Chapter 42 PrepU N204
A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? Anticipatory guidance Guided imagery Biofeedback Meditation
Anticipatory guidance Anticipatory guidance is the technique wherein the nurse uses teaching about a procedure to prepare the client for what is to come. This can help foster trust, diminish fear of the unknown, and lessen the chance of a negative response to necessary treatments. Guided imagery, biofeedback, and meditation would take time to learn and would not be effective in this current situation.
A client asks about general adaptation syndrome (GAS). Which details provided by the nurse are correct? Select all that apply. The alarm stage of GAS can last from minutes to hours. It can be a response to physiologic or psychological stress. There are three stages to GAS. GAS requires psychological hospitalization for treatment. The resistance stage usually lasts for less than a day.
The alarm stage of GAS can last from minutes to hours. It can be a response to physiologic or psychological stress. There are three stages to GAS. There are three stages to GAS: the alarm stage, the resistance stage, and the exhaustion stage. GAS can be in response to a physiologic or psychological stressor. The alarm stage is usually the shortest stage, lasting minutes to hours. Individuals progress through the resistance and exhaustion phase at different speeds depending on coping mechanisms and situations. Hospitalization is generally not required to treat GAS, but the nurse must recognize that GAS can impact all clients.
The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario? compensation sublimation projection reaction formation
compensation' Compensation is overcoming a perceived weakness by emphasizing a more desirable trait or achieving in a more comfortable area. Sublimation involves a person substituting a socially acceptable goal for one whose normal channel of expression is blocked. Projection is a person's thoughts or impulses attributed to someone else. Reaction formation is the development of conscious attitudes and behavior patterns that are opposite to what he would prefer to do.
An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping? beneficial maladaptive generational cultural
maladaptive Substance use, beginning or increasing smoking, oversleeping, overeating, undereating, oversleeping, overexercising, excessive daydreaming, and fantasizing are various ways that individuals with the inability to cope with stress successfully deal with stress.
A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities? "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." "I get so tired from working long hours at the site." "I need to get back to work here at home. That will get me back into a routine." "I guess the smoke in the air brought out my mental addiction to cigarettes."
"I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." This person is exhibiting a physiologic response to stress while also taking up a negative coping solution to diminish the symptoms. Reliving the events that were stressful is a common complaint when under anxiety. The other statements do not demonstrate the burden of role strain.
Which client statement, after a presentation about drug use, indicates to the nurse a correct understanding of the information presented? "Mixing alcohol and tranquilizers may cause physical impairment and helps wean people off drugs." "Mixing alcohol and tranquilizers may cause physical impairment and drug dependency." "Mixing alcohol and tranquilizers has legal implications and increases arousal." "Mixing alcohol and tranquilizers increase arousal and drug dependency."
"Mixing alcohol and tranquilizers may cause physical impairment and drug dependency." Stating that the mixing of alcohol and tranquilizers may cause physical impairment and drug dependency indicates to the nurse that learning has taken place, because the client's awareness of the health risks that are associated with the combination may prevent the client from using drugs. The combination of alcohol and tranquilizers can lead to drug dependency instead of weaning off drugs. The combination of alcohol and tranquilizers decreases brain activity, resulting in decreasing (not increasing) arousal.
The nurse is explaining to a group of high school students how the nervous system helps regulate homeostasis. Which statements by the nurse are correct? Select all that apply. "The sympathetic nervous system is responsible for the flight-or-fight response." "The parasympathetic nervous system increases peristalsis." "The nervous system constricts vessels to essential organs during a stress response." "The sympathetic nervous system will slow the heart rate once a threat is over." "The nervous system decreases cardiac output using the sympathetic nervous system."
"The sympathetic nervous system is responsible for the flight-or-fight response." "The parasympathetic nervous system increases peristalsis." The sympathetic nervous system is responsible for the flight-or-fight response to a threat. With the flight-or-fight response, vasoconstriction happens to the nonessential organs. This increases the blood flow to the essential organs and also increases cardiac output. The parasympathetic nervous system controls normal body functions such as digestion. It also will slow the heart rate once a perceived threat is over.
A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs? Attempt to calm the client and administer oxygen Place the client in the semi-Fowler position and have the client explain what happened to cause this reaction Administer an antianxiety medication and report to the health care provider Offer a distraction by asking about the client's family or interests and continue to monitor vitals
Attempt to calm the client and administer oxygen The alarm reaction is initiated when a person perceives a specific stressor and the person experiences an increase in energy level, oxygen intake, cardiac output, blood pressure, and mental alertness. The best way to address this is to attempt to calm the client and administer oxygen as needed to maintain oxygen levels and optimal breathing and cardiovascular function. Semi-Fowler position may help with breathing as well as taking deep breaths but is not the immediate need.
A withdrawn and isolated client is most likely suffering from what type of stressors on basic human needs? Physiologic needs Safety and security needs Self-esteem needs Love and belonging needs
Love and belonging needs Effects of stress on basic human needs varies with each individual, but there are certain characteristics that are commonly seen with stressors on the basic human needs. Withdrawal and isolation from others is commonly seen when stressors are placed on love and belonging needs. Stressors on physiologic, safety/security, and self-esteem needs have other common characteristics.
A 2-day-old, 28-week gestation preterm infant is being cared for in the neonatal intensive care unit. The mother is recovering from a cesarean section and comes in to visit for the first time today. Determining that stress can affect infant development., what situation does the nurse identify can develop? Select all that apply. Mother's increased cortisol levels lead to increased anxiety and decreased attachment. The inability to hold and touch can lead to delay in bonding between mother and infant. Excessive noise and lights can increase cortisol levels in the neonate. The mother's cesarean section will impair her ability to hold and bond. Stress does not affect the newborn
Mother's increased cortisol levels lead to increased anxiety and decreased attachment. The inability to hold and touch can lead to delay in bonding between mother and infant. Excessive noise and lights can increase cortisol levels in the neonate. Cesarean section is not a contraindication to holding an infant. Many women successfully bond with their infants following a cesarean. Increased cortisol levels can affect the mother and infant by increasing the mothers anxiety which can limit effective bonding. Stress occurs in the infant psychologically by noises and lighting and physiologically by thermoregulation and other factors.
A toilet trained toddler was admitted to the hospital for dehydration. Upon returning home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent? This behavior is sublimation. This behavior is called regression. This behavior is known as repression. This behavior is reaction formation.
This behavior is called regression. Children often regress to soiling diapers or demanding a bottle when they are ill and this is called regression. Repression is excluding an anxiety provoking event from conscious awareness. Reaction formation is when a person develops conscious attitudes and behavior patterns that are opposite to what he or she would really like to do. Sublimation is when a person substitutes a socially acceptable goal for one whose normal channel of expression is blocked.
Which stressor collected during the assessment process for an adult client requires priority intervention by the nurse? being laid off from a job experiencing the death of a friend taking early retirement downsizing of a business venture
being laid off from a job Being laid off from one's job is information that is collected during the assessment process for adult clients and requires priority intervention. This is because being laid off from one's job is a very stressful situation that personally and directly affects the client and may impact the client's well-being. Experiencing the death of a friend, taking an early retirement, and downsizing a business are all stressors, but they do not take priority.
A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that a contributor to this phenomenon is: thyroid production. adrenal function. estrogen levels. cortisol. glucose.
estrogen levels.' Women have higher levels of estrogen, which are associated with greater sensitivity to stress and a tendency towards being emotionally supportive and building meaningful relationships.
The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? alarm stage exhaustion stage resistance stage secondary stage
exhaustion stage The client is in the exhaustion stage, when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system, and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders, or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.
Which are considered internal stressors? Select all that apply. loud noises pollution illness hormonal change fear
illness hormonal change fear A stressor is anything that is perceived as challenging, threatening, or demanding. Stressors may be internal (e.g., an illness, a hormonal change, or fear) or external (e.g., loud noise or cold temperature).
A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? provide care transition at discharge for speech therapy assess blood pressure every 4 hours conduct mental status assessment every 2 hours discuss family history of hypertension
provide care transition at discharge for speech therapy Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.
During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement? reaction formation rationalization repression regression
repression Repression is the coping mechanism that this client is using, in which the client has removed the experience of being abused from conscious memory. Reaction formation is a coping mechanism that sees an individual acting just the opposite of one's feelings. Rationalization is relieving oneself of personal accountability by attributing responsibility to someone or something else. Regression is behaving in a manner that is characteristic of a much younger age.
A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention? perform meditation to relax tense and relax muscle groups systematically seek assistance from family and friends keep the home environment noise free
seek assistance from family and friends The nurse should suggest that the client seek assistance from family and friends as a crisis intervention. Adequate support during a crisis and its resolution can help clients realistically perceive the problem and reinstitute coping strategies. Performing meditation, tensing and relaxing muscle groups systematically for progressive relaxation, and keeping the home environment noise free are methods to calm and relax the client that may not necessarily help in crisis intervention.
A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea? Immediately administer an antiemetic. contact the primary care provider sit with the client and ask them about their feelings explain that the physical symptoms are all in their head
sit with the client and ask them about their feelings Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response.
A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? a quiet environment an open attitude soft music a focus of attention
soft music Music may be helpful for some but is not essential for meditation.
A middle-age woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are: stressors. stimuli. illnesses. demands.
stressors Stress is defined as any event or set of events (a stressor) that causes a response. Everyday triggers associated with work or social relationships and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors.
A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress? sympathetic nervous system parasympathetic nervous system endocrine system respiratory system
sympathetic nervous system Functions of the sympathetic nervous system under stressful conditions bring about the fight-or-flight response. Sometimes called the rest-and-digest system, the parasympathetic system conserves energy as it slows the heart rate, increases intestinal and gland activity, and relaxes sphincter muscles in the gastrointestinal tract. The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood. The respiratory system is a series of organs responsible for taking in oxygen and expelling carbon dioxide. The primary organs of the respiratory system are the lungs, which carry out this exchange of gases.
