Unit 1 EAQ questions & rationals

The nurse is teaching a patient with diabetes how to self-administer subcutaneous insulin. Which key element should the nurse keep in mind before teaching the patient about health care principles? A. Match the teaching with the patient's capabilities. B. Limit discussion of concepts and facts about health. C. Exclude family members from the teaching plan. D. Include facts about oral medications for diabetes

A When the nurse teaches medical procedures, the teaching should always match the patient's capabilities, and complicated procedures should not be taught to the patient. The nurse should explain concepts and facts about health. The nurse should involve both the patient and family members when teaching. The teaching plan is about insulin injections, so facts about oral diabetic drugs should not be included.

During the assessment interview of an older woman experiencing a developmental crisis, what does the nurse say? A. "How is this flood affecting your life?" B. "Since your husband has died, what have you been doing in the evening when you feel lonely?" C. "How is having diabetes affecting your life?" D. "I know this must be hard for you. Let me tell you what might help."

B A developmental crisis occurs as a person moves through life's stages, including widowhood.

When teaching the patient progressive muscle relaxation techniques, the nurse asks the patient to take deep breaths. What would be the next instruction after breathing deeply? A. Sit in a comfortable position B. Close your eyes and relax C. Relax all the muscle groups at one time D. Alternately tighten and relax specific muscle groups

D Anxiety causes muscle tension and progressive muscle relaxation is a technique used to relax the muscle groups. A person usually achieves a relaxed state after deep chest breathing. Once this is done, the patient is then asked to alternately tighten and relax specific muscle groups. The instructions, "sit in a comfortable position" and "close your eyes," are given before asking the patient to do deep breathing. This helps to relax the body. Not all the muscle groups should be worked on at the same time.

A patient has been advised to have a total knee replacement because of osteoarthritis. The patient is not willing to undergo the surgery, but family members want to get the surgery done to relieve the disability. The nurse explains the details of the surgery and the risks associated with it, and also discuss the patient's wishes with the family. Which nursing role is the nurse playing here? A. Educator B. Caregiver C. Case manager D. Advocate

D As a patient advocate, the nurse's duty is to provide information to help a patient and family members decide whether or not to accept a treatment. As a caregiver, the nurse's role is to help patients maintain and regain health, manage symptoms, and attain maximum functional independence. As nurse educator, the nurse is expected to teach a patient or group of patients about health and self-care activities. As a case manager, the nurse develops a care plan based on the assessment and coordinates other health care resources and services that could help the patient attain the outcome goals.

What is the approximate duration (in weeks) required by a person to resolve a crisis? Record your answer using a whole number.

6 weeks Crisis occurs when a person is under stress and is unable to cope up with it. The event that has caused the crisis usually occurs 1 to 2 weeks before the patient seeks help. A person generally resolves a crisis in some way within approximately 6 weeks.

The nurse with specialized nursing skills is capable of identifying both patient-centered problems and problems related to the health care system. According to Benner, which specialist nurse possesses such skills? A. Expert nurse B. Proficient nurse C. Competent nurse D. Advanced beginner nurse

A According to Benner, the expert nurse has specialized skills and is capable of identifying both patient-centered problems and problems related to the health care system. The expert nurse passes through five levels of proficiency when acquiring or developing these skills. The proficient nurse perceives the clinical situation as a whole, is able to assess an entire situation, and readily transfers knowledge gained from multiple previous experiences. The competent nurse is able to anticipate nursing care and establish long-range goals. The advanced beginner nurse has some level of observational experience with the situation and is able to identify meaningful aspects or principles of nursing care.

A 34-year-old man who is anxious, tearful, and tired from caring for his three young children tells you that he feels depressed and doesn't see how he can go on much longer. What is your best response? A. "Are you thinking of suicide?" B. "You've been doing a good job raising your children. You can do it!" C. "Is there someone who can help you?" D. "You have so much to live for."

A Although this sounds abrupt, the patient usually is relieved that you've broached this issue. For safety reasons it is very important to discuss the patient's suicidal thoughts.

The nursing mentor observes that a nursing student is deficient in communication skills but is good at understanding nursing theories. How should the mentor intervene with respect to this student? A. Help the student build communication skills. B. Utilize the student's services for patient education and rehabilitation. C. Utilize the student's services for coordinating and managing patient care. D. Consider the lack of communication skills unimportant, because sound knowledge ensures a good patient-nurse relationship.

A Communication is an important skill for nurses, so the mentor should help the student build communication skills. This student cannot be utilized for patient education, rehabilitation, or coordinating and managing patient care, because all these activities require good communication skills. Communication skills, not subject knowledge, ensure a good patient-nurse relationship.

The nurse is trying to assess if a patient is free from identity stressors. What would suggest that the patient has a strong identity? A. The patient has been happily married for 10 years. B. The patient exercises daily. C. The patient does not abuse substances. D. The patient is involved in church activities.

A Identity achievement is reflected by a patient's intimate relationships. The patient who has been happily married for 10 years probably has a strong identity. Positive behaviors such as exercising daily, not abusing substances, and being involved in church activities do not indicate that the patient is free of identity stressors.

The nurse determines that a patient is experiencing repeated failures, having conflicts, with others, and is more dependent on his or her parents. Which component of self-concept is affected in the patient? A. Identity B. Self-esteem C. Body image D. Role performance

A Identity is defined as an internal sense of individuality, wholeness, and consistency of a person in different situations. The experiences of repeated failures, conflicts with others, and dependency on parents disturb the internal sense of individuality and consistency of an individual. Therefore, identity is affected in the patient. Self-esteem is an individual's overall feeling of self-worth or the emotional appraisal of self. Body image is the physical appearance, structure, and function of the person. The individual has significant roles throughout life. Failure in meeting role expectations results in deficits.

While teaching about Quality and Safety Education for Nurses (QSEN) competencies, the nurse states, "This competency uses tools such as flowcharts and diagrams to make the process of care explicit." Which QSEN competency is the nurse referring to? A. Quality Improvement B. Patient-Centered Care C. Evidence-Based Practice D. Teamwork and Collaboration

A Quality Improvement is the Quality and Safety Education for Nurses (QSEN) competency that uses tools such as flowcharts and diagrams to make the care process explicit. The Patient-Centered Care competency involves family and friends in care and elicits the patient's values and preferences, providing care with respect for the diversity of the human experience. Evidence-Based Practice demonstrates knowledge of basic scientific methods, appreciates the strengths and weaknesses of scientific bases for practice, and recognizes the importance of regularly reading relevant journals. Teamwork and Collaboration recognizes the contributions of other health team members and the patient's family members and discusses effective strategies for communicating and resolving conflict.

When teaching a patient about the negative feedback response to stress, what does the nurse include to describe the benefits of this stress response? A. It results in the neurophysiological response B. It reduces body temperature C. It causes a person to be hyperviligant D. It reduces the level of consciousness to conserve energy

A The process of negative feedback senses an abnormal state such as lowered body temperature and makes an adaptive response such as shivering to generate body heat to return the body to hormonal homeostasis.

A patient lost a job recently due to poor performance at work and has no alternative source of financial support. The patient reports difficulty sleeping and loss of appetite. On medical examination, there is no organic cause found for the patient's symptoms. Which defense mechanism is the patient using? A. Conversion B. Dissociation C. Identification D. Displacement

A There are different types of ego-defense mechanisms used to cope with stressors. In conversion, anxiety is repressed unconsciously, which is then transformed into nonorganic symptoms such as difficulty sleeping or loss of appetite. In dissociation, the patient may experience a subjective sense of numbness and reduced awareness of his or her surroundings. In identification, a person assumes the qualities, characteristics, and actions of another person. In displacement, a person transfers his or her emotions from a stressful situation to a less anxiety-producing substitute.

A family of three consisting of a husband, wife, and son were involved in a motor vehicle accident. The husband and wife did not sustain any major injuries, but the child died. What could be the possible outcome of this accident? A. the husband may have a situational crisis B. The wife may have a developmental crisis C. The husband may have a developmental crisis D. The husband and wife may have a adventitious crisis

A A situational crisis occurs when external sources such as a job change, motor vehicle crash, death, or severe illness trigger stress. Therefore, all the people who survived the accident may have a situational crisis. A developmental crisis occurs when there is a change in the developmental stage of a person such as a marriage, the birth of a child, or retirement that requires new coping styles. Therefore, the husband and wife will not have a developmental crisis. An adventitious crisis occurs in situations of a major natural disaster, man-made disaster, or a crime of violence. Therefore, none of the survivors will have an adventitious crisis.

A patient mentions to the nurse that she recently lost her husband in a car accident. Which behaviors could the nurse identify as denial defense mechanisms? A. Not accepting the death of her spouse B. Not sleeping and eating C. Not disclosing her feelings to anyone D. Being speechless and numb E. Shouting and blaming God for her loss

A, B A denial defense mechanism is a reaction to emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Not discussing the loss and not accepting the loss are both denial defense mechanism behaviors. Cessation of eating and sleeping is a conversion defense mechanism. Being speechless and numb are examples of dissociative defense mechanisms. Shouting and blaming God for the loss is an example of the displacement defense mechanism.

What can cause an adventitious crisis in a person? (select all that apply) A. Tsunami B. earthquake C. child birth D. death of a pet E. Leg amputation

A, B An adventitious crisis can be triggered by a major natural disaster, a man-made disaster, or a crime of violence. Therefore, a tsunami or earthquake can result in an adventitious crisis. Childbirth, the death of a pet, or a leg amputation can cause a situational crisis.

A patient in labor has been brought to the certified nurse midwife (CNM). Which interventions should the CNM undertake in this situation? A. Conduct the labor. B. Provide care for the newborn. C. Administer uterine relaxants and refer the patient to a tertiary center. D. Perform C-section surgery. E. Provide a physical presence until the patient has been transferred to tertiary care.

A, B Certified nurse midwives (CNM) are nurses trained in providing care in pregnancy, conducting labor, and providing care to the newborn. The CNM does not have the authority to administer uterine relaxants. Performing a C-section exceeds the scope of practice for a CNM.

The nurse is assessing a patient who developed posttraumatic stress disorder (PTSD) after witnessing a plane crash. What would be the findings in this patient? A. Nightmares of the plane crash B. flashback of the plane crash C. significant weight loss D. hearing strange voices at night E. seeing strange faces at night

A, B Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs when a person witnesses or experiences a traumatic event, in this case, the plane crash. It may manifest as nightmares, flashbacks, and intrusive recollections of the event. Patients may also respond by attempting suicide or by substance abuse. A significant weight loss is usually seen in patients with depression. Auditory and visual hallucinations are seen in patients with schizophrenia.

The nurse educator is delivering a lecture on nursing as a profession to a group of nursing students who have recently joined the baccalaureate nursing degree course. Which statements are true? A. "The nurse is responsible to provide specific health care to patients." B. "The nurse is responsible and accountable to the patients." C. "Nurses have to follow a specific code of ethics while delivering care." D. "Care delivery by nurses is only based on orders given by the health care provider." E. "Nursing education involves learning the caregiving techniques without any theoretical body of knowledge."

A, B , C Nursing is a profession that involves administering quality patient-centered care in a safe and knowledgeable manner. The nurse provides a specific kind of health care to patients. The nurse is responsible for the care delivered to the patient and is accountable to the patients. Ethical health care delivery is a very important characteristic of the nursing profession. Nurses have the right to participate in the decision-making process for the patient, so they need not always rely on the prescription given by the health care provider for delivering care. Nursing education includes a theoretical body of knowledge leading to defined skills, abilities, and norms.

The nurse is undergoing crisis intervention training. What activities are performed during a crisis intervention approach? A.Helping the patient make the mental connection between the stressful event and his or her reaction to it B. Helping the patient become aware of present feelings such as anger, grief, or guilt C. Helping the patient explore coping mechanisms, and identifying new methods of coping D. Helping the patient decrease social contacts to protect against further crisis E. Helping the patient to focus on all other problems including the crisis

A, B, C A crisis intervention is a specific type of psychotherapy. It can be provided by any trained member of the health care team. In most cases, the patient may be unaware of the complete picture. This approach helps the patient to make a mental connection between the stressful event and his reaction to it. Becoming aware of present feelings such as anger, grief, or guilt helps the patient to reduce tension. Through this approach, the patient may explore new coping mechanisms. The crisis intervention approach helps the patient to make social contacts and prevents isolation. The approach uses problem solving related to the specific crisis.

A patient is diagnosed with breast cancer. She is upset about the diagnosis. What questions should the nurse ask to assess the coping skills of the patient? A. "What is bothering you most right now?" B. "Have you started drinking and smoking?" C. "Has your caffeine intake increased?" D. "What is your monthly income?" E. "How far is the health care clinic from your house?"

A, B, C Asking the patient about the issues bothering her helps the nurse understand the patient's concerns. Asking whether the patient has started drinking and smoking or has increased her caffeine intake checks the patient's maladaptive skills. Information about monthly income and the distance of the clinic from the patient's home does not help assess coping skills.

What elements influence the achievement of identity in a person? A. Sexuality B. Gender C. Ethnicity D. Place of birth E. Physical appearance

A, B, C Identity is the individual's sense of individuality. Sexuality and gender are essential components of identity. Ethnicity or racial differences are integral to a person's identity because they identify a person within an established set of values, traditions, customs, and rituals. The place of birth and physical appearance do not necessarily influence identity. p. 703

What are the common responses associated with general adaptation syndrome (GAS)? A. Alarm B. Resistance C. Exhaustion D. Helplessness E. Intrusive recollection

A, B, C The alarm stage is the stage of GAS that is characterized by the responses of fight or flight due to adrenal hormones. Resistance is a stage of GAS where the patient will show a response due to activation of the parasympathetic nervous system. Exhaustion is a stage of GAS that may lead to stress-induced illness or death. Helplessness and intrusive recollections are responses that occur in a person due to posttraumatic stress disorder.

The nurse is assessing a 47-year-old, female patient who has been recently diagnosed with carcinoma of the right breast. Her left breast was removed 2 years ago for the same reason. What symptoms in the patient may indicate ineffective coping? A. The patient appears poorly groomed B. The patient complains of weight gain C. The patient laughs inappropriately D. The patient is able to meet her basic needs E. The patient responds accurately to questions

A, B, C The nurse should be aware of the characteristics that define ineffective coping. These include poor grooming, weight gain, and inappropriate laughing or crying. A patient who is able to meet basic needs and responds accurately to the questions asked demonstrates effective coping skills.

The nurse is planning to obtain a master's degree in nursing. Which role can the nurse with a master's degree in nursing fulfill? A. Nurse educator B. Nurse administrator C. Advanced practice registered nurse D. Nurse researcher E. Physical therapist

A, B, C, D A master's degree can be pursued after a baccalaureate program. With a master's degree in nursing, a nurse can become a nurse educator, nurse administrator, advanced practice registered nurse (APRN), and researcher. A physical therapist earns a degree in physical therapy, not nursing.

Which roles and responsibilities should every nurse be expected to fill? A. Caregiver B. Autonomy and accountability C. Patient advocate D. Health promotion E. Lobbyist

A, B, C, D Each of these roles includes activities for the professional nurse. Each is used in direct care or is part of the professionalism that guides nursing practice. Some nurses are lobbyists, but being a lobbyist is not expected of all professional nurses.

Nursing is important in providing safe, patient-centered health care to the global community. Which statements are true about the nursing practice? A. Nursing practice helps shape health policy and health systems management. B. Nursing practice involves collaborative care of sick individuals of all ages, families, groups, and communities. C. Nursing practice involves helping a dying patient find relief from pain. D. Nursing practice involves interpreting clinical situations and making complex decisions based on knowledge and experience. E. Nursing practice does not incorporate ethical and social values but only knowledge of behavioral sciences.

A, B, C, D Nursing is an art and a science. The practice of nursing incorporates elements including clinical practice, education, research, management, and administration, all of which directly or indirectly have prominence in providing safe, patient-centered health care. Helping a patient achieve the goals of the therapy and educating a patient are steps towards the mission. Interpreting clinical situations and making decisions that benefit patients are integral to nursing. Nursing practice involves collaborative care of individuals of all ages, families, groups, and communities, sick or well. Nursing practice incorporates ethical and social values with the knowledge of behavioral, biological, and physiological sciences.

Which events in life can alter the self-concept of a person significantly? A. Having a child B. Losing a child C. Being promoted at work D. Taking an exam at school E. Being diagnosed with a chronic illness

A, B, C, E Having a child changes the role of a person to a parent and affects a person's self-concept. Losing a child brings shock and depression, which negatively influence the self-concept. Being promoted at work boosts an individual's self-concept. A diagnosis of a chronic illness may reduce the self-esteem of the patient considerably. Events such as taking an exam would not influence an individual's self-concept.

The nurse is attending to a 46-year-old female patient who suffers from chronic stress due to conflicts with her husband. Which physiological problems is the patient predisposed to? (select all that apply) A. Hypertension B. Depression C. Sleep deprivation D. Bipolar disorder E. Chronic fatigue syndrome

A, B, C, E When the stress response is chronically activated, the heart rate, blood pressure, and cardiac output are also chronically raised, which cause excessive wear and tear on the body. It can further lead to hypertension, depression, sleep deprivation and chronic fatigue. The chronic elevation of the heart rate, blood pressure, and cardiac output do not cause bipolar disorder, which is a psychiatric disorder.

The nurse is performing a first-time assessment of a patient who is extremely stressed. Which are the objective assessments documented by the nurse in the assessment sheet? A. Patient's behavior B. appearance of the patient C. changes of diet in the patient D. blood pressure of the patient E. Social support of the patient

A, B, D Objective assessments are the assessments that are done through observation or measurement. Information such as the patient's behavior and appearance can be observed by the nurse. Blood pressure assessment is also done by the nurse. Thus, these are considered objective assessments. As the nurse is assessing the patient for the first time, the nurse cannot observe the patient's change in diet; the nurse has to ask the patient for this information. The nurse would have to ask the patient regarding the social support system (family, co-workers, etc.). Thus, these assessments would come under subjective assessments.

A registered nurse has recently started her nursing career by joining a cardiac care unit. The mentor explains the duties of the nurse. The mentor states that the nurse does not require any permission or orders to give routine hygiene care measures. The nurse's duty is to provide holistic care to the patient. Which aspects of nursing do these duties illustrate? A. Caregiving B. Autonomy C. Educating D. Accountability E. Patient advocating

A, B, D Providing all-around care is an example of the nurse's caregiver role. Nursing interventions such as performing hygiene procedures for a patient do not require medical orders. This is an example of autonomy in nursing care. Accepting responsibility for the nursing care provided to a patient is an example of accountability in nursing care. The nurse educator teaches a patient or group of patients about health and self-care activities. The patient advocate provides information to help the patient and family members decide whether to accept a treatment and otherwise make health care-related decisions.

Which external forces influence current nursing practices? A. Bioterrorism B. Affordable Care Act C. Health insurance policies D. Static demographic factors E. Medically underserved people

A, B, E Multiple external forces affect nursing. Bioterrorism could be a reality in the near future, and nurses should have the adequate knowledge and education to handle a disaster associated with bioterrorism. The Affordable Care Act is an external influence on health care. Medically underserved people also influence nursing practice. In order to serve this population, nurses may need to promote health and disease prevention to the homeless, mentally ill, and other people who do not have adequate access to health care services. Health insurance policies do not influence nursing practices, nor do static demographics.

A 45-year-old single mother lives with her 10-year-old son who has Down syndrome. The patient's facial expressions and mannerisms demonstrate fatigue and malaise. She has an unkempt appearance and has no interest in going out and meeting people. The nurse understands that the patient is experiencing caregiver role strain. What interventions should the nurse plan for the mother and son? A. refer the son to respite care B. refer the patient to support groups C. prescribe the patient antidepressants D. Admit the patient to a psychiatric ward E. Advise the patient to do yoga and meditate

A, B, E The priority nursing intervention should be the son, who has Down syndrome. The son can participate in respite care. This would reduce the caregiver burden much more successfully than in-home services. Other measures that can reduce stress in the mother include referring her to support groups to seek help. These groups help to lower stress related to caregiving. The patient can also do yoga and meditation to manage stress. Prescribing antidepressants to the mother is not required as she is not depressed. The patient does not suffer from a psychiatric illness; therefore, admission to a psychiatric ward is not required.

Nurses are responsible for the quality of care provided to patients. Which will help nurses practice safe nursing? A. Acquiring knowledge B. Minimizing documentation C. Improving competencies D. Acquiring technical skills E. Exhibiting complete dependence

A, C, D The nursing profession is accountable for the type and quality of care delivered to patients, so nurses should prepare by acquiring and updating knowledge, improving competencies, and acquiring technical skills. Avoiding documentation may generate more complications, such as legal issues. Nurses are given autonomy for various nursing practices, so they should be dependent only in aspects of care beyond their scope of practice.

The nurse is working in a health care unit in which there have been rapid changes in health care technology systems in a short time. The nurse is unable to become comfortable with the new systems and is exhausted. The nurse feels a sense of failure and a lack of identity. What does the nurse do now? A. Identify limits and responsibilities at work. B. Spend more time at work to learn the new technology. C. Strengthen friendships outside of the workplace. D. Spend off-duty hours in activities such as sports, music, or painting. E. Spend on-duty hours researching the new technologies.

A, C, D The symptoms indicate that the nurse is experiencing burnout. The nurse should now make behavioral changes to cope with workplace stress. These include identifying the limits and responsibilities at work, which helps to focus the nursing efforts. Strengthening friendships outside of the workplace helps the nurse to obtain some relief from workplace stress. Spending off-duty hours engaged in interesting activities such as sports, music, or painting helps the nurse to de-stress. Spending more time at work to learn new technologies or do research would worsen the burnout.

The nurse educator is delivering a lecture on nursing as a profession to a group of nursing students who have recently joined the baccalaureate nursing degree course. The nurse is explaining the nursing processes by giving examples. Which examples should the nurse give while explaining nursing assessment? A. Recording body temperature two hours after administering antipyretic medication. B. Teaching the patient about the lifestyle changes required to reduce the risks of having coronary artery disease. C. Asking the patient about hygiene and sanitation in the patient's community. D. Asking the patient to demonstrate the technique of breast self-examination after teaching the technique. E. Identifying the signs of respiratory distress in a hospitalized patient.

A, C, E The nurse is responsible for collecting comprehensive data about the patient's health. The nurse records the body temperature after 2 hours to assess the effectiveness of the antipyretic medication. The nurse also asks the patient about the hygiene of the surrounding environment to assess the risk of acquiring infections caused by unhygienic surroundings. Nursing assessment also includes identifying the signs of a particular condition. Teaching a patient about the lifestyle changes required to reduce risks of ischemic heart disease is an example of the nursing process of implementation, not assessment. Asking the patient to demonstrate a technique after teaching it forms a part of the evaluation process, not the assessment process.

The nurse is teaching a group of nursing students about the general adaptation syndrome (GAS). What is true about this phenomenon? A. It is triggered directly by a physical event. B. It consists of four stages of reaction to stress. C. It is triggered directly by a psychological event. D. It involves the autonomic nervous and endocrine systems. E. It is initiated by the pituitary gland after a physical injury

A, D, E The GAS is the body's response to stress. It is triggered directly by a physical event. It involves many body systems, especially the autonomic nervous and endocrine systems. When the human body is subjected to physical or emotional stress, the pituitary gland initiates the GAS. It consists of three stages including the alarm reaction, the resistance stage, and the exhaustion stage. The GAS can be initiated indirectly by a psychological stress.

The nurse is assessing a patient who is under immense psychological stress. The nurse finds that the patient shows classic signs of the alarm reaction stage of general adaptation syndrome. What are the signs and symptoms of this stage? A. Increased heart rate B. Low blood pressure C. Constricted pupils D. Increased blood glucose levels E. Increased mental alertness

A, D, E The alarm reaction stage is the first stage of general adaptation syndrome, which is initiated due to a sudden increase in the activity of the pituitary gland in response to stress. Due to an increase in the hormonal levels and the activity of the autonomic nervous system, there is an increase in heart rate, blood pressure, and blood glucose levels. The person is highly alert and the pupils of the person dilate in order to increase the field of vision.

A 35-year-old patient approaches the nurse for advice about her children, who are ages 8 and 3 years. The patient informs the nurse that the older son likes drinking milk from his brother's sippy cup. What should the nurse explain to the woman? A. The elder son is using a regression defense mechanism. B. The elder son will develop psychiatric disorders in future. C. The elder son is using a displacement defense mechanism. D. The elder son will develop intellectual disability in the future. E. The elder son obtains psychological protection from stress with this behavior.

A, E Regression is a defense mechanism that happens unconsciously to cope with a stressor. It includes actions and behaviors related to an earlier developmental period in life. Defense mechanisms, as a rule, do not result in psychiatric disorders but are very helpful in coping with the stress. The use of defense mechanisms does not predict the development of a psychiatric disorder in the future. Drinking milk from the younger brother's cup is an example of regression; it is not an example of displacement. The use of defense mechanisms does not predict the development of an intellectual disability in the future.

A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse's first assessment for stress, what does the nurse say? A. "Tell me who I can call to help you." B. "Tell me what bothers you the most about this experience." C. "I'll contact someone who can help get you temporary housing." D. "I'll sit with you until other family members can come help you get settled."

B A patient's appraisal of the crisis is the most important area to address first.

The nurse manager is teaching about levels of stress prevention according to the Neuman Systems Model. What information does the nurse include in the teachings? A. Secondary prevention occurs before definitive symptoms appear. B. Rehabilitation of physically challenged persons is called tertiary prevention. C. Polio vaccination to children with Down syndrome is tertiary prevention. D. Prevention of diseases is primary prevention and stress prevention is tertiary prevention.

B According to the Neuman Systems Model, there are three levels of prevention: primary, secondary, and tertiary. Tertiary prevention starts as a person recovers from irreversible damage. One of the examples of tertiary prevention includes rehabilitation of a physically handicapped person. Secondary preventive measures, including investigations and treatment, are taken after the symptoms have occurred. In primary prevention, measures are taken before the occurrence of symptoms and providing vaccination is one such measure. Stress prevention is a form of primary prevention.

The nurse is assessing a recently married patient who is stressed due to responsibilities towards family and work. The patient tells the nurse that being single was better than being married. What kind of situation or crisis does the patient have? A. situational crisis B. developmental crisis C. post traumatic stress disorder D. General adaptation syndrome

B Crisis occurs when the intensity of stress is beyond the patient's ability to cope. There are three different types of crisis: developmental, situational, and adventitious. A developmental crisis occurs when a new developmental stage occurs in a person's life such as a marriage, the birth of a child, or retirement. A situational crisis occurs when external sources such as a job change or motor vehicle crash provoke stress. Posttraumatic stress disorder occurs when a person experiences a traumatic incident and responds with intense fear and helplessness. The stress in this patient is not due to a traumatic incident. General adaptation syndrome is not a type of crisis. It refers to the process of reaction to stress.

A crisis intervention nurse is working with a mother whose Down syndrome child has been hospitalized with pneumonia. During this hospitalization, the mother lost her entitlement check. When should the nurse expect the mother to regain stability? A. After 2 weeks when the child's pneumonia begins to improve B. After 6 weeks when she adjusts to the child's respiratory status and reestablishes the entitlement checks C. After 1 month when the child goes home and the mother gets help from a food pantry D. After 6 months when the child is back in school

B Generally, a person resolves the crisis and reaches psychological equilibrium in about 6 weeks.

A child performs poorly in mathematics and finds it difficult to improve even after spending more time studying. Which behavior shows that the child is using compensation as a defense mechanism? A. The child is taking lessons from an experienced math tutor. B. The child is practicing more music because the patient is good at music. C. The child is taking herbal supplements to improve memory. D. The child is eating nutritious food and practicing yoga.

B In compensation, a person makes up for a deficiency by strongly emphasizing a feature that is considered an asset. The child uses musical skill as compensation for poor performance in math. Taking math lessons is not a defense mechanism; it is a corrective action to improve competency in math. Taking herbal supplements, eating nutritious food, or practicing yoga are emotion-focused coping skills.

The nurse cares for a family of four, offering routine medical care throughout the year. Which member of the family does the nurse expect to exhibit the highest levels of self-esteem? A. A 42-year-old father B. A 8-year-old little boy C. A 15-year-old girl D. A 71 year old grandmother

B Low self-esteem is a risk factor for health problems, so the nurse would monitor this in a family that he or she sees often. Self-esteem is highest in childhood. When a person reaches adolescence, self-esteem levels decline. Self-esteem then gradually rises during adulthood and again declines slightly in old age. The pattern may vary slightly in individuals but seems unaffected by gender, socioeconomic status, and ethnicity. The 8-year-old boy is in the childhood stage and thus is expected to show the highest levels of self-esteem in the family. The father will have high self-esteem but it may not be as high as in the child. The girl, an adolescent, will generally have a low level of self-esteem. The grandmother is elderly and thus is expected to have a lower level of self-esteem.

A patient is experiencing chronic stress. Which gland in the patient's body will initiate the general adaptation syndrome (GAS)? A. Parotid gland B. Pituitary gland C. Pineal gland D. Adrenal gland

B The general adaptation syndrome is a three-stage reaction that describes how the body responds to stressors through different stages. When the body encounters a physical demand such as an injury, the pituitary gland initiates the GAS. The parotid gland secrets saliva and is not related to the GAS. The pineal and adrenal glands do not initiate the GAS.

Which nursing roles may have prescriptive authority in their practice? A. Critical care nurse B. Nurse practitioner C. Certified clinical nurse specialist D. Charge nurse E. Orthopedic nurse

B, C Nurse practitioners and certified clinical nurse specialists encompass the role and preparation of the advanced practice registered nurse. According to the American Nurses Association standards of practice, prescriptive authority may be granted to these nurses.

A head nurse is explaining to student nurses about the different levels of interventions that are used to prevent stress. What activities are included in the primary level of prevention? (Select all that apply) A. Symptom management B. Identifying individuals at risk C. Identifying populations at risk for developing stress D. Teaching Time-management techniques to patients E. Teaching relaxation techniques to patients

B, C Nursing interventions to prevent stress are divided into three levels: primary, secondary, and tertiary. At the primary level, nursing activities are directed towards identifying individuals and populations who are possibly at risk. The secondary level involves actions directed towards the management of symptoms. The tertiary level interventions help the patient to readapt to the changes in health status. It includes relaxation and time-management techniques.

The nurse works in a psychiatric unit. The nurse understands that appraisal leads to an event being perceived as stressful. Which points are true about appraisal? (select all that apply) A. Appraisal is the person's effort to manage stress. B. Primary appraisal refers to evaluating an event for its personal meaning. C. Appraisal is how people interpret the impact of the stressor on themselves. D. Appraisal is how people interpret an event and react to it. E. Appraisal is making up for a deficiency in one aspect of self-image.

B, C, D Primary appraisal is evaluating an event for its personal bearing. Appraisal is how people interpret the impact of the stressor on themselves or on what is happening and what they are able to do about it. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. An effort to manage stress is called coping.

The nurse is caring for a patient who lost his spouse in an accident. Which assessment findings would indicate ineffective coping in the patient? A.Accurate response to questions asked B. Inability to fall asleep at night C. Inappropriate laughing D. Lack of interest in food E. Inability to concentrate

B, C, D, E Ineffective coping manifests as a change in sleep pattern. The patient may not be able to fall asleep at night. The patient may show inappropriate behavior such as laughing without a reason. The patient may have a change in appetite and may lack interest in food. The patient may not answer the questions properly due to an inability to concentrate. An accurate response to questions asked indicates effective coping.

A patient is diagnosed with breast cancer. She is upset about the diagnosis. What assessment findings indicate ineffective coping related to the stress of her illness? A. The patient gives appropriate answers to the questions asked. B. The patient sleeps excessively. C. The patient laughs inappropriately. D. The patient shows lack of interest in food. E. The patient has lost 11 lbs (5 kg) of weight in 2 weeks.

B, C, D, E Sleeping excessively is an ineffective coping mechanism to escape reality. Laughing inappropriately is an inappropriate behavior and indicates ineffective coping. A lack of interest in food may indicate depression and ineffective coping. Similarly, weight loss may be a sign the patient is not coping well. Giving appropriate answers to questions indicates the patient is able to concentrate and implies that the patient is coping well with the illness.

The nurse is caring for a 16-year-old patient who is under immense stress. He is depressed because his mother had a stroke and he is the only caregiver. The nurse previously prepared a care plan and asked the patient to follow the same at home. The patient came back for reevaluation after 1 month of the initial appointment. Which questions should the nurse ask in order to find out the effectiveness of the interventions? A. "How is your mother?" B. "Has your fatigue level decreased?" C. "Which music do you prefer listening to?" D. "What changes have you brought about in your day-to- day life?" E. "How will you perform the progressive relaxation technique?"

B, D During reevaluation, the nurse should ask questions that would reflect upon the effectiveness of the patient's care plan. The nurse should ask whether the stress and fatigue levels have reduced and what changes the interventions have brought to his daily life. Asking about his mother's recovery is irrelevant to assessing the effectiveness of the plan. Asking about the type of music the patient prefers listening to should be done during the initial assessment, because listening to music could be an effective intervention to induce relaxation. Understanding of the progressive relaxation technique should be assessed during evaluation in the first session.

The nurse is explaining the physiological mechanism underlying the fight-or-flight mechanism to a patient. The nurse says that the medulla oblongata plays a major role in controlling the response of the body to a stressor. What are the functions of medulla oblongata when the body is stressed? A. Constricted pupils B. Increased respiratory rate C. Increased mental alertness D. Increased blood pressure E. Increased blood glucose levels

B, D Through its connection via the autonomic nervous system, the medulla oblongata is responsible for increasing respiratory rate, heart rate, blood pressure, and respirations as a response to stress. Increased alertness is due to the action of the reticular formation. Increased blood glucose levels occur due to the action of the pituitary. Dilated, not constricted, pupils are a response to stress.

The nurse is learning about the standards of nursing practice. Which activities are part of the practice of implementation? A. Developing strategies for patient care B. Educating patients for health awareness C. Analyzing assessment data for diagnosis D. Using therapeutic procedures for patient care E. Providing consultation to enhance patient care

B, D, E Implementation is when the nurse actually uses and performs particular actions or puts a strategy into use. Educating patients, using therapeutic knowledge, and providing consultation all provide opportunities for the nurse to implement skills. Developing strategies for patient care is a part of planning in nursing practice. Analyzing the assessment data is part of diagnosis in nursing practice.

The health care provider asks the certified registered nurse anesthetist (CRNA) to provide spinal anesthesia to a patient who is scheduled for a hernia operation. What is the CRNA's next step? A. Provide the anesthesia under the supervision of a senior nurse. B. Inform the health care provider that the CRNA has the right to provide spinal anesthesia only in a tertiary setup. C. Provide the anesthesia under the supervision of a primary health care provider with knowledge of surgical anesthesia. D. Inform the health care provider that the CRNA's services are restricted to nonsurgical procedures.

C A certified registered nurse anesthetist (CRNA) is trained at an anesthesia-accredited program. The nurse has the right to provide surgical anesthesia under the supervision of a primary health care provider with knowledge of surgical anesthesia. The CRNA should provide anesthesia only under the supervision of a primary health care provider. The CRNA can provide anesthesia even in a primary set-up, under supervision. CNRA services may be utilized even for surgical procedures.

Which statement made by a patient with cancer reflects positive thoughts about personal health? A. "I will not get better soon." B. "I am a burden to my family." C. "I have the ability to get well quickly." D. "I can't stand to look at myself anymore."

C A person's belief about personal health helps the nurse to understand the patient's self-concept. The patient who feels he or she has the ability to get well reflects positive thoughts about personal health. A verbalization such as, "I will not get better soon," indicates that the patient is suffering from chronic illnesses. If the patient states that he or she is a burden to his or her family, it indicates negative perceptions about personal health. The patient who states, "I can't stand to look at myself anymore" is indicating that he or she does not have positive thoughts about personal health.

Which type of crisis is an earthquake that has killed more than 7000 people? A. situational crisis B. maturational crisis C. adventitious crisis D. developmental crisis

C An adventitious crisis is also known as a disaster crisis. It occurs due to a major natural disaster or man-made disaster. A situational crisis occurs due to external sources such as a job change, a motor vehicle crash, or severe illness. A maturational crisis is also known as a developmental crisis. Developmental stages such as marriage, pregnancy, and the birth of a child require new coping styles. Failure to cope with the exposure to stressors during these stages leads to developmental crises.

The nurse observes that a patient whose home life is chaotic including intermittent homelessness, a child with spina bifida, and an abusive spouse who appears to be experiencing an allostatic load. As a result, what does the nurse expect to detect while assessing the patient? A. post traumatic stress disorder B. Rising hormone levels C. Chronic illness D. return of vital signs to normal

C An increased allostatic load can result in long-term physiological problems and chronic illness. Posttraumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage. Vital signs return to normal in the resistance stage.

Due to a shortage of staff, the nurse has been on duty for both morning and night shifts for the last 2 days. Which role performance is the nurse experiencing? A. Role strain B. Role conflict C. Role overload D. Role ambiguity

C Every person undergoes numerous role changes throughout life. Role overload is not being able to meet the demands of work and carve out some personal time for family. Therefore, the nurse is experiencing role overload in this situation. Role strain is the expression of feelings of frustration due to an illness or inadequate satisfaction. Role conflict occurs when a person has to assume two or more roles that are inconsistent and contradictory. Role ambiguity is unclear role expectations that create stress and confusion.

A head nurse is teaching the physiology of fight-or-flight responses to student nurses. Which system is responsible for these phenomena? A. Renin-angiotensin system B. Respiratory system C. Sympathetic nervous system D. Parasympathetic nervous system

C People experience stress in day-to-day activities. Stress stimulates thinking processes and helps people to be alert. The fight-or-flight response helps a person to prepare for action. These responses occur because of the arousal of the sympathetic nervous system. The renin-angiotensin system helps in maintaining electrolyte and fluid balance. The respiratory system does not initiate fight-or-flight responses. The parasympathetic system counteracts the action of the sympathetic nervous system.

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what does one of the first assessments include? A. The amount of family support B. A 3-day diet recall C. A thorough physical assessment D. Threats to safety in the home

C Physical causes for problems need to be discovered before treatment for psychosocial problems can be initiated.

Which event in the patient's life would be considered stress occurring due to a maturational factor? A. Adjusting to an acute illness B. Transferring to a job in a new location C. A changing family structure because of divorce D. The uncertainty associated with treatment methods

C There are numerous factors affecting the individual's life span. Maturational factors affect the mood of an individual and vary according to the life stage. Therefore, the changing of family structure because of divorce is a maturational factor producing stress in an individual. Situational stress arises from personal or family health changes or job relocation. These factors include adjusting to illness, transferring a job to a new location, and uncertainty associated with treatment methods. p. 775

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. What is the nurse's first response? A. Don't be sad, people live with cancer everday B. Have you thought about how you'll tell your family? C. I can sit with you for a while, if you'd like to talk D. I know another patient whose colon cancer was cured with surgery

C Ask the patient if he would like you to sit down for a few minutes so he can talk. Asking an open-ended question and providing an opportunity for the patient to talk allow the nurse to assess the patient's perception of the situation, which is of utmost importance.

Which structures in the body control the response to a stressor? (select all that apply) A. Pons B. Thyroid gland C. Pituitary gland D. Medulla oblongata E. The reticular formation

C, D, E Response to stress works through a negative feedback system. The structures that control these responses are the pituitary gland, medulla oblongata, and reticular formation. The pituitary gland is a small gland situated below the hypothalamus. It produces hormones necessary for adaptation to stress. The reticular formation is a small cluster of neurons situated in the brainstem and spinal cord that monitors the physiological status of the body. The medulla oblongata is situated in the lower part of brainstem and controls blood pressure, heart rate, and respirations. The pons and thyroid gland are not activated during a stress response.

While interviewing a patient who is experiencing a developmental crisis, the nurse is assessing the patient's perception of stressors. Which question should the nurse ask during the assessment? A. Do you live alone or with others? B. Do you have high blood pressure? C. Have you started smoking or drinking? D. What is bothering you most right now?

D Stressors are tension-producing stimuli. The nurse assesses the patient's perception of the stressor when there is a problem that the patient cannot solve. Therefore, the nurse asks the patient about what aspects, if any, are bothering him or her. To determine the patient's coping style and method, the nurse asks the patient about living conditions in order to assess situational support. The nurse asks the patient about blood pressure control to determine the patient's adherence to health care practices. The nurse also asks the patient about habits such as drinking and smoking to determine the coping strategies used during stress.

The nurse is evaluating the coping success of a patient experiencing stress from after being diagnosed with multiple sclerosis and psychomotor impairment. Which statement indicates that the patient is coping successfully? A. "I'm going to learn to drive a car so I can be more independent." B. "My sister says she feels better when she goes shopping, so I'll go shopping." C. "I've always felt better when I go for a long walk. I'll do that when I get home." D. "I'm going to attend a support group to learn more about multiple sclerosis."

D Support groups often benefit people experiencing stress.

A patient who is suffering from chronic stress reports sleep deprivation, chronic fatigue, and depression. On examination, the patient's blood pressure is 160/98 mm Hg and the heart rate is 78 beats/minute. What could be the most probable reason for this presentation? A. Inability to sleep B. Polymyalgia Rheumatica C. Increased venous return to the heart D. Excessive wear and tear by hormones

D The symptoms indicate that the patient is in a state of allostatic load. A chronic stress response and excessive wear and tear by hormones results in this state. The persistence of the allostatic load can cause problems such as chronic hypertension, depression, insomnia, and autoimmune disorders. Insomnia is one of the symptoms and not the cause. Polymyalgia rheumatica does not present in this way. Increased venous return to the heart does not lead to all these symptoms.

A patient newly diagnosed with type 2 diabetes says, "My blood sugar was just a little high. I don't have diabetes." How does the nurse respond? A. "Let's talk about something cheerful." B. "Do other members of your family have diabetes?" C. "I can tell that you feel stressed to learn that you have diabetes." D. The nurse responds with silence.

D The nurse understands that denial is a defense mechanism that assists in coping with a shock. Therapeutic use of silence gives patients the time to process their thoughts.

A 45-year-old single mother lives with her 10-year-old son who has Down syndrome. The patient's facial expressions and manners demonstrate fatigue and malaise. She has an unkempt appearance and has no interest in going out and meeting people. The patient states that she feels worthless and is overburdened with her responsibilities. What are the differential nursing diagnoses for this patient? A. Anemia B. Psychosis C. Depression D. Ineffective coping E. Caregiver role strain

D, E The patient feels worthless and is unable to cope with stressful events in her life; therefore, the diagnosis should be ineffective coping. The patient is feeling overburdened with the caregiving responsibilities of her son. Therefore, an additional diagnosis should be caregiver role strain. Anemia and depression are medical diagnoses and are not indicated in this case.