Chapter 8, Stress and Disease

During which stage of the general adaptation syndrome is fight-or-flight first exhibited in a client?

Alarm. The alarm stage or reaction is the stage in which the central nervous system is aroused and the body's defenses are mobilized (e.g., fight-or-flight). The stage of resistance or adaptation contributes to sustaining the fight-or-flight reaction. Exhaustion occurs when the body is no longer able to bring about a return to homeostasis after continuous stress, leading to the onset of certain diseases.

A client has an exaggerated pathophysiologic response to stress. Which term should the nurse use to describe this condition?

Allostatic overload is an exaggerated pathophysiologic response to stress.

Which elderly person is most predisposed to mortality with the spouse's hospitalization or death?

A wife within 1 month after her husband's death. A study found that a husband's death raised his partner's 1-month mortality risk by 61%. A wife's hospitalization increased her husband's chances of dying within 1 month by 35%; a husband's hospitalization increased his wife's chances of dying by 44%. Likewise, a wife's death increased her partner's 1-month mortality risk by 53%

During the initial interview, the nurse determines that a patient who has anxiety caused by job stress and is at risk of altered immunity. Which patient statement supports the nurse's suspicion?

"I do deep breathing exercises in the morning before work." A patient who tries to hide anxiety from his or her family may be using conceal as a coping strategy. This is considered a maladaptive coping strategy, which is associated with altered immunity. A patient who goes to church regularly may be using religion and spirituality as an effective coping mechanism, so this patient is less likely to have altered immunity as a result of anxiety. Deep breathing exercises are a relaxation technique that is an effective coping strategy to reduce stress and anxiety. Agreeing to start therapy indicates a willingness to engage in a problem-focused adaptive coping response. Exercise is generally a healthy, adaptive way to cope with stress and anxiety.

During the initial interview, the nurse determines that a patient who has anxiety caused by job stress is at risk of altered immunity. Which patient statement supports the nurse's suspicion?

"I tell my family that work is great so they won't worry." A patient who tries to hide anxiety from his or her family may be concealing as a coping strategy. This is considered maladaptive, which is associated with altered immunity. Deep-breathing exercises are an effective coping strategy to reduce stress and anxiety. Agreeing to start therapy indicates a willingness to engage in a problem-focused adaptive coping response. Exercise is generally a healthy, adaptive way to cope with stress and anxiety.

A client is experiencing multiple stressors simultaneously. In what order does the chain of events occur during the alarm reaction when this client is stressed?

1. A stressor is sensed and the hypothalamus triggers corticotropin-releasing hormone 2. Anterior and posterior pituitary as well as the sympathetic nervous system are stimulated to release hormones 3. Norepinephrine, epinephrine, antidiuretic hormone, and adrenocorticotropic hormone are released 4. Norepinephrine increases blood pressure, and epinephrine causes bronchodilation and increased glycogenolysis. 5. Blood glucose increases. The sequence of events in the alarm reaction includes: a stressor is sensed and the hypothalamus triggers corticotropin-releasing hormone, then the anterior and posterior pituitary as well as the sympathetic nervous system are stimulated to release hormones. Norepinephrine, epinephrine, antidiuretic hormone, and adrenocorticotropic hormone are released; next, norepinephrine increases blood pressure, and epinephrine causes bronchodilation and glycogenolysis. Finally, blood glucose increases.

A client has experienced chronic stress, which has adversely affected immunity. When explaining this to the client, in which order should the nurse present the components of the hypothalamic-pituitary-adrenal (HPA) axis?

1. Stressor is experienced. 2. Hypothalamus secretes corticotropin-releasing hormone (CRH). 3. Pituitary gland produces adrenocorticotropic hormone (ACTH). 4. Adrenal glands produce glucocorticoids. In the HPA axis, a stress induces secretion of CRH by the hypothalamus. CRH stimulates the secretion of ACTH from the pituitary gland. ACTH induces secretion of the glucocorticoids from the adrenal gland cortex. Primarily cortisol is released.

The nurse is preparing information for an educational presentation on the stress-age syndrome. The nurse includes which pieces of information in the presentation? Select all that apply.

1. Alterations in lipoproteins will occur. 2.Free radicals will damage cells. 3. Patterns of chronic inflammation develop. 4. Increased levels of ADH The stress-age syndrome changes include: alterations in: lipoproteins, free radical damage of cells, and patterns of chronic inflammation. Increased, not decreased, levels of ADH occur. The stress-age syndrome is associated with hypercoagulation of blood and an increased risk for clotting rather than bleeding.

Which information from the staff indicates teaching by the nurse was successful about the systems involved in the hypothalamic-pituitary-adrenal (HPA) axis? Select all that apply.

Autonomic nervous system, Central nervous system, Endocrine system, and Immune system. A holistic and complex model that involves biochemical relationships of the central nervous system, autonomic nervous system, endocrine system, and immune system is often cited together as the hypothalamic-pituitary-adrenal (HPA) axis. The gastrointestinal system is not included in the HPA axis.

A nurse is educating a health class about stress-related diseases and conditions like cardiovascular disease, osteoporosis, and type 2 diabetes mellitus. Which pathophysiologic process that is common to all these diseases will the nurse include in the teaching session?

Chronic inflammatory processes play a critical role. Several conditions with variable pathophysiologic characteristics appear to have a common origin relating to chronic inflammatory processes. These conditions include cardiovascular disease, osteoporosis, arthritis, and type 2 diabetes mellitus. Sedentary lifestyle, obesity, fast food consumption, and genetic propensity are not critical components of the common pathophysiologic process.

A client is experiencing physiologic stress. The nurse monitors the client for increased blood glucose levels. What is the rationale for the nurse's action?

Cortisol is released. Cortisol increases blood glucose levels by stimulating gluconeogenesis in the liver and promoting other hormones such as epinephrine, glucagon, and growth hormone to increase glucose. Insulin facilitates movement of glucose into cells and lowers blood glucose levels. Aldosterone regulates sodium balance and does not influence blood glucose levels. Norepinephrine regulates cardiovascular responses during the stress response.

A nurse is describing the key systems involved in allostatic overload. Which key systems should the nurse include in the teaching session? Select all that apply.

Cortisol, Catecholamines, and Proinflammatory cytokines. Key systems involved in allostatic overload (exaggerated pathophysiologic responses to stress) include the concentrations of cortisol, catecholamines of the sympathetic nervous system, and proinflammatory cytokines, as well as a decline in parasympathetic activity, not an activation. Cardiovascular deactivation is not a key system in this process.

A client is stressed and releases cortisol. Which physiologic effect of cortisol does the nurse expect to occur?

Decreased bone formation.

A client had chronic stress that eventually led to a stress-related condition. Which term should the nurse use to describe this condition?

Disease of adaptation. Chronic stress led to exhaustion, marking the onset of certain diseases (diseases of adaptation). The "fight or flight" occurs in the first stage of stress (alarm). Allostasis is considered an adaptive physiologic response to stressful events (e.g., fight or flight). Having chronic stress and developing a stress-related condition is maladaptive, not adaptive. Psychoneuroimmunology is the study of how the consciousness (psycho), the brain and spinal cord (neuro), and the body's defenses against infection and abnormal cell division (immunology) interact.

A client has been caring for an ailing mother for 18 months. In addition, the client has recently lost a job and is having difficulty finding a new one. Blood pressure has recently been running higher than normal. What is the client experiencing?

Disregulated allostasis. Chronic or disregulated allostasis is long-term or chronic exaggerated response to stress. In this example, an otherwise healthy individual has been suffering from a great deal of stress for a long time. This has caused wear and tear on the body and has resulted in an elevated blood pressure. Homeostasis is a balanced, optimal, steady state. There is no such term as chronic homeostasis. Allostasis is considered an adaptive physiologic response to stressful events (e.g., fight or flight).

The nurse is assessing the coping strategies of a client as part of risk factor management for the client's high blood pressure. Which assessment finding should the nurse identify as a maladaptive coping strategy?

Eating twice a day rather than three times. Maladaptive coping can result in a change in behavior contributing to potentially adverse health effects (e.g., increased smoking, change in eating habits). Mediation, yoga, and biofeedback are adaptive coping strategies. Exercise and social support have also been found to be effective stress relievers.

Which finding did the nurse use to make the clinical determination that a child is experiencing a reactive stress response?

Fear of an examination. Reactive stress response is a physiologic response derived from psychological stressors. The most probable reason for the child's stress response would be the fear of an examination. The stress may produce dry mouth and an increased heart rate. Fear of loneliness is an anticipatory stress response. Posttraumatic stress disorder is a conditioned stress response. Fear of health care professionals is an anticipatory stress response

While reviewing the psychological history of an adolescent patient, the nurse learns that the patient was sexually abused during childhood and has repressed the memories of abuse. Which conditions does the nurse look for in this patient? Select all that apply.

Hyperglycemia and Low monocyte count. When a patient represses the memories of a traumatic event, it indicates that the patient adapts repression as a coping style. Repression can cause a decrease in the monocyte count and an increase in serum glucose levels. Therefore, the nurse anticipates finding a low monocyte count and hyperglycemia in the patient. Repression is associated with higher, rather than lower, EBV antibody titers. Repression increases stress, which causes hypertension rather than hypotension. Repression leads to higher rather than lower eosinophil counts.

When a client is stressed, which glands produce the nonspecific physiologic responses of the general adaptation syndrome? Select all that apply.

Hypothalamus, Pituitary gland, and Adrenal glands. Interactions among the sympathetic branch of the autonomic nervous system and the hypothalamus, pituitary gland, and adrenal glands produce the nonspecific physiologic responses of the general adaptation syndrome.

The nurse is doing a pelvic examination on a patient who has severe vaginal bleeding. Which physiological change does the nurse expect to find in the patient?

Increase in somatotropin levels. A pelvic examination triggers stressful stimuli and increases the secretion of somatotropin hormone. A stressful stimulus, like a pelvic examination, increases prolactin levels. Testosterone levels decrease during stressful responses. Severe vaginal bleeding causes hemorrhage, and increases the level of β-endorphins to control the blood pressure.

When a client is stressed and epinephrine is released, which clinical manifestation will the nurse observe?

Increased blood glucose. Epinephrine causes transient hyperglycemia (increased blood glucose). Epinephrine will increase heart rate and myocardial contractility. The venous return to the heart will increase, thus increasing cardiac output. Norepinephrine regulates blood pressure and dilates pupils.

Which information from the staff indicates teaching by the nurse was successful about the physiologic changes cortisol produces during the stress response? Select all that apply.

Increased blood pressure, Atrophy of the lymphoid tissue, and Increased lipogenesis of the face and trunk. Increased blood pressure, atrophy of the lymphoid tissues, and increased lipogenesis of the face and trunk are the effects of cortisol. Cortisol also causes increased cardiac output, decreased luteinizing hormones, and increased blood levels of amino acids.

Which effect will the nurse expect to occur when a client's body releases cortisol?

Increased gastric secretions. Cortisol promotes gastric secretion in the stomach and intestines, potentially causing gastric ulcers. Cortisol's actions on carbohydrate metabolism result in increased blood glucose levels. Cortisol maintains blood pressure and optimizes myocardial performance; it does not decrease heart rate. Cortisol does not increase sweating.

A nurse is asked by a co-worker what physiologic changes occur when epinephrine is released during the stress response. How should the nurse reply? Select all that apply.

Increased lipolysis, Increased blood glucose, and increased force of cardiac contraction. Increased force of cardiac contraction, increased blood glucose, and increased lipolysis are all effects of epinephrine. Epinephrine causes bronchodilation, not bronchoconstriction, and increased cardiac output, not decreased. Retention of water occurs in the stress response as a result of increased release of antidiuretic hormone (ADH).

A client has elevated levels of glucocorticoids and catecholamines from prolonged stress. Which clinical manifestation indicates the client has decreased innate immunity?

Increased risk of infection. Elevated levels of glucocorticoids and catecholamines may decrease innate immunity and increase autoimmune (adaptive) responses. This may help explain the seemingly contradictory stress response of immunosuppression and increased risk of infection (decreased innate immunity) with a heightened antibody response and autoimmune disease (increased adaptive immunity). While a Th1 and Th2 shift does occur, these lymphocytes are involved in adaptive immunity, not innate.

A nurse is teaching about neuropeptide Y (NPY). Which information should the nurse include in the teaching session?

It is implicated in atherosclerosis. Because NPY is a growth factor for many cells, it is implicated in atherosclerosis and tissue remodeling. NPY, a sympathetic neurotransmitter, has recently been shown to be a stress mediator (it is not inhibited by stress).

A nurse is teaching about peripheral corticotrophin-releasing hormone (CRH). Which information should the nurse include in the teaching session? Select all that apply.

Its target is mast cells and It increases vascular permeability. Peripheral (immune) CRH is proinflammatory, causing an increase in vasodilation and vascular permeability. Therefore, it appears that mast cells are the target of peripheral CRH. CRH is proinflammatory, not anti-inflammatory. It causes vasodilation, and is not a vasoconstrictor. CRH is secreted by the hypothalamus , not the pituitary, and also peripherally at inflammatory sites (called peripheral or immune CRH).

A client, experiencing multiple stressors simultaneously, developed sleep deprivation and used repression as a coping mechanism. Which effects should the nurse monitor for in this client? Select all that apply.

Lower monocyte counts, Elevated blood glucose levels, Reduced natural killer (NK) cell activity, and Higher Epstein-Barr virus (EBV) antibody titers. Repression was associated with lower monocyte counts, higher (not lower) eosinophil counts, higher serum glucose levels, and more (not less) self-reported medication reactions in medical outpatients and with higher Epstein-Barr virus (EBV) antibody titers in students. Even partial sleep deprivation was associated with reduced natural killer (NK) cell activity in healthy subjects.

In preparing an educational presentation on hormones that influence the stress response, which information should the nurse include in the teaching session?

Melatonin is produced by the pineal gland and effects lymphocyte function. Melatonin is produced in the pineal gland and affects lymphocyte function.

The nurse is assessing a patient who has truncal obesity, thin extremities, a moon-shaped face, and a buffalo hump on the back. Which conditions should the nurse screen for in the patient? Select all that apply.

Metabolic syndrome and Type 2 diabetes mellitus. Truncal obesity, thin extremities, a moon-shaped face, and a buffalo hump are the clinical manifestations of Cushing syndrome. Cushing syndrome is associated with increase in serum glucocorticoids (GCs) levels, which can lead to metabolic syndrome or type 2 diabetes mellitus. High GCs levels cause hypertension, but not hypotension. An increase in the GCs levels increase cortisol levels and result in hypercortisolism. Hyperglycemia occurs in Cushing syndrome.

The nurse is caring for a patient who is receiving cortisol replacement therapy. Which interventions included in the patient's care plan help to provide safe and effective treatment? Select all that apply.

Monitoring the patient's blood glucose levels and Monitoring the WBC count. Cortisol replacement therapy increases serum cortisol levels. This causes gluconeogenesis and reduces immunity, which causes the patient to be at risk for diabetes mellitus, as well as infection. Therefore, the nurse should monitor the patient's blood glucose levels and white blood cell count. Cortisol increases calcium excretion and causes hypocalcemia. Therefore, the nurse should avoid providing a low-calcium diet to the patient. Cortisol does not cause dehydration and hypothyroidism, so the nurse will not have to administer intravenous fluids or monitor the patient's thyroid hormone levels.

The nurse is caring for a patient who is receiving cortisol replacement therapy. Which interventions included in the patient's care plan help to provide safe and effective treatment? Select all that apply.

Monitoring the patient's blood glucose levels and Monitoring the patients WBC count. Cortisol replacement therapy increases serum cortisol levels. This causes gluconeogenesis and reduces immunity, which causes the patient to be at risk for diabetes mellitus, as well as infection. Therefore, the nurse should monitor the patient's blood glucose levels and white blood cell count. Cortisol increases calcium excretion and causes hypocalcemia. Therefore, the nurse should avoid providing a low-calcium diet to the patient. Cortisol does not cause dehydration and hypothyroidism, so the nurse will not have to administer intravenous fluids or monitor the patient's thyroid hormone levels.

What other signs should the nurse expect to assess in the patient with truncal obesity who has laboratory values indicating increased glucocorticoid levels? Select all that apply.

Moon face, buffalo hump, and increased abdominal fat. A patient with truncal obesity and increased glucocorticoid levels could indicate Cushing syndrome. Manifestations of Cushing syndrome include moon face, buffalo hump, and thin extremities. Elevated glucocorticoids contribute to the development of hypertension and increased abdominal fat because the glucocorticoids mediate the redistribution of stored calories into the abdominal region.

When a client is stressed and glucocorticoids are released, what do they regulate? Select all that apply.

Overall, glucocorticoids have an important role in the homeostasis of the central nervous system. These hormones regulate memory, cognition, mood, and sleep. The hypothalamus regulates temperature, not glucocorticoids.

A client has a physiologic response derived from psychologic stressors. Which term should the nurse use to describe this process?

Reactive response. Reactive response refers to a physiologic response derived from psychologic stressors. Exhaustion occurs when there is continuous stress, causing progressive breakdown of compensatory mechanisms and homeostasis. Homeostasis is an optimal steady state. Anticipatory response occurs when physiologic responses develop in anticipation of disruption of the optimal steady state.

When a client's body begins to react to the actions of cortisol, norepinephrine, and epinephrine, which stage of the general adaptation syndrome is the client experiencing?

Resistance. The resistance or adaptation phase begins with the actions of the adrenal hormones cortisol, norepinephrine, and epinephrine. The alarm phase (reaction) begins when a stressor activates the hypothalamus and sympathetic nervous system. Exhaustion (also known as allostatic overload) occurs if stress continues and adaptation is not successful, ultimately causing impairment of the immune response, heart failure, and kidney failure, which lead to death.

Which information indicates the nurse has a good understanding of the stress response and the immune system?

T cell growth factor interleukin-2 can up-regulate adrenocorticotropic hormone (ACTH). The T cell growth factor interleukin-2 can up-regulate ACTH. ( Stress response decreases T cell cytotoxicity and B cell function) Stress and negative emotions are associated directly with the production of increased (not decreased) levels of proinflammatory cytokines, providing a possible link between stress, immune function, and disease. When melatonin production is blocked (by continuous light or by pharmacologic means), the immune response is suppressed (not enhanced), whereas administration of melatonin reverses these effects. Stress-induced immune changes affect many immune cell functions, including decreased natural killer cell and T cell cytotoxicity and impaired B cell function.

When a client is stressed, which immune response can the nurse expect?

Th2 shift. A T-helper 2 cell (Th2) shift occurs during the stress response from the effects of cortisol. Stress can activate an immune response through cortisol, causing suppression of Th1 and innate immunity. The immune response has several changes due to stress.

The nurse is explaining the stress response to another health professional. In which order should the nurse present the information?

The first step is that a stressor stimulates the stress response, activating the sympathetic nervous system. In turn, norepinephrine stimulates neuropeptide Y to be released, causing vasoconstriction.

The nurse is caring for a patient with posttraumatic stress disorder. After assessing the patient, the nurse concludes that the patient is at risk for coronary heart disease. Which finding supports the nurse's conclusion?

The patient's blood pressure is 130/90 mm Hg. A blood pressure of 130/90 mm Hg indicates that the patient has prehypertension. Anxiety increases the progression of prehypertension to hypertension and increases the risk of coronary artery disease. A heart rate of 90 beats per minute is a normal finding. A respiratory rate of more than 25 breaths per minute indicates that the patient has tachypnea. However, tachypnea may be a symptom of a pulmonary disorder, not coronary heart disease. A serum level of 150 mg/dL low-density lipoproteins is a normal finding.

A nurse is teaching a client about catecholamines. Which information should the nurse include in the teaching session?

They include epinephrine and norepinephrine. Catecholamines include epinephrine and norepinephrine. Norepinephrine is secreted from the sympathetic nerves, and epinephrine is secreted from the adrenal medulla. Epinephrine and norepinephrine cannot cross the blood-brain barrier. The heart rate is increased, not decreased.

The home health nurse is visiting a female client with a chronic dysrhythmia for a health check. The client states that she has received news this morning that the company she worked for has filed for bankruptcy and she will no longer be receiving a pension or health insurance. What is the nurse's greatest concern?

sudden cardiac arrest