Foundations- Ch 38

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "Let me help you two calm down a bit so I can take you to your daughter."

2, 4, 3, 1

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement.

1

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? 1. Results in neurophysiological response 2. Reduces body temperature 785 3. Causes a person to be hypervigilant 4. Reduces level of consciousness to conserve energy.

1

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. Which of the following are true about work-related stress? Select all that apply. 1. Job-related stress can affect the quality of patient care. 2. Stress can affect nurses' efficiency and decision making. 3. Nurses who talk about feeling stress are unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in healthcare technology. 5. Nurses cannot resolve job-related stress.

1, 2, 4

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. Which of the following are true about work-related stress? (Select all that apply.) 1. Job-related stress can affect the quality of patient care. 2. Stress can affect nurses' efficiency and decision making. 3. Nurses who talk about feeling stress are unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in health care technology. 5. Nurses cannot resolve job-related stress.

1, 2, 4

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? Select all that apply. 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help. 5. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

1, 2, 5

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help. 5. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

1, 2, 5

A crisis intervention nurse is working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in special-school classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? Select all that apply. 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1, 3, 4

A crisis intervention nurse is working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in special-school classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1, 3, 4

Which assessment question would provide information related to caregiver strain on the daughter of a terminally ill patient? 1. "Do you find yourself either unable to sleep or sleeping too much?" 2. "When was your last physical examination?" 3. "How are you involving the rest of the family in your mother's care?" 4. "Do you attend every appointment with your mother?"

1. "Do you find yourself either unable to sleep or sleeping too much?"

Which questions would be appropriate to ask when assessing a patient's coping mechanisms? Select all that apply. 1. "How have you dealt with stressful situations in the past?" 2. "Are you experiencing feelings of anxiety or nervousness?" 3. "Were these techniques of handling stress effective?" 4. "Whom can you ask for assistance from during stressful times?" 5. "Have you experienced any changes in your life recently?"

1. "How have you dealt with stressful situations in the past?" 3. "Were these techniques of handling stress effective?" 4. "Whom can you ask for assistance from during stressful times?"

Which question would help the nurse assess a patient's spiritual and cultural coping mechanisms? 1. "Whom do you see for health care in addition to your health care provider or nurse?" 2. "Whom do you turn to when you need help?" 3. "Do you suffer from physical illnesses?" 4. "Do you experience diarrhea or constipation during challenging situations?"

1. "Whom do you see for health care in addition to your health care provider or nurse?"

Which findings would be expected when assessing a patient at the end of life? Select all that apply. 1. Apnea 2. Increased blood pressure 3. Increased heart rate 4. Decreased urine output 5. Well-perfused extremities

1. Apnea 3. Increased heart rate 4. Decreased urine output

Which physical sign found during an assessment would alert the nurse to the possibility of an adult patient under acute stress? Select all that apply. 1. Heart rate 98 bpm 2. Blood pressure 138/88 3. Temp 98.8° F 4. Respiratory rate 20 5. Heart rate 62 bpm

1. Heart rate 98 bpm 2. Blood pressure 138/88

Which nursing assessment finding indicates the patient is close to death? 1. The patient has stopped eating and drinking 2. The patient is unable to ambulate 3. The patient refuses visitors 4. The patient stops taking medications

1. The patient has stopped eating and drinking

When assessing a patient for stress, which symptoms might the nurse expect to see? Select all that apply. 1. Nervousness 2. Irritability 3. Muscle tension 4. Increased concentration 5. Weight loss

1. Nervousness 2. Irritability 3. Muscle tension 5. Weight loss

Which patient is likely experiencing stress? 1. Patient that is panting and sweating during assessment 2. Patient with a loudly grumbling stomach 3. Patient resting with eyes closed 4. Patient laughing while talking with the office receptionist

1. Patient that is panting and sweating during assessment

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? 1. Results in neurophysiological response 2. Reduces body temperature 3. Causes a person to be hypervigilant 4. Reduces level of consciousness to conserve energy.

1. Results in neurophysiological response

Which patient behaviors observed during the health history interview suggest the patient should be further assessed for stress? 1. Staring at the floor and responding with abrupt, monosyllable answers 2. Sitting with crossed legs and taking notes 3. Sitting upright and telling the nurse about a recently read novel 4. Holding wife's hand and nodding

1. Staring at the floor and responding with abrupt, monosyllable answers

Which sign of death is known as "rigor mortis"? 1. Stiffening of the joints of the body 2. Cooling after death 3. Paling, then blushing, of the skin 4. Absence of heartbeat and respirations

1. Stiffening of the joints of the body

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. What is the correct order for the nurse's discussion with the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "Let me help you two calm down a bit so I can take you to your daughter."

2, 4, 3, 1

A patient with type 2 diabetes is experiencing a lot of work-related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, and his doctors want him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? (Select all that apply.) 1. Increases in antidiuretic hormone (ADH) 2. Increases in cortisol 786 3. Increases in aldosterone 4. Increases in adrenocorticotropic hormone (ACTH) 5. Increases in epinephrine

2, 4, 5

Which question should the nurse ask the family of a dying parent to assess anticipatory grief? 1. "When dealing with your parent's illness have you been able to continue with your other life responsibilities?" 2. "Are you having difficulty making decisions?" 3. "What are you doing to care for yourself?" 4. "Do you feel capable to continue caring for your parent at home?"

2. "Are you having difficulty making decisions?"

Which patient action most likely indicates the patient is experiencing stress? 1. Heavy, labored breathing 2. Frequent adjustment of position 3. Eye-rolling while answering questions 4. Stomach growling during examination

2. Frequent adjustment of position

A patient with type 2 diabetes is experiencing a lot of work-related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, and his doctors want him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? Select all that apply. 1. Increases in antidiuretic hormone (ADH) 2. Increases in cortisol 3. Increases in aldosterone 4. Increases in adrenocorticotropic hormone (ACTH) 5. Increases in epinephrine

2. Increases in cortisol 4. Increases in adrenocorticotropic hormone (ACTH) 5. Increases in epinephrine

Which part of the nurse's assessment of a dying patient would be important to share with the patient's loved ones who are gathered around them? 1. The patient eats the same thing for every meal 2. The patient wants to get up and walk 3. The patient is febrile and diaphoretic 4. There is an increase in bowel sounds

2. The patient wants to get up and walk

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis.

3

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. Which of the following statements indicate that the patient is beginning to cope with the diagnosis? Select all that apply. 1. "I'm going to learn to drive a car so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3, 5

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. Which of the following statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3, 5

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal 5. Depression

3, 5

Which question, related to socioeconomic status, should the nurse ask the caregiver of a terminally ill patient? 1. "Do you understand the side effects of the patient's medications?" 2. "Does the patient take medications daily?" 3. "Do you have trouble being able to pay for all of the patient's medications?" 4. "Do you monitor how much fluid the patient takes with medications?"

3. "Do you have trouble being able to pay for all of the patient's medications?"

Which patient statement made in response to an assessment question about coping indicate the patient's ability to cope with a current stressor? 1. "I love my new job but the commute is too long." 2. "I am much more relaxed now that I am retired." 3. "I have reached out to human resources to get information on flexible hours to help my commute at my new job." 4. "I am falling behind on my work because of problems at home."

3. "I have reached out to human resources to get information on flexible hours to help my commute at my new job."

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3. A thorough physical assessment

Which assessment finding describes the sign of death known as "algor mortis"? 1. Increasing apnea 2. Heart rate of 0 BPM 3. Body temperature of 97.5° C 4. Dropping of the jaw 5. Stiffening of the joints

3. Body temperature of 97.5° C

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? Select all that apply. 1. Posttraumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal 5. Depression

3. Chronic illness 5. Depression

Which signs or symptoms can be directly related to high levels of stress? 1. Vomiting after taking medications 2. Post-surgical pain 3. Nausea while waiting for test results 4. Flushed cheeks after physical therapy

3. Nausea while waiting for test results

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "What do you mean when you say you can't go on any longer?"

4

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? 1. Loss of autonomy caused by health problems 2. Physical appearance, family, friends, and school 3. Self-esteem issues, changing family structure 4. Search for identity with peer groups and separation from family

4

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which of the following are appropriate responses or actions of the nurse? Select all that apply. 1. "I know another patient whose colon cancer was cured by surgery." 2. Straighten the patient's bed and room 3. "Have you thought about how you are going to tell your family?" 4. "Would you like for me to sit down with you for a few minutes so you can talk about this?" 5. Sit quietly with the patient

4, 5

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which of the following are appropriate responses or actions of the nurse? (Select all that apply.) 1. "I know another patient whose colon cancer was cured by surgery." 2. Straighten the patient's bed and room 3. "Have you thought about how you are going to tell your family?" 4. "Would you like for me to sit down with you for a few minutes so you can talk about this?" 5. Sit quietly with the patient

4, 5

Which question will provide information about current stressors in a patient who reports recent increases in migraines and significant weight loss? 1. "Do your friends and family know about your migraines?" 2. "How long have you had migraines?" 3. "How much weight have you lost?" 4. "Have you experienced changes in your anxiety level due to your new job?"

4. "Have you experienced changes in your anxiety level due to your new job?"

Which assessment question provides information related to the amount of stress the spouse of a dying patient is experiencing? 1. "What do you do to calm down when you are heavily stressed?" 2. "What kinds of hobbies do you like to take part in when you are stressed?" 3. "Do you feel like your life has been more manageable since we met last year?" 4. "On a scale of 1-5 with one being very little and 5 being all consuming, how much stress do you feel?"

4. "On a scale of 1-5 with one being very little and 5 being all consuming, how much stress do you feel?"

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "What do you mean when you say you can't go on any longer?"

4. "What do you mean when you say you can't go on any longer?"

Which tool would the nurse use to identify the needs of a patient at home suffering from a terminal illness? 1. Palliative Performance Scale 2. Karnosfsky Performance Scale 3. Functional Assessment Staging tool (FAST) 4. Toolkit of Instruments to Measure End of Life Care (TIME)

4. Toolkit of Instruments to Measure End of Life Care (TIME)

When doing an assessment of a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the crash whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

PTSD