, the person may successfully recover from a stressor.
D) Successful adaptation depends on the adequacy of the person’s internal and external resources.
Rationale:
In the stage of resistance, physiologic reserves are mobilized to increase the resistance to stress. Few overt physical signs and symptoms occur. The individual is expending energy to adapt, and successful adaptation depends on the adequacy of the person’s internal and external resources. When resources are adequate, the person may successfully recover from a stressor; if adaptation does not occur, the person may move to the next stage, exhaustion. The stage of exhaustion occurs when all energy for adaptation has been expended. Physical symptoms of the alarm reaction stage may briefly reappear in a final effort by the body to survive. This stage of exhaustion can often be reversed with an external source of adaptive energy (e.g., medication or psychotherapy). However, the person in this stage may become ill and die if assistance from an outside source is not available.
The nurse provides information to a client about stress-management techniques. Which statement by the client indicates a need for further information?
A) “Listening to music can be really soothing.”
B) “Getting enough sleep every night will help me deal with the stress.”
C) “I should get regular exercise as part of my stress-management program.”
D) “Everyone thinks that caffeine can make the stress worse, but that’s a myth.”
D) “Everyone thinks that caffeine can make the stress worse, but that’s a myth.”
Rationale: Stress-management techniques include listening to music, having pets around, getting a massage, laughter and humor, participating in a regular exercise program, getting adequate sleep, and reducing or eliminating caffeine intake. Reducing or eliminating caffeine intake can yield more energy and help produce a relaxing feeling.
A client tells the nurse that he is experiencing a great deal of work-related stress and is taking an anxiolytic medication. He tells the nurse that he read on the Internet that St. John’s wort, an herbal product, is helpful in reducing stress and says that he would like to try taking it. Which is the best response for the nurse to give the client?
A) “It’s an herbal product made from a plant, so it’s harmless.”
B) “You’ll need to discuss the use of St. John’s wort with your health care provider before taking it.”
C) “I read the same thing, and I know that you can buy St. John’s wort at any health food store.”
D) “You should give it a try. I would suggest taking it every morning that you’re scheduled to work.”
B) “You’ll need to discuss the use of St. John’s wort with your health care provider before taking it.”
Rationale: The use herbal therapies in combination with other medications can result in significant and potentially dangerous medication interactions. The nurse should tell the client that he should discuss the use of St. John’s wort with his health care provider. Therefore the other options are incorrect.
The nurse employed in hospice care is reading the records of assigned clients. Which client does the nurse identify as being at risk for disenfranchised grief?
A) The mother of a child who was killed in an automobile accident
B) A same-sex partner of a client with acquired immunodeficiency syndrome
C) A client with terminal cancer who is receiving a great deal of support from his wife
D) A client with end-stage renal disease who relies heavily on religious beliefs for hope
B) A same-sex partner of a client with acquired immunodeficiency syndrome
Rationale: Disenfranchised grief occurs when societal norms do not define a loss as a loss within its traditional definition. Basically, the survivor is not acknowledged for the loss and as a result is not given support by others. One example of disenfranchised loss is the death of a same-sex lover. In such a situation, grief may need to be hidden for the surviving partner to avoid negative social pressure. The mother of a child killed in an automobile accident, a client with terminal cancer, and a client with end-stage renal disease who relies heavily on religious beliefs for hope are not at risk for disenfranchised grief.
The nurse is evaluating the grief process for a woman whose husband died in an automobile accident 2 months ago. Which outcomes would the nurse identify as successful? Select all that apply.
A) The client refuses to take on new responsibilities.
B) The client demonstrates lengthening periods of stability.
C) The client expresses positive expectations about the future.
D) The client reports decreased preoccupation with the loss of her husband.
E) The client’s daughter reports that her mother has not paid any bills since the death of her husband.
B) The client demonstrates lengthening periods of stability.
C) The client expresses positive expectations about the future.
D) The client reports decreased preoccupation with the loss of her husband.
Rationale:
Grieving is a normal process in which people come to terms with losses. Successful outcomes associated with the grief process include the ability to tolerate intense emotions, reduced preoccupation with the deceased (loss), demonstration of increasing periods of stability, tending to previous responsibilities, taking on new roles and responsibilities, having the energy to invest in new endeavors, the expression of positive expectations about the future, and remembering positive as well as negative aspects of the deceased loved one. Refusing to take on new responsibilities and not attending to responsibilities are unsuccessful outcomes.
Which therapeutic nursing actions should the nurse use when dealing with the husband of a client who is dying? Select all that apply.
A) Encouraging the husband to express his feelings and concerns
B) Making decisions for the husband to lessen his burden of grief
C) Determining how much the husband wishes to know about the care being provided to his wife
D) Refraining from demonstrating emotion over the client’s terminal situation in the presence of the husband
E) Telling the husband that it will be easier to accept the loss if he avoids reminiscing and talking about his life with his wife
A) Encouraging the husband to express his feelings and concerns
C) Determining how much the husband wishes to know about the care being provided to his wife
Rationale:
The nurse needs to assist the client, family, and significant others through the process of grief. The use of therapeutic communication techniques is important in promoting the process. It is important for the nurse to determine the needs of the family or significant other and how much information they wish to receive about the client’s condition and the care being provided to their loved one. The nurse should also encourage reminiscing and the expression of feelings and concerns, which will help loved ones move through the grief process. The nurse should not make decisions for the family unless they specifically request that the nurse do so. Instead, the nurse should assist with the decision-making process if asked and avoid interjecting personal views or opinions. The nurse should acknowledge his or her own feelings. It is also acceptable for the nurse to express his or her own emotions with the family as appropriate.
The nurse is providing physical care to a client who has recently been told that he has inoperable lung cancer with a poor prognosis. The client says to the nurse, “I am so scared of dying. You hear so many stories about death. If only someone could tell me what it is really like.” Which response should the nurse give the client?
A) “What stories have you heard?”
B) “You’re scared of dying. Let’s talk about what makes you scared.”
C) “I’ve heard a lot of stories, too. I wish I could give you an answer to this one.”
D) “People who have died and been resuscitated say it’s a beautiful experience.”
B) “You’re scared of dying. Let’s talk about what makes you scared.”
Rationale: The nurse should use the therapeutic communication technique of paraphrasing and a response that is open-ended, which is also therapeutic. The nurse should restate the client’s message and provide the client an opportunity to express his feelings, concerns, and fears. The responses in the incorrect options do not focus on the client’s concern.
The home care nurse making a visit to a client who is receiving hospice care understands that hospice care is intended to achieve certain outcomes. What are these outcomes? Select all that apply.
A) Relief of symptoms
B) Postponement of death
C) Hastening of disease remission
D) Facilitation of a peaceful death
E) Provision of the best possible quality of life
A) Relief of symptoms
D) Facilitation of a peaceful death
E) Provision of the best possible quality of life
Rationale:
In hospice care, an interdisciplinary approach is used to assess and address the holistic needs of clients and families to ensure the best possible quality of life and a peaceful death. The holistic approach neither hastens nor postpones death, nor does it hasten remission of the disease; instead, it provides relief of symptoms.
