chapter 8 fundamentals of nursing practice questions

Place in order the neuroendocrine responses that occur during the fight-or-flight response.

- antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water - corticotropin releasing hormone (CRH) is released from the hypothalamus - endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well being and reducing pain - adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone) - thyroid stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy - corticotropin - releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH)

What can a nurse do during the assessment process to help a client focus who is experiencing post-traumatic stress disorder? Select all that apply.

- ask short, direct questions - ask open ended questions as client begins to give more detail - demonstrate empathy and develop a rapport - recognize and relieve the immediate stressor

A mother has just learned her son has been involved in a fatal car accident. Match the actions to their chronological stage of crisis.

- begins to call relatives, states she is okay - can't decide if she should call work first or go to the hospital or pack a bag - explains to visitors everything is okay, he really was fortunate it wasn't worse than it could have been, "he will be fine" tell everyone to go home (doesn't want visitors now) - begins to make plans for therapy, at home care, work schedules - begins to overeat and indulge in excessive alcohol consumption

A client brought in from a sports injury to the right arm is being monitored for inflammation. What are the phases of the inflammation process the nurse should be watching for?

- blood vessels constrict to control bleeding - phagocytes rush to the site and engulf bacteria and other foreign material - exudate forms - tissue is replaced through regeneration or repair

A client who experienced a traumatic sexual assault is expressing feelings of guilt, embarrassment, fear, and self-blame. What nursing outcomes would be appropriate for this client? Select all that apply.

- client will have a resolution of embarrassment, self blame, guilt, and fear - client will state the results of the physical examination completed in the emergency department - client will discuss the need for follow up crisis counseling and other supports

A client who experienced a traumatic sexual assault is expressing feelings of guilt, embarrassment, and self-blame. What nursing actions would be appropriate for this client? Select all that apply.

- establish trust and rapport - provide strict confidentiality - do not use judgemental language and tone - encourage verbalization

Which is an effect of vascular response in inflammation? Select all that apply.

- hyperemia - edema - leukocytes move to the area

What signs of the resistance stage of GAS can the nurse see in this client? Select all that apply.

- ineffective coping mechanisms - weight loss - abnormal vital signs - extreme fatigue

A client who has a strong spiritual belief in healing is in the adaptation stage of stress. What practices might this client engage in to reduce stress? Select all that apply.

- practice meditation - pray - meet with clergy

The nurse is conducting an educational session on stress with a group of business administrators. Which type of stressors would most likely be problems for this population? Select all that apply.

- time stressors - situational stressors - anticipatory stressors

Which are issues a nurse should be aware of when assessing anxiety and ego defense mechanisms? Select all that apply.

- when used sparingly, defense mechanisms can be helpful - when overused, defense mechanisms become habits that appear as if we are coping - if defense mechanisms are inadequate to diminish perceived threats and restore equilibrium, anxiety disorders may develop

Which client is using conversion as a defense mechanism?

a client who is overwhelmed with stress and experiences nausea and vomiting

Which stage of general adaptive syndrome (GAS) would a client be in if they are experiencing tachycardia, tachypnea, and hypertension?

alarm

A client presents with sweating and trembling and is tearful, stating they are nauseated and feel restless. What assessment should the nurse perform first?

anxiety

A client is discussing an extended family-related conflict with the nurse and states they are tired of the problem and do not participate in family get-togethers because of it. Which ego defense mechanism will the nurse document that the client is using?

avoidance

A client begins experiencing chest pain off and on for a few days and continues to work without seeking medical attention. Which response to stress is this client demonstrating?

avoiding the stressor

The nurse is caring for a client who is in the alarm stage of a stress response. Which clinical finding corresponds to the production of aldosterone, antidiuretic hormone, and renin?

decreased urine output

Evelyn is a 47-year-old who recently lost her husband in a tragic accident. In addition, she is responsible for the daily care of her elderly mother who is suffering with Alzheimer's disease and failing health. Evelyn is in the office experiencing chest pain, extreme fatigue, and shortness of breath. It is discovered she has gained about 10 pounds in a short period of time and has started smoking again after 25 years. What action should the nurse take first?

explore other possible maladaptive coping mechanisms

A client in a group setting begins to kick a trash can and yell at other clients. Which behavior would the nurse note in the client's medical record?

hostility

A coworker makes a sarcastic remark when the nurse is late for their shift and "throws" a stack of paperwork and a list of clients who need assessing to them before they can settle in. Why is this coworker possibly behaving this way?

hostility and resentment of the late nurse

Which somatoform disorder would the nurse expect to find in the medical record of a client who is constantly fearful of becoming ill?

hypochondriasis

A client is admitted to the hospital after suffering a stroke. They have been able to manage their home and self-care independently but now are unable to speak clearly, are paralyzed, and become frustrated as they attempt to communicate their needs. What stressor is most concerning for them as they enter the hospital?

loss of privacy and control

A client will be discharged soon after having surgery. After a visit with their spouse and children, the client exhibits signs of regression in their therapy and begins to experience excessive pain and fatigue, stating they don't think they're ready to go home. What should the nurse assess for in this client?

malingering

What is a CAM (complementary and alternative medicine) therapy a nurse can teach the client that involves a heightened awareness of the mind, body, and spirit?

meditation

The nurse recognizes that a coworker has been working extra shifts and has had several clients die recently. The coworker has made several mistakes when administering medications and is fatigued, forgetful, and preoccupied. What should the nurse do to help prevent burnout in the coworker?

offer support to help with tasks or with their feelings and suggest speaking with a supervisor

A client has just learned of the loss of a close friend. She tells others that she is fine when asked and everything will be all right. Which phase of crisis is she experiencing?

precrisis

The nurse is working in a mental health clinic and a client states, "My coworker did not do well on our team presentation, and that's why I got fired!" As the nurse documents the findings, what defense mechanism is this client using?

projection

The nurse is assessing a 13-year-old client brought in from a sports injury to the right arm. The client immediately retracts their arm when it is touched. What type of local adaptive response is this?

reflex pain response

Which localized physiological response would the nurse anticipate a client may experience during an intravenous insertion?

reflex pain response

Which stage of general adaptive syndrome (GAS) would a client be in if they were failing to adapt to the point where exhaustion will occur if left unresolved?

resistance

A client was brought into the emergency department and was the victim of a robbery. Upon assessment, his heart rate is 112 bpm, respirations 34 and deep, and he is complaining of nausea and lower abdominal pain. What is causing this reaction?

stimulation of the sympathetic nervous system