Funds Chapter 42

A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities?

"I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes."

A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction?

"I just had a baby 3 weeks ago."

Which statement made by the client indicates a need for further teaching regarding stress management?

"I manage my stress with occasional alcohol and alprazolam."

A client asks the nurse how cortisol works. What is the appropriate nursing response?

"It suppresses the immune response."

The nurse is explaining to a group of high school students how the nervous system helps regulate homeostasis. Which statements by the nurse are correct? Select all that apply.

- "The sympathetic nervous system is responsible for the flight-or-fight response." - "The parasympathetic nervous system increases peristalsis."

Which outcome(s) will the nurse include in the plan of care for a client experiencing caregiver role strain? Select all that apply.

- Client will demonstrate appropriate coping strategies. - Client will identify support mechanisms to help with stress. - Client will identify one or two stressors to eliminate.

A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because "I got mad at her and wished she would go away." Based on this information, the nurse would estimate the sister's age to be:

7 years

Which nurse is most likely to experience the greatest amount of stress related to his or her position as a nurse?

A graduate nurse working on a telemetry unit

A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation?

Anticipatory guidance

Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?

Anticipatory guidance

A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response?

Coping responses

The nurse is caring for a client with chronic pain. Which long-term coping strategies may be helpful in this situation?

Deep breathing and meditation

A nurse has accepted numerous overtime shifts over the past several months. Which behavior indicates the nurse is experiencing burnout?

Dozing at the desk during downtime

An occupational health nurse at an oil refinery on the Gulf Coast of Texas performs client education with an adult client. The client is being seen after having suffering a chemical burn in an accident at the refinery. Which type of stressor has this client been exposed to?

Physiologic

The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client?

Refer the client to a support group

A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in?

Resistance

The nurse is facilitating an evening meditation and deep breathing class for breast cancer survivors. Which outcome will the nurse anticipate occurring after performing deep breathing with the clients?

Slowed heart rate

A 7-year-old child has been the victim of abuse. The child appears stoic and disconnected while being interviewed by the nurse. Although the child currently has a painful injury, the child does not cry or flinch when the area is touched. Which explains the child's stoic behavior?

The child has learned to cope by shutting off feelings.

Which client would the nurse expect to have negative coping skills?

a 19-year-old diagnosed with schizophrenia who is heading off to college

A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of:

adaptation

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario?

compensation

A Spanish-speaking client is admitted to the emergency department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

contact a translator

The nurse is providing care to the following clients. The nurse assesses the client exhibiting maladaptive behavior as the client who is:

experiencing a terminal illness and states, "If I pray to God and go to church each week, I will live."

The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize?

impaired concentration

An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping?

maladaptive

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms?

moderate anxiety

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

provide care transition at discharge for speech therapy

After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify?

rationalization

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

sit with the client and ask them about their feelings

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?

sympathetic nervous system

A withdrawn and isolated client is most likely suffering from what type of stressors on basic human needs?

Love and belonging needs

Which are considered internal stressors? Select all that apply.

- illness - hormonal change - fear

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement?

repression

The adult children of a client diagnosed with brain death are trying to come to terms with this diagnosis. Which statement(s) by the children exhibits normal grieving to the nurse? Select all that apply.

- "We have to accept this is really happening right now." - "She would want us to donate her organs to others." - "I am so angry with mom for leaving all of us so suddenly." - "I just need to get out of here right now and go for a walk." - "We should start thinking about the funeral arrangements."

An older adult client assumed care of a parent with dementia and had to decrease work hours to stay and home and care for the parent. Due to the decrease in hours, it is difficult to meet financial obligations. What actions by the nurse would be appropriate for this client? Select all that apply.

- Make a referral to the case manager to determine available resources. - Have the client make an appointment with social services to assist with financial resources. - Suggest the client join a support group for caregivers of parents with dementia.

A client asks about general adaptation syndrome (GAS). Which details provided by the nurse are correct? Select all that apply.

- The alarm stage of GAS can last from minutes to hours. - It can be a response to physiologic or psychological stress. - There are three stages to GAS.

Which response to long-term stress may present itself in clients? Select all that apply.

- alcoholism - hypertension - bulimia

A nurse is teaching a client regarding effective coping strategies. Which teaching will the nurse include? Select all that apply.

- making an appointment with a counselor - writing a list of pros and cons - practicing yoga and relaxation - praying

The nurse is making preparations for a group of clients who have been experiencing some stressful events in their lives. Which nursing strategies should the nurse use to assist these clients? Select all that apply.

- preventing additional stressors - assessing the client's response to stress - implementing stress management techniques - assisting in maintain a network of social support

The nurse is caring for four clients. Which client does the nurse identify as the highest risk for social readjustment concerns?

77-year-old whose spouse just died

Which response to stressors results from the activation of the local adaptation syndrome (LAS)?

A girl quickly withdraws her hand from a stream of hot tap water.

Which client is handling stress by using the defense mechanism termed displacement?

A mother who is angry at her husband shouts at the kids to "keep quiet."

The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action?

Advocate for the client's choice.

A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs?

Attempt to calm the client and administer oxygen

When nurses become overwhelmed in their jobs and develop symptoms of anxiety and stress, they are experiencing what condition?

Burnout

What is a general task for a client adapting to acute and chronic illness?

Maintain self-esteem

A school nurse is talking with teen related to school and home situations. The teen states, "I can't focus when I study, can't eat or sleep, and I feel like I'm going to pass out sometimes." The nurse believes the teen is experiencing which disorder?

Moderate anxiety response

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation?

Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease.

A client who has been working with an organization for several years did not get a promotion. As a result, the client has gone into depression. Which suggestion should the nurse make in order to help the client with his stress?

Seek professional help.

A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors?

Social Support

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is notimportant?

Soft Music

A toilet trained toddler was admitted to the hospital for dehydration. Upon returing home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent?

This behavior is called regression.

In contrast to anxiety, fear is characterized by:

a cognitive response to a known threat.

The nurse is preparing to administer an injection to an adult client and states, "Try to stay as still as possible." Which stage of the General Adaptation Syndrome (GAS) is the nurse addressing by making this statement?

alarm

A teenage girl is discussing her recent breakup with her boyfriend. She tells the nurse she just stays in bed all day and cannot seem to feel any better. She says she is only relieved of the pain while sleeping. The nurse identifies this coping strategy as:

avoidance coping.

An intensive care unit (ICU) nurse with 11 years of experience has been frequently absent or late for shifts, has been verbally abusive with coworkers she feels are unskilled at the technological tasks of the job, and cursed under her breath at a distraught family member today. The nurse manager is threatening to suspend her if it happens again. The ICU nurse may be experiencing:

burnout

Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with:

clear identification of the relevant problem.

A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using:

coping mechanism.

A client is having a stress response related to a recent accident while boating. What does the nurse identify will be excreted from the adrenal cortex in response to this reaction?

cortisol

The client is a single mother of two children who attends college and works full time. She is seeing the college nurse due to a crying outburst in class. The last step of crisis intervention that the nurse employs is:

determining if the outcome has been achieved.

A client with diabetes mellitus is experiencing acute stress. The nurse identifies that the client will be secreting excess levels of cortisol. What should the nurse monitor the client for related to the increased levels of cortisol?

elevated glucose levels

A 78-year-old widower was recently relocated to an assisted living facility. His aunt used to live in this facility and always talked fondly about her fellow residents and the staff. However, the nurse has noticed that the client has spent most of his time in his room alone. What type of stress is the nurse most concerned about with this client?

environmental stress

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?

exhaustion stage

A client who has a history of sexual abuse is demonstrating repression. What client behavior does the nurse expect?

having no memory of the sexual abuse

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

limit the family visits to once daily

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention?

seek assistance from family and friends

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as:

severe.

The nurse determines that a client understands instruction regarding progressive relaxation when the client states that the technique requires:

tensing and relaxing various muscle groups.

The nurse at the student health center is seeing a group of nursing students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What does guided imagery involve?

the mindful use of a word, phrase, or visual image that allows oneself to be distracted and temporarily escape from stressful situations