Foundations of Nursing - Unit 4 Exam
Describe the nursing process and nursing care for a client with altered sensory perception LO 4 - 4 questions
*ASSESS THE SENSES AT ADMISSION Assessment: -Nursing history -Physical examination -Risk factors for impaired sensory perception -Mental status ie. LOC LOO, clear speech? ST/LT memory -Level of consciousness , arousal, alert or unresponsive? -Environment: do they hear us? if not can they feel us? of n/a do a sternum rub to assess if they respond to pain -Support network: overload and deprivation, what do they do for their impairment Analysis/Nursing Diagnosis: -Acute confusion -Chronic confusion -Risk for dry eye -Impaired meory -Unilateral neglect
Elenore is an older adult who lives alone and has fallen and fractured her hip. She cannot get to the phone to call for help. Her pain worsens as time passes and she becomes confused as she waits for someone to find her. What factors are exacerbating the situation? (Select all that apply) A. Cognitive impairment B. Need to be independent C. Hunger D. Helplessness E. Fear
A. Cognitive impairment D. Helplessness E. Fear
The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? (Select all that apply) A. Confusion B. Moaning C. Irritability D. Poor eye contact E. Restlessness
A. Confusion B. Moaning C. Irritability E. Restlessness
What is the consequence when the nurse denies a client the use of a defense mechanism? A. Causes more anxiety B. Precipitates withdrawal C. Facilitates effective coping D. Encourages emotional growth
A. Causes more anxiety
A posttraumatic sexual assault victim has a nursing diagnosis of Rape-Trauma Syndrome r/t sexual assault AEB guilt and embarrassment, physical trauma, fear, and self-blame. What nursing outcomes would be appropriate for this client? (Select all that apply) A. Client will have a resolution of embarrassment, self-blame, guilt and fear B. Client will state the results of the physical examination completed in the emergency department C. Client will discuss the need for follow-up crisis counseling and other supports D. Nurse will approach the client in a nonjudgmental manner E. Nurse will arrange for crisis counseling
A. Client will have a resolution of embarrassment, self-blame, guilt and fear B. Client will state the results of the physical examination completed in the emergency department C. Client will discuss the need for follow-up crisis counseling and other supports
A client who is withdrawn says, "When I have the opportunity, I am going to commit suicide. Which is the best response by the nurse?" A. "You have a lovely family. They need you." B. "You must feel overwhelmed to want to kill yourself." C. "Let's explore the reasons you have for wanting to live." D. "Suicide does not solve problems. Tell me what is wrong."
B. "You must feel overwhelmed to want to kill yourself."
The nurse is speaking with a client who is confused and is getting agitated. Which communication technique is most appropriate when the client asks about the whereabouts of his or her spouse who has been deceased for 3 years? A. "Your husband is not here." B. "You must miss your husband." C. "Your spouse passed away 3 years ago." D. "Why do you keep asking for your spouse? You know your spouse isn't here."
B. "You must miss your husband."
The nurse is caring for a client who says, "Food just doesn't taste good anymore." What priority action should the nurse take? A. Determine who fixes the client's meals B. Determine what medications are taken C. Monitor dietary intake D. Ask what dietary restriction he follows
C. Monitor dietary intake
Explain pharmacologic and non-pharmacological approaches to pain control LO 4 - 4 questions
Chemical pain relief measures include: -Nerve blocks -Epidural injection -Local anesthesia -Topical anesthesia Radiofrequency and surgery: -Radiofrequency ablation -Surgery includes: cordotomy, rhizotomy, neurectomy, sympathectomy
Describe the GAS and LAS responses to stress LO 2 - 4 questions
Local adaptation syndrome (LAS): -Response to stress involving specific body part, tissue, or organ -Short-term attempt to restore homeostasis -Localized -Types include reflex pain response and inflammatory response Inflammatory process: -Vascular response -Cellular response -Exudate formation -Healing
A nurse is caring for a client who is scheduled for IV chemotherapy for cancer. Which defense mechanism is being used when the client says to the daughter, "Be brave"? A. Rationalization B. Minimization C. Substitution D. Projection
D. Projection
Which stage of General Adaptive Syndrome (GAS) would a client be in if he or she was failing to adapt to the point that exhaustion will occur if left unresolved? A. Alarm B. Recovery C. Adaptive D. Resistance
D. Resistance
Be able to select physiological and spiritual responses to stress LO 4 - 2 questions
Psychological responses: -Includes feelings, thoughts, and behaviors -Anxiety and fear -Ego defense mechanisms (ie. denial, rationalization, projection) -Anger -Depression Spiritual responses: -Depending on a higher power or religious community for support when coping with stress -Searching for a larger meaning in the illness or other stressor -Viewing stress as a test, a punishment, or a challenge -Alarm stage: common response is to pray or ask for help -Adaptation stage: prayer, meditation, and religious affiliation can also help during the second stage -Exhaustion or recovery: spiritual resources may become exhausted, creating spiritual distress, leaving the person feeling abandoned, helpless, and hopeless
Explain the relationship between stressors, responses, and adaptation LO 1 - 2 questions
Types of stressors: -Distress: can threaten health ie. continual financial worries -Eustress: good stress ie. passionate kiss -Developmental: associated with life stages ie. college graduation -Situational: random, unpredictable ie. hurricane, accident -Time: unable to meet demands ie. multiple demands, rushing -Anticipatory: the future ie. upcoming exam -Physiological: affect body: structure/function ie diseases, mobility problems -Psychosocial: arise from life event or relationships ie. work pressure, family arguments
Recognize the initial steps of crisis intervention LO 7 - 1 question
1. Assess the situation 2. Ensure safety 3. Defuse the situation 4. Decrease the person's anxiety 5. Determine the problem 6. Decide on the type of help needed 7. Return the person to his or her pre-crisis level of functioning. This may involve crisis counseling and/or home crisis visits
Which defense mechanism is being used when a client who has just been diagnosed with terminal cancer calmly says to the nurse," I'll have to get on the internet to assess my options"? A. Intellectualization B. Introjection C. Depression D. Denial
A. Intellectualization
Which statement by a dying client reflects Kubler-Ross's stage of depression in the grief process? A. "I am so upset that I will not be here for my daughter's wedding" B. "I wrote a letter to be read by my daughter on the day of her wedding" C. "I just need to get a little stronger so I can go to my daughter's wedding" D. "I don't care if I die as long as I live long enough to see my daughter married"
A. "I am so upset that I will not be here for my daughter's wedding"
The nurse is presenting a workshop on stress and adaptation to a group of teenagers. A teenager approaches the nurse and says, "Sometimes I feel stressed when I have to take a test. I feel my heart is going faster and I have a hard time focusing. I'm scared I'm going to fail. Do you think that is normal?" What is the most appropriate response by the nurse? A. "You may need to develop some additional stress-reducing activities." B. "A little stress is not necessarily a bad thing. It can help you to focus." C. "As long as you are getting through the test, I think you will be just fine." D. "I think you should talk to your teacher about getting accommodations for testing."
A. "You may need to develop some additional stress-reducing activities."
The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? (Select all that apply) A. Atelectasis B. Fever C. Hypertension D. Nausea and vomiting E. Increased urine output
A. Atelectasis B. Fever C. Hypertension D. Nausea and vomiting
At the end of a meditation session, which physical assessment finding would suggest that the relaxation technique was successful? A. Decreased blood pressure B. Decreased peripheral skin temperature C. Increased bowel motility D. Increased respiratory rate
A. Decreased blood pressure
A man with a heart conditions continues to perform strenuous sports against medical advice. Which defense mechanism does the nurse identify the client is using? A. Denial B. Repression C. Introjection D. Dissociation
A. Denial
A posttraumatic sexual assault victim has a nursing diagnosis of Rape-Trauma Syndrome r/t sexual assault AEB guilt and embarrassment, physical trauma, and self-blame. What nursing intervention would be appropriate for this client? (Select all that apply) A. Establish trust and rapport B. Provide strict confidentiality C. Do not use judgmental language and tone D. Encourage verbalization E. Leave alone to process details of event
A. Establish trust and rapport B. Provide strict confidentiality C. Do not use judgmental language and tone D. Encourage verbalization
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone
A. Furosemide B. Ibuprofen
Which factors could cause a person to develop a partial seizure? (Select all that apply) A. Meningitis B. Head trauma C. Brain tumors D. Sleep deprivation E. Hereditary factors F. High levels of anticonvulsants
A. Meningitis B. Head trauma C. Brain tumors D. Sleep deprivation
A 44-year-old female client who was just admitted states, "I must be under too much stress at work and home. I just do not feel well." Which physical findings are consistent with the client's statement? (Select all that apply) A. Mucous membranes are dry B. Legs are continually moving in the bed C. Pupils are constricted and reactive to light D. Palms of her hands are sweaty E. Blood pressure is 178/96 mm Hg
A. Mucous membranes are dry B. Legs are continually moving in the bed D. Palms of her hands are sweaty E. Blood pressure is 178/96 mm Hg
Which pain scales are used to determine a client's level of pain? (Select all that apply) A. Numeric B. FACES C. Visual analog scale D. The intensity word scale E. OPQRST-AAA
A. Numeric B. FACES C. Visual analog scale
The nurse is caring for a client who is in the alarm stage of a stress response. Which clinical finding corresponds to the production of aldosterone, antidiuretic hormone, and renin? A. Oliguria B. Hyperglycemia C. Decreased peristalsis D. Increased tidal volume
A. Oliguria
Which interventions should the nurse include in the plan of care for a client who is disoriented to time? (Select all that apply) A. Open the drapes during the day B. Place some clocks in the client's room C. Wear a name badge with large letters D. Provide personal mementos and photos E. Speak in a slow, calm manner without rushing
A. Open the drapes during the day B. Place some clocks in the client's room
Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay? A. Place her bed in the lowest position B. Place her in a semi-private hospital room C. Assign a team of caregivers D. Restrict visitation
A. Place her bed in the lowest position
The nurse is working in a mental health clinic and a client states, "My coworker did not do well on our joint presentation, and that's why I got fired!" As the nurse documents the findings, what defense mechanism is this client using? A. Projection B. Minimization C. Rationalization D. Intellectualization
A. Projection
A woman with diabetes does not follow her prescribed diet and states, "Everyone with diabetes cheats on their diet." Which defense mechanism does the nurse identify this client is using? A. Rationalization B. Sublimation C. Undoing D. Denial
A. Rationalization
Which localized physiological response would the nurse anticipate a client may experience during an intravenous insertion? A. Reflex pain response B. Inflammatory response C. Fight-or-flight response D. General adaptation syndrome
A. Reflex pain response
A client expresses a sense of hopelessness. Which concern identified by the nurse is the priority? A. Risk for self-harm B. Inability to cope C. Powerlessness D. Fatigue
A. Risk for self-harm
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain
A. Role conflict
Which factors can impact a person's sensory alteration? (Select all that apply) A. Sensory deficit B. Sensory overload C. Sensory withdrawal D. Sensory deprivation E. Sensory denial
A. Sensory deficit B. Sensory overload D. Sensory deprivation
An older adult is tearful, shaky, withdrawn, tachycardic, and sleepless. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." Which statement can be made about this anxiety reaction? (Select all that apply) A. She lacks adaptive coping mechanisms B. It concerns anticipation of danger rather than a present danger C. There is a psychological rather than a physical threat D. Her symptoms are emotional and not physical E. It concerns future or anticipated events
A. She lacks adaptive coping mechanisms B. It concerns anticipation of danger rather than a present danger C. There is a psychological rather than a physical threat E. It concerns future or anticipated events
The nurse is conducting an educational session on stress with a group of executives. Which type of stressors would most likely be problems for this population? (Select all that apply) A. Time stressors B. Home life stressors C. Situational stressors D. Anticipatory stressors E. Physiological stressors
A. Time stressors C. Situational stressors D. Anticipatory stressors
The nurse enters a room and notes the client's eyes are closed. The nurse says the client's name without response. What should be the nurse's next action? A. Touch the client B. Call a code blue C. Perform a sternal rub D. Obtain an interpreter
A. Touch the client
A primary health-care provider informs a client that the diagnosis is inoperable cancer and the prognosis is poor. After the primary health-care provider leaves the room, the client begins to cry. Which should the nurse do? A. Touch the client's hand to provide support B. Leave the room to give the client privacy to cry C. Telephone the client's family to inform them of the diagnosis D. Ask the client questions to encourage an expression of feelings
A. Touch the client's hand to provide support
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear
A. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction
The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity. Which clinical manifestations should the nurse instruct the family to report? (Select all that apply) A. Withdrawal B. Depression C. Aggression D. Combative E. Hallucinations F. Social isolation
A. Withdrawal B. Depression E. Hallucinations F. Social isolation
The nurse is caring for a client with postsurgical pain. At what point is it important to assess the pain level? (Select all that apply) A.When there are nonverbal cues of pain B. At the beginning of the shift C. After physical activity D. Every 30 minutes during the shift E. Before physical activity
A.When there are nonverbal cues of pain B. At the beginning of the shift C. After physical activity E. Before physical activity
Explain the relationship between stressors, responses, and adaptation LO 1 - 2 questions
Adaptation: The process in which we live with our stressors -A possible/desired outcome of stress -Involves adjusting to the stress/stressor -Allows for normal growth and development, and effective responses to life's challenges Ability to adapt depends on: -Intensity of the stressor -Effectiveness of coping skills -Personal factors
Describe the nursing process and nursing care for a client with pain LO 5 - 4 questions
Assessing pain: includes OPQRST -Obtaining a complete pain history ie. onset, location, aggravating/alleviating factors Analysis/Nursing Diagnosis: -Acute pain -Chronic pain Nursing considerations: -Managing pain in the elderly -Managing pain in clients with addictions: *Remember, we are not treating their addiction, we are treating their pain -Use of placebos
A nurse is caring for a client who is being admitted for a cardiac catheterization. The client tells the nurse, "I am so stressed out." Which question should the nurse ask when assessing the effectiveness of the client's coping ability? A. "How do you feel when you are stressed?" B. "How have you coped with similar stressors before?" C. "Did you receive treatment for any stress-related problems in the past?" D. "What has been the most stressful event that you have ever had before?"
B. "How have you coped with similar stressors before?"
A nurse is teaching a client about the positive effects of exercise to reduce anxiety. Which client comment about how exercise reduces anxiety indicates that the client understands the nurse's teaching? A. "It interferes with the ability to concentrate." B. "It stimulates the production of endorphins." C. "It reduces the metabolism of epinephrine." D. "It decreases the acidity of blood."
B. "It stimulates the production of endorphins."
A nurse is caring for a client whose partner passes away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."
B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
Which client is using conversion as a defense mechanism? A. A client who wishes to be a singer, but becomes a football player B. A client who is overwhelmed with stress and experiences nausea and vomiting C. A client who lost a spouse and states he or she knows the spouse is in a better place and no longer in any pain D. A client who has always wanted to be a police officer but cannot pass the test and becomes a security guard
B. A client who is overwhelmed with stress and experiences nausea and vomiting
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply) A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns
B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities E. Encourage the client in the expression of feelings and concerns
A client is discussing an extended family-related conflict with the nurse and states he is tired of the problem and does not participate in family get-togethers because of it. Which ego defense mechanism will the nurse document that the client is using? A. Denial B. Avoidance C. Projection D. Displacement
B. Avoidance
A client begins experiencing chest pain off and on for a few days and continues to work without seeking medical attention. Which response to stress is this client demonstrating? A. Altering the stressor B. Avoiding the stressor C. Analyzing the stressor D. Adapting to the stressor
B. Avoiding the stressor
A client in a group setting begins to kick a trash can and yell at other clients. Which behavior would the nurse note in the client's medical record? A. Anger B. Hostility C. Depression D. Defense mechanisms
B. Hostility
A 74-year-old client is hospitalized with acute onset delirium of unknown etiology. The nurse questions the family and asks what has changed recently. Which responses made by the family could have contributed to the delirium? (Select all that apply) A. Bipolar disorder B. New medication C. Electrolyte imbalance D. Urinary tract infection E. Physical changes in the brain
B. New medication C. Electrolyte imbalance D. Urinary tract infection
A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply) A. Speak at a higher volume to the client B. Make sure only one person speaks at a time C. Avoid discouraging the client by indicating that they cannot be understood D. Allow plenty of time for the client to respond E. Use brief sentences with simple words
B. Make sure only one person speaks at a time D. Allow plenty of time for the client to respond E. Use brief sentences with simple words
A client is told that surgery is necessary. The client begins to experience elevations in pulse, respirations, and blood pressure. Which stage of anxiety is indicted by these nursing assessments? A. Mild B. Moderate C. Severe D. Panic
B. Moderate
To provide appropriate nursing care, which concept about anxiety is important to consider? A. Panic attacks related to anxiety, which generally have a slow onset, can be prevented if identified early. B. One can conceptualize anxiety as being similar to the health-illness continuum C. People who lead healthy lifestyles rarely experience anxiety D. Anxiety is an abnormal reaction to realistic danger
B. One can conceptualize anxiety as being similar to the health-illness continuum
A client with a terminal illness tells the nurse, "I have lived a long life. I am ready to go." Which is the nurse's best response? A. Offer the client a backrub B. Sit quietly by the client's bedside C. Tell the family about the clients statement D. Discuss with the client how dying is part of the life cycle
B. Sit quietly by the client's bedside
The home health nurse enters the apartment of an elderly client who lives alone and immediately determines the client has a hearing impairment. Which finding supports this conclusion? A. The house has all the lights on in every room B. The television is on very loud in the same room as the client C. There is a magnifying glass laying on the bedside table D. The nurse spots assistive devices such as a wheeled walker
B. The television is on very loud in the same room as the client
The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? (Select all that apply) A. Talk in a quiet tone of voice B. Validate understanding of verbal communication C. Speak slowly, articulating clearly D. Ask whether he has a "good ear." E. Explain things before performing them
B. Validate understanding of verbal communication C. Speak slowly, articulating clearly D. Ask whether he has a "good ear." E. Explain things before performing them
Differentiate various types of pain according to origin and time frame LO 1 - 2 questions
By origin: where it begins -Cutaneous/superficial: the skin -Deep somatic: connective tissue -Visceral: organs -Radiating/referred: think heart attack pain/pain in the shoulder -Phantom: mental pain, ie. amputations -Psychogenic: physiological pain that has psychological source "it's all in your head" By cause: -Nociceptive: most common, response to stimuli, physical trauma, visceral and somatic -Neuropathic: nerve communication, complex and often chronic By duration: -Acute: short duration, rapid onset -Chronic: 3-6 months or longer, interferes with ADL's -Intractable: chronic and highly resistant to pain relief, cancer type pain By description: -Quality: aching, throbbing, stabbing, burning -Periodicity: episodic, intermittent, constant -Intensity: mild, distracting, moderate, severe, intolerable
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm stage D. Recovery stage
C. Alarm stage
Which word reflects the ability of a nurse to perceive a client's emotions accurately? A. Autonomy B. Sympathy C. Empathy D. Trust
C. Empathy
A client says to a nurse, "I'm the same age as my father when he died. Am I going to die of my cancer?" Which is the appropriate inference about what the client is experiencing? A. Grieving associated with the potential for death B. Powerlessness associated with feelings of being out of control C. Fear associated with the perceived threat to biological integrity D. Impaired coping associated with inadequate psychological resources
C. Fear associated with the perceived threat to biological integrity
Which factors affect the perception of a stimulus? (Select all that apply) A. Position of the stimulus B. Prior stimuli experience C. Location of the receptors D. Number of receptors activated E. Frequency of action potentials generated F. Changes of frequency, location, and number of stimuli
C. Location of the receptors D. Number of receptors activated E. Frequency of action potentials generated F. Changes of frequency, location, and number of stimuli
A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment B. Encourage visitors to distract the client C. Provide a private room, and limit stimulation D. Speak at a higher volume to the client
C. Provide a private room, and limit stimulation
A client is scheduled for an elective abortion. Which is the best way for the nurse to reinforce this client's self-esteem needs? A. Supporting the use of defense mechanisms B. Encouraging social interaction with others C. Providing a non judgemental environment D. Employing a positive mental attitude
C. Providing a non judgemental environment
A nurse concludes that is woman is remembering only the good times after the death of her husband. Which defense mechanism is the woman using? A. Compensation B. Minimization C. Repression D. Regression
C. Repression
The nurse is caring for a client who has been in the intensive care unit for a week. The nurse notes that the client is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes? A. Sensory deficit B. Sensory deprivation C. Sensory overload D. Sensory withdrawal
C. Sensory overload
A confused client becomes extremely upset. Which is the best action by the nurse? A. Speak louder with a lower-pitched voice B. Use touch to communicate caring and concern C. Talk to the client in a way that is simple and direct D. Administer medication to minimize the client's anxiety
C. Talk to the client in a way that is simple and direct
A client strongly states the desire to go to the hospital coffee shop for lunch regardless of hospital policy. Which does the nurse conclude that this behavior most likely reflects? A. Anger with the policies of the hospital B. Dissatisfaction with hospital meals C. The need to regain a little control D. A desire for a change of scenery
C. The need to regain a little control
Describe effects of prolonged stress and unsuccessful adaptation on various body systems LO 5 - 2 questions
Consequences of failed adaptation include: -Stress-induced organic responses -Continual stress -Repeated central nervous system stimulation -Elevation of certain hormones -Results in long-term changes in body systems such as development of ulcers, diabetes Somatoform disorders: -Hypochondriasis -Somatization ie. stress expressed in physical symptoms -Somatoform pain disorder -Malingering ie. when you don't really have symptoms but say you do to get out of something Stress-induced psychological responses: -Crisis -Burnout -Post-traumatic stress disorder (PTSD)
Differentiate between the processes of reception, perception, and reaction to sensory stimuli LO 1 - 3 questions
Consists of three components: 1. Stimulus: trigger that stimulates receptor ie. smell, taste, sound; meaning depends on reception and processing ie. loud noise, bright light, sour fruit 2. Reception: how we receive the stimulus, process of receiving stimuli from nerve endings, occurs through receptors ie. thermoreceptors (temp regulation), proprioceptors (awareness of body in space), photoreceptors (in eyes, receiving light) 3. Perception: how we interpret the stimulus, everyone is different; ability to interpret sensory impulses; ability to give meaning to impulses Includes: -Location of receptors -Number of receptors activated -Frequency of action potentials -Changes in above Arousal: LOC and alertness, takes place in the brainstem; composed of consciousness and alertness; mediated by reticular activating system (RAS); affected by environment and medications Response to sensations: discards, stores, and sends impulses; factors affecting the response include intensity of stimulus, contrasting stimuli, adaptation to stimuli ie. alarm fatigue, previous experience. Requires people to be alert and receptive to stimulation
Explain the relationship between stressors, responses, and adaptation LO 1 - 2 questions
Coping strategies: Adaptive: -Healthy choices ie food, exercise, sleep -Directly reduce negative effects of stress Examples include change in lifestyle, problem-solving Maladaptive: -Unhealthy style, temporary fix -Possible other harmful effects -Examples include substance abuse, overeating Three general approaches for coping depending on situation: -Alter the stressor: change jobs -Adapt to the stressor: changing thoughts about nursing clinicals -Avoid the stressor: ending a relationship
An older client with a history of congestive heart failure was just admitted to the hospital for chest pain. The patient asks a nurse, "Why did the chest pain begin after I thought someone was trying to break into my house?" What is the nurse's best response? A. "The decrease in the need for oxygen during the fight-or-flight response experience with fear is most likely the reason that you developed chest pain." B. "Fear causes an increase in glucose levels, which limits blood flow and causes chest pain." C. "Fear causes the parasympathetic system to use all available adrenaline, leaving you so tired that you developed chest pain." D. "Fear causes an increase of the body's heart rate and blood pressure, which can place additional stress on your damaged heart and cause chest pain."
D. "Fear causes an increase of the body's heart rate and blood pressure, which can place additional stress on your damaged heart and cause chest pain."
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night."
D. "I take the batteries out of my hearing aids when I take them off at night."
Which statement best describes adaptation in relation to sensory perception? A. Adaptation involves a stimulus and how the brain recognizes it B. Adaptation is the process of receiving stimuli and transmitting the impulse C. Adaptation is the sense a person has of how his or her own body is positioned D. Adaptation is how a person becomes accustomed to a sound or odor that is present for an extended period of time
D. Adaptation is how a person becomes accustomed to a sound or odor that is present for an extended period of time
A nurse identifies that a client is mildly anxious, Which assessment of the nurse supports this conclusion? A. Preoccupied B. Forgetful C. Fearful D. Alert
D. Alert
Which situation identified by the nurse reflects the defense mechanism of displacement? A. A woman is very nice to her mother-in-law, who she secretly dislikes B. A man says that he is not so bad, so don't believe what they say about him C. An adolescent puts a poor grade on a test out of her mind when at her after-school job D. An older man gets angry with friends after family members attempt to talk with him about his illness
D. An older man gets angry with friends after family members attempt to talk with him about his illness
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting
D. Convening a family meeting
The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use. Which medication may have caused this sensory loss? A. Lisinopril (Zestril) B. Vinblastine (Velban) C. Atorvastatin (Lipitor) D. Gentamicin (Garamycin)
D. Gentamicin (Garamycin)
Which stimulates an infant's tactile senses? A. Lights and colors B. Mother's voice C. Smell of breast milk D. Holding and cuddling
D. Holding and cuddling
Which somatoform disorder would the nurse expect to find in the medical record of a client who is constantly fearful of becoming ill? A. Malingering B. Pain disorder C. Somatization D. Hypochondriasis
D. Hypochondriasis
When assessing a client for anxiety, which characteristic about anxiety should the nurse consider? A. It is triggered by a known stressor B. It occurs simultaneously with fear C. It is a response that is avoidable D. It is a universal experience
D. It is a universal experience
The nurse is developing a plan of care for a client with new hearing aids. Which long-term goal is most appropriate for the client? A. The client will wear the hearing aids 90% of the time B. The client will demonstrate successful insertion of the hearing aids C. The client will verbalize an understanding of the need for hearing aids D. The client will demonstrate how to properly care for the hearing aids within 2 weeks
D. The client will demonstrate how to properly care for the hearing aids within 2 weeks
Explain the relationship between stressors, responses, and adaptation LO 1 - 2 questions
Factors that influence adaptation: Personal perception of stressor: -Is understanding of stressor realistic? -How successful have previous adaptation attempts been? Overall health status: -The number of illnesses present and the chronicity of illnesses may affect the ability to adapt to new stressors -The more comorbidities, the harder to cope Support system: -Includes friends, family providing emotional, financial, physical help -Strong support = better adaptation Hardiness "will to live": -Personal factors include age, developmental level, and life experiences
Describe pain transmission, perception and interpretation of pain. Include the gate control theory and the body's natural analgesic system LO 2 - 3 questions
Factors that influence pain include: -Emotions -Past experience with pain -Developmental stage: do they have the ability to communicate? -Sociocultural factors: cultural expectations -Communication skills: verbal and nonverbal cues, facial expressions, emotional state -Cognitive impairments: impacts communication Body reaction to pain: impact of unrelieved pain on body systems -Endocrine -Cardiovascular -Musculoskeletal -Respiratory -Genitourinary -Gastrointestinal
A nurse manager is reviewing coping factors with the members of the team. List at least four factors that influence an individual's ability to cope. List three interventions the nurse can take to assist the client in coping with a stressful event or situation.
Factors: 1. Number of stressors 2. Duration of the stressors 3. Intensity of the stressors 4. Individual's past experiences 5. Current support system 6. Available resources Interventions: 1. Be empathetic in communication, and encourage the client to verbalize feelings 2. Identify the client's and family's ability to deal with the current situation 3. Encourage the client to describe coping skills used effectively in the past 4. Identify the client's and family's strengths and abilities 5. Identify available community resources, and refer the client for counseling if needed
Describe the GAS and LAS responses to stress LO 2 - 4 questions
General adaptation syndrome (GAS): -Selye's theoretical model of physiological responses to stress -Nonspecific bodily responses shared by all people -Response to distress as well as eustress -Involves three stages Alarm stage: -Cardiovascular system: vasoconstriction, elevated blood pressure -Respiratory system: dilated bronchioles -Metabolic system: increased availability of glucose -Urinary system: sodium and water retention -Gastrointestinal system: decreased peristalsis -Musculoskeletal system: increased blood flow to muscles Resistance stage: -Goal: maintenance of homeostasis -Involves use of coping mechanisms; psychological and physical which leads to return of normal vital signs -Failure to adapt to or contain stress leads to third phase Exhaustion: -If adaptive mechanisms become ineffective/nonexistent -Decrease in blood pressure, elevated pulse, respiration -Usually ends in disease or death Recovery: -Third stage, if adaptation is successful
Be able to demonstrate and list stress-management techniques that nurses can utilize for clients and themselves LO 6 - 2 questions
Health promotion activities (through teaching): -Promote adequate nutrition -Help client establish a routine that includes regular exercise -Teach client importance of getting 7 to 8 hours of sleep per day -Encourage participation in leisure activities -Help clients to manage time, balance responsibilities, prioritize tasks -Advise clients to avoid maladaptive behaviors: excess alcohol, caffeine, sweets, smoking, illicit drugs -Use of specific interventions to relieve anxiety -Anger management -Stress management techniques include meditation, biofeedback, reiki, humor -Change perception of self -Change perception of stressor -Identify and use support systems -Reduce the stress of hospitalization -Use spiritual support -Employ crisis intervention -Use proper referrals
A nurse is teaching a group of newly licensed nurses how to intervene for clients who have sensory impairment. List at least six interventions for clients who have hearing loss. List at least six interventions for clients who have vision loss.
Hearing loss: -Sit and face the client -Avoid covering your mouth while speaking -Encourage the use of hearing devices -Speak slowly and clearly -Do not shout -Try lowering vocal pitch before increasing volume -Use brief sentences with simple words -Write down what clients do not understand -Minimize background noises -Ask for sign-language interpreter if necessary Vision loss: -Call clients by name before approaching to avoid startling them -Identify yourself -Stay within the clients' visual field if they have a partial loss -Give specific information about the of items or areas of the building -Explain interventions before touching clients -Before leaving, inform clients of your departure -Carefully appraise clothing and suggest changes if soiled or torn -Make a radio, television, CD player, or digital audio player available -Describe the arrangement of the food on the tray before leaving the room
Discuss the inflammatory response: What triggers it, and what physiological changes occur? LO 3 - 2 questions
Inflammatory process: -Vascular response -Cellular response -Exudate formation -Healing
Explain pharmacologic and non-pharmacological approaches to pain control LO 4 - 4 questions
Non-pharmacological measures: Cutaneous stimulation, ie. Gate Theory: -TENS -PENS -Spinal cord stimulator -Acupuncture -Acupressure -Massage -Use of heat and cold -Contralateral stimulation ie. phantom pain -Oral sucrose ie. babies during circumcision -Immobilization: helps decrease stimulations -Cognitive behavioral interventions: changing your thoughts associated with pain Pharmacological measures: -Nonopioid analgesics: mild to moderate pain, includes NSAIDs, acetaminophen -Adjuvant analgesics: anticonvulsants, antidepressants -Opioid analgesics: narcotics, morphine, fentanyl, includes IV, transdermal, and epidural forms, and client-controlled analgesia pumps *will depress respiratory functions, assess for RR, SPO2, and CO2 levels
Identify culturally competent mechanisms to assess pain, including subjective and objective data LO 3 - 1 question
Nonverbal signs of pain: -Elevated pulse/blood pressure -Crying, moaning -Grimacing -Guarding -Facial expression, posture, body position -Vital signs changes: will change in acute pain -Behavioral manifestations -Pain as an expression of weakness -Assess for depression: present in most patients with chronic pain Pain scales include: -Visual analogue scale (VAS) -Numeric rating scale (NRS) -Simple descriptor scale -Wong-Baker faces pain rating scale
Describe the nursing process and nursing care for a client with altered sensory perception LO 4 - 4 questions
Nursing interventions for altered level of consciousness: 1. Attend to body systems -Eye care ie. eye drops -Range of motion -Skin care/mouth care ie. oral care -Urinary drainage, ie. indwelling catheter, incontinence -Bowel management -Nutrition ie. no eating = feeding tube after several days Nursing interventions for client at risk for seizures: 1. Before a seizure event: may get an aura, seizure pads, side rails up, need an IV site 2. During a seizure event: turn the patient on their side, Oxygen, stay with the patient, don't put anything in their mouth unless airway needed 3. After a seizure: "post-ictal" phase - very disoriented and confused, dim lights-reduce stimulation, monitor vital signs 4. Lifestyle management -Encourage the client to get sufficient rest and a healthy diet -Avoid excess alcohol and any drugs that may interact with seizure medications -Advise the client to visit his primary care provider regularly
Describe the nursing process and nursing care for a client with altered sensory perception LO 4 - 4 questions
Planning outcomes/evaluation: Examples include, -Effectively copes with excessive environmental stimuli ie. still able to do ADL's -Reports adequate sleep and rest Nursing interventions for the confused client: 1. Reorient frequently -State your name, day, date, time -Provide clocks, calendars -Provide visual clues to time -Use personal belongings, bring in items from home 2. MAINTAIN A SAFE ENVIRONMENT 3. Communicate clearly and slowly, respond to feelings and use gestures 4. Limit choices, give one or two choices 5. Promote feelings of security 6. Use alternative therapies, ie. music, prn meds
List factors placing clients at risk for altered sensory perception and identify signs and symptoms of sensory overload and sensory deprivation LO 2 - 3 questions
Sensory deprivation: occurs as a result of altered sensory reception in which the person does not receive and process meaningful sensory input *ie. elderly-depression helpful tools include: baked goods, outdoor walks, busy blankets Sensory overload: occurs when stimuli such such as pain, unfamiliar sights, sounds, odors, and routines overwhelm the patient's senses. *ie. traffic, concerts, newborns, ICU patients, autistic children Sensory deficits: may stem from impaired reception, perception or both *ie. loss of taste, smell, hearing, vision, touch
Differentiate between the processes of reception, perception, and reaction to sensory stimuli LO 1 - 3 questions
Sensory systems include: -Vision -Hearing -Taste -Smell -Touch *Impaired senses=SAFETY CONCERN *Provide information about the internal and external environment *Allows for response to changes ie. adding layers if cold, or adding light when dark *Helps maintain homeostasis *Necessary for human growth and development ie. lack of stimulation for infants leads to failure to thrive
Discuss ways to maintain independence and safety for a client with sensory deficits LO 3 - 3 questions
Taste: aromatherapy, nausea and nutrition management. Checking the fit of dentures or dental appliances, frequent oral hygiene to encourage appetite and enhance the sense of taste. Assess for sores on the tongue, palate, and cheeks. Teach the patient to eat foods one at a time, or drink water between bites to enhance flavor. Use seasonings, salt substitutes, spices or lemon to improve the taste of food unless contraindicated. Touch: strength training, balance, and peripheral sensation management. Tai chi, dance, yoga, running, swimming, light weights, stretching. Balance conditioning, full ROM and rotational movements. When helping the patient walk, ask which side the patient prefers.
Describe pain transmission, perception and interpretation of pain. Include the gate control theory and the body's natural analgesic system LO 2 - 3 questions
Transduction: activation of nociceptors by stimuli, have to have this before we have pain Transmission: conduction of pain message to spinal cord, injuries in the spinal cord interrupt transmission Pain perception: recognizing and defining pain in the cortex Pain modulation: changing pain perception Endogenous analgesia: we make our own opioids naturally to help with pain relief Gate control theory: -C fibers produce pain, dull, achy pain -A delta fibers inhibit pain *By stimulating a nerves surrounding areas, it disrupts pain perception. *Includes TENS unit stimulation, hot/cold therapy, massage, acupuncture
Discuss ways to maintain independence and safety for a client with sensory deficits LO 3 - 3 questions
Vision: make sure eyeglasses are clean, in good repair and are the proper prescription and within reach. Assist with contact lenses as needed. Keep the bed in a low position, and offer magnifying lenses, large print, audio and braille media. Use soft, diffuse lighting without glare, provide an unclutter environment and orient the patient to the room arrangement. Place personal items within reach, and provide referrals for supportive services. Identify items on food trays as they relate to the numbers on a clock face. Hearing: Inspect ear canals for cerumen impaction, teach patients to use blinking alarm clocks, security alarms, and smoke detectors. Ensure hearing aid batteries are charged, and use closed-captioning, voice control for mobile devices and computers. Provide them written instructions for treatments and self-care.
