prepu chapter 41 foundations

An individual steps into a tub of very hot water and immediately jumps out again. What mechanism caused this response?

Reflex pain response

Which question would be helpful in eliciting data about the effects of stress during a health history?

"How does your body feel when you are upset?"

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?

"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 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."

The nurse teaches a client about the use of yoga as a stress management intervention. Which client statement indicates to the nurse that learning has taken place?

"It reduces physical and emotional tension through postural changes and focused concentration."

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 old

A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crisis is she experiencing?

Situational

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.

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

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

The nurse walks into the client's room and finds her sobbing uncontrollably. When the nurse asks what the problem is, the client responds, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this client's care plan, the nurse notes a nursing diagnosis of Ineffective Coping related to stress. What is the best outcome the nurse can expect for this client?

Client will adapt relaxation techniques to reduce stress.

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 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

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?

Ineffective Individual Coping

A nurse assigned to a newly admitted client realizes that the client finds the facility environment extremely stressful. What would be most appropriate for the nurse to do to decrease sensory stimulation of the client?

Keep down the conversational noise in the hallway.

An adolescent client is brought to the clinic by the parents, who inform the nurse that they are concerned that the adolescent is using maladaptive coping mechanisms to deal with a bullying issue at school. Which statement(s) by the parents should the nurse report to the health care provider as correlating with the use of maladaptive coping mechanisms? Select all that apply

Our adolescent is sleeping a lot more than usual." "We have tried to discuss the issues so we can find a solution but are met with anger and hostility." "We have found evidence of drug use, which is very unlike our adolescent.

The client has just been informed about having a terminal illness. Which should the nurse anticipate when taking the client's current vital signs

Pulse oximetry: 100%

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

While obtaining an initial assessment of a client, the nurse gathers information about the client's stress history. What would the nurse collect as subjective data?

Structured interview

The emergency department nurse suspects that an older adult client who fell and broke her hip is using a defense mechanism when the client states:

They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight."

A nurse is trying to assess a client's stress type; however, the client is very depressed and quiet and does not reply to the nurse's questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client?

The nurse should demonstrate confidence and expertise.

The nurse is caring for two clients on the same unit. One client states that cold temperatures and loud noises are stressors. The other client says the temperature is fine and the noises do not bother him. What is the difference between the two clients related to these stressors?

The perception and effects of stressors are highly individualized.

Which of the following best describes stress?

a response to changes in the normal balanced state

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 young wife asking everyone repeatedly if they know where her husband is.

A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which stress-reduction technique should the nurse use with this client?

advocate on behalf of the client to others

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?

alcohol use

A client, while driving, hits a small child crossing the road. The child survives with some minor bruises and cuts. The client feels very stressed and is depressed when thinking of the child's injury. Which technique should the nurse implement in this case?

alternative thinking

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 client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?

coping mechanism

A young mother tells the nurse, "I can't stop smoking. That is what I do to make myself feel better." What is the term used to describe this behavior?

coping mechanism

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

coping mechanism.

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

The nurse is describing the effect of stress on the body to a group of health practitioners. Which statements accurately describe the role of stress on the health and illness of clients? Select all that apply.

he health-illness continuum is affected by stress. As the duration, intensity, or number of stressors increases, a person's ability to adapt is lessened. Recovery from illness and return to normal function are compromised by prolonged stress.

The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system?

heart rate of 102 bpm

Which are considered internal stressors? Select all that apply.

illness hormonal change fear

A 65-year-old client has experienced the death of a parent and a family pet in the span of 1 month. Which action is a coping mechanism that demonstrates adaptation?

joining the local garden club

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 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

In evaluating the therapeutic outcome of using biofeedback to help a client work through a stressful situation, the nurse would expect the client to:

maintain vital signs within normal limits.

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

What are examples of psychosocial stressors? Select all that apply.

news reports on television about a war fearing a terrorist attack Being involved in an accident

A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?

nontherapeutic coping strategy

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

A new graduate is having difficulty coping with the role transition from student to registered nurse (RN). Which defense mechanism is being exhibited when the nurse states, "I hate going in to work on weekends. The aides are lazy, the clients are all complaining, and the families are all crazy!"

reaction formation

A client who is a single parent of two small children is working two part-time jobs. The client comes into the clinic for an appointment looking disheveled and fatigued. Which health promotion activities would this client benefit from? Select all that apply.

reduction of stressors perfection reduction

The client is a child age 5 years hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of:

regression.

A nurse teaches a client deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique?

relaxation

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

A client visits a health care facility reporting work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case?

sensory manipulation technique

Which behaviors represent effective coping mechanisms? Select all that apply.

setting limits with family members who upset you learning relaxation techniques taking a vacation

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 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?

soft music

In what phase of the general adaptation syndrome (GAS) is a client who is using all of the physiologic adaptive mechanisms for dealing with stress leaving no defense against the distress?

stage of exhaustion

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

Which group of terms best describes anxiety?

unknown cause, emotional, apprehensive

The client is a new graduate and has been working on a medical-surgical unit for approximately 4 months. The shifts are 12.5 hours in length and 3 to 4 times/week. The nurse recognizes there have been many stressful days on the job and makes a decision to participate in activities to reduce stress. What activities are recommended to reduce stress for the nurse? Select all that apply

walk at a fast pace in neighborhood for 3 to 4 days/week on days not working attend church services of the nurse's faith once a week to facilitate praying participate in an enjoyable hobby, such as painting find a more experienced nurse who could mentor the new nurse

The client is a new graduate and has been working on a medical-surgical unit for approximately 4 months. The shifts are 12.5 hours in length and 3 to 4 times/week. The nurse recognizes there have been many stressful days on the job and makes a decision to participate in activities to reduce stress. What activities are recommended to reduce stress for the nurse? Select all that apply.

walk at a fast pace in neighborhood for 3 to 4 days/week on days not working attend church services of the nurse's faith once a week to facilitate praying participate in an enjoyable hobby, such as painting find a more experienced nurse who could mentor the new nurse

Which emotional clinical manifestations of stress should the nurse anticipate when providing care to an adolescent client?

withdrawal, depression, and angry outbursts