asessment 1 chapter 5 prepU

"Swelling is a normal response from your body to prepare for healing."

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy?

swelling is a normal response from your body to prepare for healing

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy?

Bruxism and excessive sweating

A client admitted for a voluntary breast reduction is displaying many signs and symptoms of stress. Which of the following findings would be consistent with this analysis by the nurse?

job loss, bankruptcy, and loss of house

A client comes to the clinic and reports frequent headaches and daily fatigue that is interfering with normal functioning. During collection of psychosocial history, the nurse notes a stressor sequence that may be causing the physical deviations. Which series of events represents a stressor sequence?

cholesterol 277 mg/dL

A client experiencing extreme stress has a serum cortisol level of 41 mcg/dL. Which additional laboratory value will the nurse expect in this client?

participation in church activities

A client has experienced a stressful life event and expresses a desire to return to the church community. What is the best resource for the nurse to suggest to the client to use for coping with stress?

increased body temperature

A client has gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the client experience with this inflammatory infection?

Brain cells without oxygen die in approximately 3 to 6 minutes.

A client is experiencing difficulty speaking and numbness on his right side. His wife calls a neighbor who is a nurse for help. Upon arrival at the scene, the nurse calls 911 immediately. Which of the following displays the nurse's critical clinical judgment?

vital signs, height and weight, level of cognitive ability, indications of emotional distress, issues with movement or sensation

A client presents to the provider's office for an annual wellness exam. On which areas will the nurse focus to determine physiologic and psychological stressors when assessing this client? Select all that apply.

model an attitude of realistic hope, encourage the use of spiritual resources, provide information about health conditions, assist with identifying short and long term goals

A client states, "I'm just so overwhelmed trying to take care of the kids, keep the house clean, and do well at my job. I don't know what to do." Which education will the nurse provide to help this client cope? Select all that apply.

with decreased use of your legs, the cell size reduces

A client who has been confined to bed for more than 1 year is concerned about the shrinking size of his legs. How will the nurse respond to the client's concern?

high blood pressure, palpitations

A client who has had a traumatic experience states that he has no lasting effects from this experience. His wife disagrees. Which of the following will the nurse assess if the wife is correct about the lasting stress?

provide education

A client who is going to have surgery is slightly nervous. What nursing intervention is most important for the nurse to perform?

"New gastrointestinal cells replace damaged ones constantly."

A client with a foodborne illness is concerned his gastrointestinal tract will never be the same again. Which of the following would be an appropriate response from the nurse?

"This type of group promotes freedom to express self and exchange ideas."

A client with a new ostomy is hesitant to participate in a support group. Which response will the nurse give the client to encourage the client to consider participating?

When members of the community share a heritage that is unfamiliar to the nurse

A community health nurse understands the importance and impact of cultural competence when caring for clients in the community. In what situation will the nurse find that cultural competence is particularly important?

are helpful because stress stimulates the release of vasoconstricting catecholamines.

A nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques:

anger, ambivalence, dispair

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply.

increased sympathetic activity

A nurse is assessing a patient with posttraumatic stress disorder (PTSD) who is exhibiting physiologic manifestations. The nurse interprets these manifestations as being the result of which of the following?

my father was diagnosed with depression in his 40s

A nurse is conducting an assessment of a client. Which client statement would indicate to the nurse that the client has a nonmodifiable risk factor for mental health problems?

Establishing a trusting nurse-patient relationship

A nurse is developing a plan of care for a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following would be the priority?

genetic counseling

A nurse is developing a set of programs that focuses on reducing the risk factors for mental health problems for a community health care center. Which program would be least appropriate?

"The nerves are being stimulated by the pressure from the swelling at the sprain."

A nurse is giving discharge instructions to a client who came to the emergency department following an ankle sprain. The client asks "Why does this hurt so much?" Which response would be most appropriate from the nurse?

"My life is worthless, and I don't know why I'm here."

A nurse is interviewing a client for possible depression. What client statement will most likely reflect clinical depression?

A group related by reciprocal caring, mutual responsibilities, and loyalties

A nurse is preparing to make a home visit to a family. Which of the following would the nurse need to keep in mind as most reflective of a family?

facilitating their acceptance of the loss, acknowledge the intensity of the pain, assisting them in adapting to life after the loss, promoting the development of new relationships

A nurse is providing care to a grieving client and family. Which of the following would the nurse incorporate into the plan of care? Select all that apply.

addiction is not a result of a person having moral faults

A nurse is teaching a group of families who have members experiencing addiction about this problem. Which of the following, if stated by the families, indicates that the teaching was successful?

"My stomach feels really upset--sometimes like I'm going to vomit."

A nurse is working in a university health center. A 20-year-old client comes to the center with vague complaints. The client states that she's been cramming for a final examination scheduled for the next day. The nurse suspects that the client is experiencing anxiety. Which of the following statements from the client would most support the nurse's suspicions?

communication skills

A nurse is working with a family that is under stress. Which trait would the nurse emphasize in the plan of care as being most useful to the family's coping?

client was a victim of a rape and beating

A nurse suspects that a client may be experiencing post-traumatic stress disorder (PTSD). Which assessment finding would help support the nurse's suspicion?

need for control over a situation

A nurse who is considering the possibility of becoming involved in home care asks a home care nurse about the characteristics needed for this practice area. Which of the following would the home care nurse be least likely to include?

Sit with her and provide an opportunity for her to talk about her concerns.

A patient with a strong history of breast malignancy in her family is scheduled for a breast biopsy in the morning. What would be the most appropriate nursing action when caring for this patient the evening before surgery?

tachycardia

A physiologic indicator when assessing for posttraumatic stress disorder (PTSD) is

increased concentration

After educating a class about depression, the instructor determines that additional class time is needed for teaching when the class identifies which of the following as an indicator of depression?

"Individuals frequently engage in substance use and abuse to enhance their decision-making ability."

After teaching nursing students about substance abuse and its effects on individuals and families, the instructor determines that additional teaching is necessary when the students state which of the following?

socialization

During a family assessment, the mother states, "When I was a child, we always had a special dinner on Christmas Eve, that my mother had when she was a child. Now our family follows the same tradition." The nurse interprets this statement as indicating which family function?

spiritual distress

During an interview, a patient states, "I don't know why God is punishing me like this." The nurse would most likely identify which nursing diagnosis as a priority?

a telephone call to a spiritual leader

During assessment, a client states, "I don't know why God is punishing me like this." What coping strategy will the nurse offer the client?

radiation beams used for cancer treatment, stab wound from a pocket knife, inadequate consumption of calories

Identify the following agents or stressors that may cause a client cellular injury. Select all that apply.

dopamine

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?

exposure to an overwhelming traumatic event

Nursing students are reviewing information about post-traumatic stress disorder (PTSD). They demonstrate understanding of this information when they identify which of the following as the common underlying issue?

individuals with substance abuse often have difficulty using adaptive behaviors

Students are reviewing information about substance abuse and its effects on individuals and families. The students demonstrate understanding of this topic when they identify which of the following?

acute, time limited

Studying for the NCLEX-RN examination is an example of which type of stressor?

stress awareness stage

The general adaptation syndrome (GAS) is a nonspecific physiologic response to a stressor. Which stage is not a part of the process?

"Many people who have difficulty talking about a situation are able to write about it. I would suggest spending some time each day writing about your feelings."

The nurse has been talking to a client who has had difficulty coping with a new situation. The nurse has met with the client a number of times but each time the client is reluctant to talk about the situation or the feelings associated with it. Which statement by the nurse would be MOST helpful to the client in this situation?

sweating, pale skin color, rapid heart rate, report of nausea

The nurse is assisting a client recovering from an acute illness transfer from the bed to a chair. Which assessment finding(s) indicates to the nurse that the activity was physiologically challenging for the client? Select all that apply.

benzodiazepines

The nurse is caring for a client with an anxiety disorder. The client reports feelings of anxiousness when in social situations. Which classification of medications does the nurse anticipate?

hemophilia, phenylketonuria, sickle cell anemia

The nurse is caring for a client with an anxiety disorder. The client reports feelings of anxiousness when in social situations. Which classification of medications does the nurse anticipate?

allow client to verbalize feelings of loss

The nurse is developing a plan of care to assist a patient in coping with a below-the-knee amputation (BKA) on the right leg. Which intervention should the nurse include?

I was able to put on my socks and shoes with this device

The nurse is evaluating care provided to a client with hemiplegia. Which client statement indicates that care has been effective?

"No, the right amount of stress can be motivating to accomplish goals."

The nurse is instructing a community education class on stress. The nurse asks the participants, "Is all stress bad for you?" Which answer by the participants indicates that teaching has been effective?

Does the patient belong to a group that is mutually dependent and communicative?

The nurse is performing an assessment to determine the patient's social support systems. What question is important for the nurse to ask?

cortisol 35 mcg/dl (965.58 mmol/l)

The nurse is reviewing a client's 0800 laboratory data. Which laboratory value concerns the nurse?

helplessness, anxiety, inadequacy

The nurse is teaching a community group about emotions experienced with stress. What emotions will the nurse include in the teaching? Select all that apply.

tense and relax specific muscles

The nurse is using progressive muscle relaxation with a client to reduce stress. What will the nurse teach the client to do?

continue to function well

The nurse is working with a client who is in a stressful situation. The nurse evaluates the client's resiliency by assessing the client's ability to do what?

place the client supine or prone in a quiet room then read the instructions

The nurse notes that a client who reports feeling stressed is fidgeting with her hands, nervously tapping her feet, and showing restless behaviors. The nurse suggests progressive muscle relaxation. How will the nurse proceed?

viruses

The patient wants to be prescribed an anti-infective drug for the flu. The nurse understands that anti-infective medications would not be useful against which biologic agents?

hyperplasia

What is the term for an adaptation to environmental stress that occurs when tissue mass enlarges due to cell multiplication and increased stimulation?

Include physical, emotional, and social elements

When approaching health care holistically, which of the following would the nurse do?

increased heart rate

Which condition is a sympathetic-adrenal medullary response to stress?

distress

Which of the following conditions triggers the general adaptation syndrome?

frequent activation of the sympathetic nervous system

Which of the following factors are implicated in the development of heart disease?

A response by the sympathetic nervous system

Which of the following responses is most helpful to the client when in an emergency situation?

positive self-talk

Which of the following would a nurse least likely assess in a client experiencing anxiety?

clinical pathways, practice guidelines, and standards of care

Which tools do case managers commonly rely on to plan and coordinate client care?

second intention

Which type of healing occurs when the edges are not approximated and the wound fills with granulation tissue?

"When one family member becomes ill, other members are affected."

While interviewing the wife of a patient with multiple health problems, the spouse states, "I'm not the one who is ill, but I feel like I'm getting sick all the time." Which response by the nurse would be most appropriate?

cardiovascular

Years ago a client was informed that he had pre-hypertension. He admits that he has not had his blood pressure monitored for more than 3 years. Currently, the nurse assesses his blood pressure to be 178/104. Which body system may display a cellular adaptation to this condition?

brain

cells in which organ are unable to regenerate