Chapter 5

Which of the following would a nurse least likely assess in a client experiencing anxiety? a. Muscle tension b. Sleeping difficulties c. Irritability d. Positive self-talk

Positive self-talk

The patient wants to be prescribed an anti-infective drug for the flu. The nurse understands that anti-infective medications would not be useful against which biologic agents? a. Fungi b. Viruses c. Mycoplasmas d. Bacteria

Viruses

The nurse is instructing a community education class on stress. The nurse asks the participants, "Is all stress bad for you?" Which answer by the participants indicates that teaching has been effective? a. "No, the right amount of stress can be motivating to accomplish goals." b. "No, not all stress is bad, but all stress can make a person sick." c. "Yes, all stress is bad but in varying degrees depending on the nature." d. "Yes, all stress has negative effects on the body systems."

"No, the right amount of stress can be motivating to accomplish goals."

After teaching nursing students about substance abuse and its effects on individuals and families, the instructor determines that additional teaching is necessary when the students state which of the following? a. "Substance abuse involves use of alcohol and illegal, prescribed, or over-the-counter drugs." b. "People experiencing substance abuse problems often have difficulty using adaptive behaviors." c. "Substance abuse is widespread, occurring in all types of settings." d. "Individuals frequently engage in substance use and abuse to enhance their decision-making ability."

"Individuals frequently engage in substance use and abuse to enhance their decision-making ability."

A client with a foodborne illness is concerned his gastrointestinal tract will never be the same again. Which of the following would be an appropriate response from the nurse? a. "Gastrointestinal cells can adapt to the new environment created by the infection." b. "New gastrointestinal cells replace damaged ones constantly." c. "It's true. You may have to readjust your eating habits." d. "Give it time. Don't worry."

"New gastrointestinal cells replace damaged ones constantly."

A nurse is giving discharge instructions to a client who came to the emergency department following an ankle sprain. The client asks "Why does this hurt so much?" Which response would be most appropriate from the nurse? a. "The nerves are being stimulated by the pressure from the swelling at the sprain." b. "The hypothalamus gets reset by the injury and produces the pain response." c. "The local heat at the sprain causes pain." d. "The blood vessels are damaged, and this releases histamine, which causes pain."

"The nerves are being stimulated by the pressure from the swelling at the sprain."

A client is informed that a recent Pap smear shows hyperplasia of cervical cells. What teaching will the nurse provide to this client? a. "The cells of the cervix have changed shape." b. "The mature cells changed to another type of cell." c. "The number of cervical cells is increased." d. "The cells of the cervix are increased in size."

"The number of cervical cells is increased."

A client with a new ostomy is hesitant to participate in a support group. Which response will the nurse give the client to encourage the client to consider participating? a. "Be sure to change your appliance before attending the support group." b. "In time you will want to talk to someone with the same problem that you have." c. "Support groups often have a religious component to help you accept your condition." d. "This type of group promotes freedom to express self and exchange ideas."

"This type of group promotes freedom to express self and exchange ideas."

While interviewing the wife of a patient with multiple health problems, the spouse states, "I'm not the one who is ill, but I feel like I'm getting sick all the time." Which response by the nurse would be most appropriate? a. "Why don't you focus on how well you are coping?" b. "Let's talk with your doctor about getting you checked out." c. "Maybe you are catching something from your husband." d. "When one family member becomes ill, other members are affected."

"When one family member becomes ill, other members are affected."

A nurse is assessing an adult and suspects that the patient is experiencing anxiety. Which statement(s) would support the nurse's suspicions? Select all that apply. a. "It seems like my mind is all over the place." b. "It seems like everything is really annoying me." c. "I've been having palpitations lately." d. "My friends and I go out to the movies once or twice a month." e. "My new position at work is really challenging."

-"It seems like my mind is all over the place." -"It seems like everything is really annoying me." -"I've been having palpitations lately."

A client reports experiencing extreme stress with home life and work responsibilities. Which intervention(s) will the nurse recommend the client use to reduce their level of stress? Select all that apply. a. Broaden social network. b. Utilize relaxation techniques. c. Implement healthy eating habits. d. Perform health risk appraisal. e. Ensure adequate financial resources.

-Broaden social network. -Utilize relaxation techniques. -Implement healthy eating habits. -Ensure adequate financial resources.

A nurse has developed a plan of care for a patient with a nursing diagnosis of "risk for spiritual distress." Which interventions would the plan most likely include? Select all that apply. a. Demonstrate acceptance of the patient. b. Encourage the patient to talk about his or her faith. c. Limit the amount of time spent with the patient. d. Actively listen to the patient. e. Encourage the patient to avoid usual rituals.

-Demonstrate acceptance of the patient. -Encourage the patient to talk about his or her faith. -Actively listen to the patient.

Which of the following responses is most helpful to the client when in an emergency situation? a. A response by the musculoskeletal system b. A response by the cardiovascular system c. A response by the central nervous system d. A response by the sympathetic nervous system

A response by the sympathetic nervous system

A nurse is teaching a group of families who have members experiencing addiction about this problem. Which of the following, if stated by the families, indicates that the teaching was successful? a. Addiction is not a result of a person having moral faults. b. Addiction rarely results in the person experiencing relapse. c. A single factor is usually responsible for development of addiction. d. Addiction results from a defect in the person's character.

Addiction is not a result of a person having moral faults.

A nurse is working with a client to integrate effective coping skills into the client's life. Which activities would be used to achieve this? a. All are correct. b. Explore coping strategies the client has found helpful in the past and encourage their continued use. c. Cultivate relationships with family and friends who are supportive. d. Reestablish priorities to strike a healthy balance between work and play.

All are correct.

The nurse is caring for a client with diabetes who has an infection. The nurse creates a plan of care for the client based on a knowledge of the hypothalamic-pituitary response to stress by including which nursing intervention in the plan of care? a. Measurement of intake/output b. Increase in insulin dosage c. Assessment for hyperglycemia d. Restriction of dietary protein

Assessment for hyperglycemia

The nurse is caring for a client with an anxiety disorder. The client reports feelings of anxiousness when in social situations. Which classification of medications does the nurse anticipate? a. Benzodiazepines b. Corticosteroids c. Antipsychotics d. Adrenergic blockers

Benzodiazepines

Cells in which organ are unable to regenerate? a. Liver b. Kidney c. Brain d. Pancreas

Brain

A client admitted for a voluntary breast reduction is displaying many signs and symptoms of stress. Which of the following findings would be consistent with this analysis by the nurse? a. Neck pain and easy bruising b. Drooling and urinary frequency c. Bruxism and excessive sweating d. Dizziness and increased sense of smell

Bruxism and excessive sweating

A nurse is working with a family that is under stress. Which trait would the nurse emphasize in the plan of care as being most useful to the family's coping? a. Cognitive abilities b. Emotional strengths c. Individual talents d. Communication skills

Communication skills

Which of the following conditions triggers the general adaptation syndrome? a. Eustress b. Helplessness c. Distress d. Placebo effect

Distress

The nurse is caring for a client diagnosed with Parkinson disease. The nurse is most correct to correlate the client's uncontrolled tremors as a physical characteristic of a lack of which neurotransmitter? a. Dopamine b. Norepinephrine c. Serotonin d. Acetylcholine

Dopamine

Which of the following would be the priority when providing care to a client with posttraumatic stress disorder (PTSD)? a. Establishing a trusting nurse-client relationship b. Assisting the client in working through the trauma c. Helping the client address the trauma experienced d. Teaching the client appropriate methods for coping

Establishing a trusting nurse-client relationship

A nurse is developing a plan of care for a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following would be the priority? a. Teaching coping skills for self-care b. Administering prescribed drug therapy c. Assisting the patient to work through the traumatic experience d. Establishing a trusting nurse-patient relationship

Establishing a trusting nurse-patient relationship

The nurse is conducting a community education program on stress. The nurse includes which information? a. Effective stress adaptation is a disease precursor. b. Excessive stress response increases susceptibility to illness. c. Short-term stress increases susceptibility to disease. d. Stressors elicit a state of homeostasis.

Excessive stress response increases susceptibility to illness.

What is the term for an adaptation to environmental stress that occurs when tissue mass enlarges due to cell multiplication and increased stimulation? a. Dysplasia b. Atrophy c. Metaplasia d. Hyperplasia

Hyperplasia

A patient has a hemoglobin level of 7 g/dL. What should the nurse be alert to assess for? a. Hypertension b. Hypoxia c. Hyperemia d. Hypoglycemia

Hypoxia

The nurse conducting a community educational program on stress is including Lazarus's cognitive appraisal theory. The nurse evaluates that the participants understand the teaching when they state that during primary appraisal, which action occurs? a. Evaluation of what might be done b. Identification of the event as stressful c. Conflict between desire and need d. Change in a previous opinion

Identification of the event as stressful

When approaching health care holistically, which of the following would the nurse do? a. Include physical, emotional, and social elements b. Foster the use of technological advances in care c. Emphasize the client's strengths with passive participation d. Focus on complementary and alternative practices

Include physical, emotional, and social elements

A client has gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the client experience with this inflammatory infection? a. Intestinal inflammation b. Stomatitis c. Increased body temperature d. Redness of the anus

Increased body temperature

Which of the following would least suggest emotional health? a. Acceptance of reality b. Management of every day challenges c. Realistic sense of hopelessness d. Pursuit of personal goals

Realistic sense of hopelessness

During a family assessment, the mother states, "When I was a child, we always had a special dinner on Christmas Eve, that my mother had when she was a child. Now our family follows the same tradition." The nurse interprets this statement as indicating which family function? a. Socialization b. Boundary setting c. Management d. Education

Socialization

During assessment, a client states, "I don't know why God is punishing me like this." What coping strategy will the nurse offer the client? a. a telephone call to a spiritual leader b. offering to watch television with the client c. a discussion of current events d. assistance with a warm shower

a telephone call to a spiritual leader

A nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques: a. are helpful because they distract the client from focusing on claudication pain. b. haven't proven useful in clients with peripheral vascular disease. c. are helpful because stress stimulates the release of vasoconstricting catecholamines. d. are helpful only because they assist in smoking cessation.

are helpful because stress stimulates the release of vasoconstricting catecholamines.

The nurse is reviewing a client's list of health problems. Which conditions indicate that the client has been exposed to chronic sympathetic-adrenal-medullary responses? Select all that apply. a. cardiovascular disease b. arteriosclerosis c. high blood pressure d. multiple sclerosis e. osteoarthritis

cardiovascular disease arteriosclerosis high blood pressure

The nurse is reviewing a client's 0800 laboratory data. Which laboratory value concerns the nurse? a. calcium 9.1 mg/dl (2.27 mmol/l) b. potassium 3.7 mEq/l (3.7 mmol/l) c. cortisol 35 mcg/dl (965.58 mmol/l) d. sodium 137 mEq/l (137 mmol/l)

cortisol 35 mcg/dl (965.58 mmol/l)