NURS (FUNDAMENTAL): Ch 41 NCLEX Stress and Adaptation
A 55-year-old widow recently assumed care of her 85-year-old mother. She had to cut back on her hours at work in order to be present in the home because she is concerned about her mother's safety. She is struggling to make mortgage payments as a result. Which is an applicable NANDA-I nursing diagnosis for this situation? Select all that apply. a) Compromised Family Coping r/t change in family dynamics b) Caregiver Role Strain r/t change in family dynamics c) Anxiety r/t change in family dynamics d) Readiness for Enhanced Family Process r/t change in family dynamics
a, b There is no evidence that this family is ready to change its family process. There is also no evidence of anxiety.
A withdrawn and isolated patient is most likely suffering from what type of stressors on basic human needs? a) Love and belonging needs b) Self-esteem needs c) Physiologic needs d) Safety and security needs
a) Love and belonging needs Effects of stress on basic human needs varies with each individual, but there are certain characteristics that are commonly seen with stressors on the basic human needs. Withdrawal and isolation from others is commonly seen when stressors are placed on love and belonging needs. Stressors on physiologic, safety and security, and self-esteem needs have other common characteristics.
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? a) Moderate anxiety b) Obstructive sleep apnea c) Herniated lumbar disc d) Type 2 diabetes
a) Moderate anxiety This client may have increased anxiety from adjusting to retirement, a significant life stressor.
A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for more teaching? a) "I must breathe in and out in rhythm." b) "I should take my pulse and expect it to be faster." c) "I can expect my muscles to feel less tense." d) "I will be more relaxed and less aware."
b) "I should take my pulse and expect it to be faster." No matter what the technique, relaxation involves rhythmic breathing, a slower pulse, reduced muscle tension, and an altered state of consciousness.
When nurses become overwhelmed in their jobs and develop symptoms of anxiety and stress, they are experiencing what condition? a) Culture shock b) Burnout c) Ineffective coping d) Adaptation syndrome
b) Burnout The feeling of being overwhelmed in one's job and development of symptoms of anxiety and stress is referred to as burnout. Burnout can be compared with the exhaustion stage of anxiety and is characterized by a wide range of behaviors. Culture shock is a feeling of uneasiness or uncertainty in different and unfamiliar surroundings. The change that takes place as a result of the response to a stressor is adaptation. Ineffective coping means that a person does not deal effectively with stressors.
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? a) Adaptation often fails during stressful events and results in homeostasis. b) Stress is a part of our lives and eventually this young woman will adapt c) Acute anxiety and depression are seldom associated with stress. d) Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease.
d) Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. When adaptation fails, the result is disease. If a person is overwhelmed by stress that person may never adapt. Acute anxiety and depression are frequently associated with stress.
A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using: a) adaptation technique. b) withdrawal behavior. c) defense mechanism. d) coping mechanism.
d) coping mechanism.
A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using: a) defense mechanism. b) adaptation technique. c) withdrawal behavior. d) coping mechanism.
d) coping mechanism. Anxiety often is managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. Coping mechanisms are immediate responses and are often involuntary. Crying is considered a coping mechanism. The change that takes place as a result of the response to a stressor is adaptation. Withdrawal is a type of coping mechanism. Defense mechanisms protect one's self-esteem and are useful in mild to moderate anxiety; if they used to an extreme, however, they distort reality and create problems with relationships.
A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? a) transmits sensation of pain b) stabilizes mood and regulates temperature c) promotes coordinated movement d) heightens arousal and increases energy
d) heightens arousal and increases energy Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.
In evaluating the therapeutic outcome of using biofeedback to help a client work through a stressful situation, the nurse would expect the client to: a) identify support personnel and services. b) verbalize the actions and side effects of his medications. c) re-demonstrate a home care procedure properly. d) maintain vital signs within normal limits.
d) maintain vital signs within normal limits. Biofeedback is the relaxation technique that involves clients learning to use mental processes to control their physiologic responses to events. Clients can learn to alter their autonomic nervous system and control their vital signs and uncomfortable symptoms. Identifying support services, re-demonstrating procedures, and understanding medications can reduce stressful feelings, but they are not biofeedback principles.
A nurse is assessing a client for anxiety. Which questions should the nurse ask to elicit subjective data related to anxiety? (Select all that apply.) a) "How often do you have sex?" b) "Has your heart felt like it was racing or skipping a beat?" c) "Have there been any changes in your appetite?" d) "Do you feel like you get angry or upset easily?" e) "Do you wake easily from sleep?"
b, c, d Anxiety can manifest in different ways. To obtain subjective data the nurse should ask about appetite, changes in heart rhythms or breathing, and anger or sadness issues. Anxiety usually causes a lack of sleep, not waking easily from sleep. Changes in sexual desire may be a reaction to anxiety, but asking how often one has sex does not gather the needed information about anxiety.
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: a) 15 years b) 3 years c) 7 years d) 21 years
c) 7 years
A nurse is providing a seminar about stress. Which information should the nurse include? (Select all that apply.) a) People can have a positive or negative reaction to stress. b) One effective coping mechanism will inhibit stressors. c) Adaptation occurs to maintain balance from stress. d) Stressors are either positive or negative. e) Stress can be physical and psychological.
a, c, e Stress can be both physical and psychological. Stressors are neither positive nor negative but can cause a person to react either positively or negatively. The body seeks homeostasis by adapting to stress. Stress cannot be inhibited by one coping mechanism.
A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to these complaints? a) "Are you worried about failing your exams?" b) "Have you been staying up late studying?" c) "Are you using any recreational drugs?" d) "Do you have trouble managing your time?"
a) "Are you worried about failing your exams?" Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress.
A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? b) "Listing alternatives is the initial step." c) "I will list alternatives after I develop the plan." d) "I do not need to evaluate the outcome of my plan."
a) "I need to identify the problem first." Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified.
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? a) Resistance stage b) Exhaustion stage c) Secondary stage d) Alarm stage
b) Exhaustion stage
A teen is worried that her boyfriend is under "a lot of stress" with his home life, classes, clubs, community service, and part-time work. She asks the nurse what medication he should take to "calm down." Which response would be best? a) "Isn't he passing his classes? Did you tell his parents this was happening?" b) "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives." c) "What medication is he taking now? I can recommend something, but we need to make sure there won't be an interaction with something else." d) "It sounds like he is in too many extracurricular activities. Can you convince him to drop out of some of those clubs?"
b) "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives." The most therapeutic approach would be to enlist the girl's help in getting the boy to sit down and discuss what is happening with someone trained in therapeutic communication. Decreasing the activities may help but may be unacceptable to the young man. Directing attention to his academic problems, asking the girlfriend about health issues and medications, and asking about parental involvement at this stage may damage the trust relationship the nurse has with them.
A nurse is interviewing a patient who just received news that he has pancreatic cancer. The patient tells the nurse that getting cancer could never happen to him. Which defense mechanism is this patient demonstrating? a) Projection b) Denial c) Displacement d) Repression
b) Denial Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing.
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? a) "I get so tired from working long hours at the site." b) "I need to get back to work here at home. That will get me back into a routine." c) "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." d) "I guess the smoke in the air brought out my mental addiction to cigarettes."
c) "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." This person is exhibiting a physiologic response to stress, while also taking up a negative coping solution to diminish the symptoms. Reliving the events that were stressful is a common complaint when under anxiety. The other statements do not demonstrate the burden of role strain.
The nurse is providing care to the following clients. The nurse assesses the client exhibiting maladaptive behavior as the client who is: a) participating in a smoking cessation program after her father was diagnosed with lung cancer. b) 84 years old with multiple health problems and requesting to see an end-of-life care specialist. c) experiencing a terminal illness and states, "If I pray to God and go to church each week, I will live." d) overweight, consumes 1,600 calories/day, and exercises 30 minutes a day 5 times each week.
c) experiencing a terminal illness and states, "If I pray to God and go to church each week, I will live."
Which behaviors represent effective coping mechanisms? Select all that apply. a) setting limits with family members who upset you b) learning relaxation techniques c) sleeping 14 hours a night d) taking a vacation e) denying responsibility for a DUI conviction f) sleeping 3 hours a night
a, b, d Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective.
A client asks about general adaptation syndrome (GAS). Which of the following details provided by the nurse are correct? (Select all that apply.) a) There are three stages to GAS. b) The alarm stage of GAS can last from minutes to hours. c) The resistance stage usually lasts for less than a day. d) GAS requires psychological hospitalization for treatment. e) It can be a response to physiological or psychological stress.
a, b, e There are three stages to GAS: the alarm stage, the resistance stage, and the exhaustion stage. GAS can be in response to a physiological or psychological stressor. The alarm stage is usually the shortest stage, lasting minutes to hours. Individuals progress through the resistance and exhaustion phase at different speeds depending on coping mechanisms and situations. Hospitalization is generally not required to treat GAS, but the nurse must recognize that GAS can impact all clients.
A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a) Progressive muscle relaxation b) Meditation c) Anticipatory socialization d) Biofeedback e) Rhythmic breathing f) Guided imagery
a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches.
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: a) allostatic load. b) burnout. c) sleep deprivation. d) repression.
b) burnout. Burnout is the term used to describe behaviors that occur when a person is overwhelmed with the demands of a situation and is similar to the exhaustion stage of anxiety. This is commonly seen in nurses who work in high-stress environments. The individual in this scenario may have a great allostatic load and/or sleep deprivation, but there is no evidence of this in the given scenario. Repression is when a person copes by unconsciously denying the occurrence of a stressful event.
A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? a) stabilizes mood and regulates temperature b) heightens arousal and increases energy c) transmits sensation of pain d) promotes coordinated movement
b) heightens arousal and increases energy Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.
A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an): a) concern. b) stressor. c) adjustment. d) threat.
b) stressor.
A nurse is assessing the developmental levels of patients in a pediatric office. Which individual would a nurse document as experiencing developmental stress? a) An infant who learns to turn over b) A school-aged child who learns how to add and subtract c) An adolescent who is a "loner" d) A young adult who has a variety of friends
c) An adolescent who is a "loner" The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.
A nurse is performing an assessment of a female patient who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a) Ineffective Coping related to the new parenting role b) Ineffective Denial related to ability to care for a newborn c) Anxiety related to change in role status d) Situational Low Self-Esteem related to fear of parenting
c) Anxiety related to change in role status The nursing diagnosis of Anxiety indicates situational/maturational crises or changes in role status. Ineffective coping refers to the inability to appraise stressors or use available resources. Ineffective denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem diagnoses feelings of worthlessness related to the current situation the person is experiencing, not related to the fear of role changes.
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? a) Endocrine system b) Parasympathetic nervous system c) Sympathetic nervous system d) Respiratory system
c) Sympathetic nervous system
Aleah is a 22-year-old college student who recently engaged in sexual intercourse with a new partner. When the nurse tells her that she is pregnant, she states, "That's not possible, I got my period last week." This is an example of what defense mechanism? a) Regression b) Rationalization c) Suppression d) Denial
d) Denial Aleah is exhibiting denial by refusing to accept something as is.
Which client would the nurse expect to have negative coping skills? a) a 37-year-old factory worker who is laid off for the summer b) a 13-year-old diabetic who joins a softball league c) a 72-year-old retiree who needs to take an expensive new chemotherapeutic agent d) a 19-year-old diagnosed with schizophrenia who is heading off to college
d) a 19-year-old diagnosed with schizophrenia who is heading off to college All of these clients will be facing stressors and need to develop adaptation skills. The client with schizophrenia, a chronic but manageable psychiatric illness, is most at risk for reacting negatively to the new life stressor. Clients with mental illness may have decreased physiologic reserve with which to effectively cope and adapt.
Many families are sheltering in the local middle school gymnasium during a severe tornado outbreak. Many homes have been destroyed and lives lost. The community health nurse expects to see negative stress reactions to the crisis, such as: a) a man enlisting others to help him look for lost pets. b) a young boy asking everyone if they need some water or food. c) an older adult couple staying near each other constantly. d) a young wife asking everyone repeatedly if they know where her husband is.
d) a young wife asking everyone repeatedly if they know where her husband is. Disasters are considered adventitious crises. Those who are affected will utilize coping skills, good or bad, to maintain homeostasis. Positive coping might involve supporting loved ones and helping others adapt. Negative coping might include denial, anger, withdrawal, and panic.
Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse? a) A graduate nurse working on a telemetry unit b) A nurse who is an editor of a nursing journal c) A nurse with one year of experience working on an oncology unit d) A nurse with 10 years of experience working as a nurse educator
a) A graduate nurse working on a telemetry unit Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care.
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 first step of crisis intervention that the nurse employs is what? a) Assisting the client to identify the reason for her outburst b) Asking the client, "What would happen if you did this solution?" c) Having the client select an acceptable solution to her problem. d) Outlining several solutions to the crisis with the client
a) Assisting the client to identify the reason for her outburst Crisis intervention is a five-step problem-solving technique. The first step is to identify the problem. The other options follow problem identification.
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? a) Environmental stress b) Psychological stress c) Physiologic stress d) Sociocultural stress
a) Environmental stress Environmental stress is common when individuals move to a new location, even if that move is voluntary. It is associated with a lack of familiarity with the sights, smells, and sounds of the location. Relocation also requires alteration in daily routine which is in itself stressful.
A nurse assesses patients in a long-term care facility for diseases that are exacerbated by stressors. What is an autoimmune disease that is related to stress? a) Grave's disease b) Hypertension c) Asthma d) Esophageal reflux
a) Grave's disease The cumulative negative effects of stress on the body can cause the exacerbation of autoimmune disorders, including Grave's disease. Asthma, hypertension, and esophageal reflux are diseases associated with stress but are not autoimmune in nature.
A nurse working on an oncology floor often sits with her clients in a calm, quiet, dimly lit environment and describes a walk along the ocean's shore. The nurse provides details of the walk and verbally paints a picture for the client. What best defines this form of stress management? a) Guided imagery b) Anticipatory guidance c) Meditation d) Biofeedback
a) Guided imagery Guided imagery involves creating a mental image based upon a verbal description offered by another individual. Biofeedback is a method of gaining mental control of the autonomic nervous system and regulating body responses. Meditation involves relaxing major muscle groups and repeating a word silently during exhalation. Anticipatory guidance focuses on physiologically preparing a person for an unfamiliar or painful event.
A school nurse is listening to a teen describe symptoms related to his schoolwork. The boy states he can't focus when studying, is unable to eat and sleep, and felt like he was going to "pass out" the other day during a geometry test. The nurse believes the teen is experiencing which disorder? a) Moderate anxiety response b) Panic attacks c) Psychological alarm reaction d) Obsessive-compulsive disorder (OCD)
a) Moderate anxiety response Inability to concentrate, nausea, insomnia, dizziness, and hyperventilation are all symptoms of moderate-level anxiety. Alarm reaction is the initial physiologic response to a stressor described in Selye's general adaptation syndrome theory. OCD is a psychiatric pathology. Panic attacks go a step further in the anxiety cascade; the client is unable to function at this level.
A nurse is caring for an older male patient in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on this patient data, what would be a priority intervention for this patient? a) Monitoring food and drink temperatures to prevent burns b) Providing adequate pain relief measures to reduce stress c) Monitoring for depression related to social isolation d) Providing meals high in carbohydrates to promote healing
a) Monitoring food and drink temperatures to prevent burns A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the ChooseMyPlate dietary guidelines.
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: a) severe. b) mild. c) moderate. d) panic.
a) severe. Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.
A nurse is assessing a 49-year-old male patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a) Changes in appetite b) Changes in elimination patterns c) Decreased pulse and respirations d) Use of ineffective coping mechanisms e) Withdrawal f) Attention-seeking behaviors
a, b Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.
A nurse witnesses a street robbery and is assessing a 26-year-old female patient who is the victim. The patient has minor scrapes and bruises and tells the nurse, "I've never been so scared in my life." What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a) Increased heart rate b) Decreased muscle strength c) Increased mental alertness d) Increased blood glucose levels e) Decreased cardiac output f) Decreased peristalsis
a, c, d The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest.
The nurse provides education about physiological stressors. The nurse recognizes the education to be effective when the client identifies which of the following as physiological stressors? (Select all that apply.) a) Outside temperature of 100 degrees b) Accidental death of a child c) Excessive protein in the diet d) Upper respiratory infection e) Rheumatoid arthritis
a, c, d, e A physiological stressor can include excessive temperatures, infections, illness, and imbalances in nutrition. The death of a child would be a psychological stressor.
A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client? a) Exercise b) Alcohol abuse c) Cocaine use d) Projection
b) Alcohol abuse Alcohol abuse is a common altered coping pattern for individuals with poor coping skills. It is legal and easily accessible. Phrases such as "I just cannot cope" and "I need to numb the pain" are common among those who abuse alcohol.
Which statement correctly explains a person's interactions with basic human needs? a) Stress affects all people in their attainment of basic human needs in the same manner. b) As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. c) Basic human needs and responses to stress are generalized. d) Basic human needs and responses to stress are unaffected by sociocultural backgrounds, priorities, and past experiences.
b) As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. Both the attainment of basic human needs and the adaptation to stress require energy and motivate behaviors. As a person strives to meet basic human needs at each level, stress can be either a stimulus or a barrier. How basic human needs are met and responses to stress are unique to the person, depending on the individual's sociocultural background, priorities, and past experiences. In all people, the failure to meet needs results in an imbalance in homeostatic mechanisms and, eventually, illness.
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? a) Reaction formation b) Compensation c) Projection d) Sublimation
b) Compensation Compensation is overcoming a perceived weakness by emphasizing a more desirable trait or achieving in a more comfortable area. Sublimation involves a person substituting a socially acceptable goal for one whose normal channel of expression is blocked. Projection is a person's thoughts or impulses attributed to someone else. Reaction formation is the development of conscious attitudes and behavior patterns that are opposite to what he would prefer to do.
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? a) Defense mechanism b) Coping mechanism c) Withdrawal behavior d) Stress adaptation
b) Coping mechanism Coping mechanisms are immediate responses and are often involuntary. The heart beating rapidly and hands that are shaking are considered coping mechanisms. The change that takes place as a result of the response to a stressor is stress adaptation. Defense mechanisms protect one's self-esteem and are useful in mild to moderate anxiety; if they are used to an extreme, however, they distort reality and create problems with relationships. Withdrawal is a type of coping mechanism.
A 35-year-old woman comes to the local health center with a large mass is her right breast. She has felt the lump for about a year but was afraid come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this client? a) Chronic Confusion b) Ineffective Individual Coping c) Self-Esteem Disturbance d) Altered Family Process
b) Ineffective Individual Coping Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case the client was unable to access health care even when she was aware the disorder could be life threatening. Self-Esteem Disturbance and Altered Family Process are nursing diagnoses that are often associated with breast cancer, but her ineffective individual coping has created a significant safety risk and is therefore the most appropriate nursing diagnosis. The client's behavior was motivated by fear, not confusion.
A teenager is unable to eat breakfast and is pacing in the house 2 hours before his appointment for his driving road test. He takes the test and passes. The driving test administrator says to the teen, "You did very well. You weren't nervous at all, were you?" What level of anxiety was the teen experiencing prior to and during his road test? a) Panic b) Mild anxiety c) Moderate anxiety d) Severe anxiety
b) Mild anxiety The teenager was exhibiting symptoms of mild anxiety, which includes increased focus and alertness, leading to positive effects. Moderate, severe, and panic levels of anxiety produce negative symptoms ranging from poor concentration to inability to function.
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? a) Reflex pain response b) Resistance c) Alarm reaction d) Exhaustion
b) Resistance This client's situation is an example of the resistance stage of the GAS. Stress is continuing, but the client is maintaining homeostasis. Alarm is the initial stage when major stress is encountered. Exhaustion is when homeostasis can no longer be achieved. The reflex pain response is part of the local adaptation syndrome.
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? a) Tense and relax muscle groups systematically. b) Seek assistance from family and friends. c) Perform meditation to relax. d) Keep the home environment noise free.
b) Seek assistance from family and friends. The nurse should suggest that the client seek assistance from family and friends as a crisis intervention. Adequate support during a crisis and its resolution can help clients realistically perceive the problem and reinstitute coping strategies. Performing meditation, tensing and relaxing muscle groups systematically for progressive relaxation, and keeping the home environment noise free are methods to calm and relax the client that may not necessarily help in crisis intervention.
In contrast to anxiety, fear is characterized by: a) short-term resolution. b) a cognitive response to a known threat. c) the creation of an action plan to deal with a perceived threat. d) a real, rather than perceived, threat.
b) a cognitive response to a known threat. Fear is a cognitive response to a known threat, while anxiety is the emotional response to that threat. Fear does not necessarily resolve in the short term, and an action plan may or may not be formulated by the individual. The fact that fear involves the identification of a known threat does not necessarily mean that the object of fear is objectively real.
The client is a 33-year-old secondary education teacher. Lately, he tells his nurse, there were several incidences of violence in the school where he teaches. What symptoms during the client history and physical examination would indicate that the client is experiencing physical manifestations of stress? Select all that apply. a) difficulty viewing objects more than 100 feet away b) an extra heart sound every fourth to sixth beat c) report of frequent evening headaches relieved by sleep d) a blood pressure of 110/68
b, c Palpitations are a common manifestation of stress. They may be auscultated during exam or detected on an EKG. Tension headaches frequently manifest in the evening and are always relieved. A headache that does not go away is an ominous sign. A blood pressure of 110/68 is normal for an adult man. Problems with distance vision are not associated with stress.
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? a) Meditation b) Biofeedback c) Anticipatory guidance d) Guided imagery
c) 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? a) Guided imagery b) Relaxation c) Anticipatory guidance d) Normalization
c) Anticipatory guidance Anticipatory guidance involves preparing a client psychologically for an event in the knowledge that familiarity reduces anxiety. Guided imagery involves the creation of mental image, not education. Relaxation focuses on the control of the body's responses to stress. Normalization is not a specific stress management technique.
A nurse is working with a 67-year-old Asian American woman on diet changes to help with weight loss. She is explaining her role in the family as the one who prepares the meats for the family, while her daughter is responsible for preparing vegetables. Based on the nurse's knowledge of traditional Asian cultures, the nurse knows what to be true? a) Family is the only thing that is important. b) Older adults never change their eating patterns. c) Families operate in a collectivistic manner. d) Families operate in an individualistic manner.
c) Families operate in a collectivistic manner.
A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a) Decreasing pulse b) Increasing sleepiness c) Increasing energy levels d) Decreasing respirations
c) Increasing energy levels The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness.
A 15-year-old student is on the high school soccer team. She tells a nurse how she has really started to take a leadership role on the team. When the nurse talks with the client's mother, the mother tells the nurse that her daughter's best friend is a natural leader and may be voted team captain next year. The client's behavior is an example of what defense mechanism? a) Lying b) Denial c) Introjection d) Projection
c) Introjection Introjection is when an individual adapts a characteristic of someone else.
A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing? a) Alarm stage b) Primary stage c) Resistance stage d) Exhaustion stage
c) Resistance stage The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress.
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? a) Change the job. b) Take a break from the job. c) Seek professional help. d) Accept the changes.
c) Seek professional help. The client should seek professional help, where he can talk freely about his anger and sense of betrayal. The client should then explore other options in a calmer frame of mind. Changing jobs, compromising, or taking a break from the job will not help the client solve the problem.
A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors? a) Personal hygiene b) Economic status c) Social support d) Eating habits
c) Social support A person's response to stressors depends on social support, intensity of the stressor, number of stressors, duration of the stressor, physical health status, life experiences, coping strategies, personal beliefs, attitudes, and values. A person's response to stressors is independent of education, eating habits, economic status, or personal hygiene.
A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which instruction would the nurse provide in this type of stress management? a) The nurse teaches patients rhythmic breathing to perform prior to the procedure. b) The nurse tells patients to focus on a pleasant place, mentally place themselves in it, and breathe slowly in and out. c) The nurse teaches patients about the pain involved in the procedure and methods to cope with it. d) The nurse teaches patients to create and focus on a mental image during the procedure to become less responsive to the pain.
c) The nurse teaches patients about the pain involved in the procedure and methods to cope with it. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, their anxiety is reduced, which occurs when teaching about the pain involved and related pain relief measures. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.
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 not important? a) a focus of attention b) a quiet environment c) soft music d) an open attitude
c) soft music Music may be helpful for some, but is not essential for meditation.
A medical student is experiencing major life changes—the board exam, an internship, and a wedding all within 2 months of graduation. She is particularly susceptible to which conditions? Select all that apply. a) Acute narrow-angle glaucoma b) Mitral valve prolapse c) Asthma d) Bipolar depression e) Psoriasis f) Rheumatoid arthritis
c, e, f Increased stress (allostatic load) can predispose a person to illness, even if the stressor is a positive event. Psoriasis, rheumatoid arthritis, and asthma are examples of stress-related illness.
A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement? a) "It's so hard to get them into a routine after summer break. I go through this every year with all my kids." b) "We've all been talking to him about what school will be like; his brother had the same teacher and really liked her." c) "I am bringing him to the orientation so he can meet his teacher and some classmates." d) "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."
d) "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."
A nurse interviews a woman who was abused by her partner and is staying at a women's shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a) "Patient displays moderate anxiety related to her situation." b) "Patient manifests panic related to feelings of impending doom." c) "Patient describes severe anxiety related to her situation." d) "Patient expresses fear of her husband."
d) "Patient expresses fear of her husband." Fear is a response (feeling of dread) to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation.
Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? a) Mild anxiety b) Moderate anxiety c) Severe anxiety d) A panic attack
d) A panic attack Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living, and it increases alertness and perceptual fields.
A freshman college student comes to the health clinic reporting insomnia and difficulty concentrating in class. The student has three red, scaly patches of skin on his arms and chest. The nurse believes the primary nursing diagnosis for this client is: a) Sleep Deprivation related to change in living arrangements b) Impaired Skin Integrity related to psoriasis c) Disturbed Thought Processes related to increased scholastic workload d) Anxiety related to stress of achievement in school
d) Anxiety related to stress of achievement in school This student, new to college, is demonstrating classic anxiety symptoms stemming from high stress levels. The best nursing diagnosis would be Anxiety. Sleep deprivation, impaired skin integrity, and disturbances of thought are applicable, but these diagnoses do not address the primary problem.
A child has been admitted to the medical center with severe depression and stress, and has been avoiding going to school for these reasons. How should the nurse attempt to treat the child? a) Administer therapy that alters the child's mood and feelings. b) Administer antidepressants to counter stress. c) Teach the child the importance of being happy and unstressed. d) Find the factors that have caused stress and depression.
d) Find the factors that have caused stress and depression. The nurse in this case should try to find the factors that have caused stress and depression in the child. The nurse should calmly talk to the child and find the reason for his avoiding going to school. The child will not understand the importance of being happy and unstressed. Also, administering therapies or antidepressants is inappropriate.
A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be appropriate for these patients? a) Discouraging over-verbalization of fears and anxieties b) Focusing on the outcome as opposed to the details of the surgery c) Providing time alone for reflection on personal strengths and weaknesses d) Mutually determining expected outcomes of the plan of care
d) Mutually determining expected outcomes of the plan of care Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. Explain all procedures including sensations likely to be experienced during the procedure, and stay with the patient to promote safety and reduce fear.
A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt, the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a) Arrange to have the infant removed from the home. b) Inform other members of the family of the situation. c) Increase the number of visits by the visiting nurse. d) Notify the care provider and recommend respite care for the mother.
d) Notify the care provider and recommend respite care for the mother. Reactions of family members to home health care for long periods of time, called caregiver burden, include chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker and/or arrange for respite care for the family.
