FN - Unit 4 - Chapter 43: Stress and Adaptation
A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of: appraisal. secondary appraisal. buffering. adaptation.
adaptation. Adaptation is the process of adjusting to, or accommodating, a stressor. Appraisals involve the subjective evaluation of a potential stressor. Buffering is something that reduces the intensity of stress.
A client has experienced the loss of a loved one and is in the grieving process. The grief following this stressful event may be documented as what type of event? chaos. coping. distress. adaptation.
distress. Stress is unavoidable. The resulting feelings of angst and grief are sometimes labeled distress.
A client has been admitted to the mental health unit and states to the nurse, "I just couldn't take it anymore. The stress of what is going on in my life has taken over." What questions asked by the nurse can assist with determining adaptation to stress? Select all that apply. "Do you understand that everyone feels stressed out at times in their life?" "Why do you think you can't handle life right now?" "What type of past experiences have you had that have been traumatic to you?" "When life events have occurred that caused you distress, how did you cope with it?" "Who do you talk to when you are feeling anxious or stressed about things?"
"What type of past experiences have you had that have been traumatic to you?" "When life events have occurred that caused you distress, how did you cope with it?" "Who do you talk to when you are feeling anxious or stressed about things?" The person's responses and the degree of stress depend in part on the nature, intensity, timing, number, and duration of stressors. Adaptation to stress also depends on a person's age, developmental level, past experiences, support systems, and coping mechanisms. Adaptive responses include the mind-body interaction, anxiety, and coping or defense mechanisms. Asking the client about past experiences or coping mechanisms used to deal with past experiences can allow the nurse to determine adaptive or non-adaptive coping skills for further education. Determining the client's support system is important to be sure the client has someone the client feels they can go to for assistance. Asking the client about why they can't handle life is non-therapeutic and difficult for the client to respond to at this stage of the therapeutic relationship. Asking the client about understanding everyone feels stressed, demeans the client and doesn't treat them as an individual.
Which response to stressors results from the activation of the local adaptation syndrome (LAS)? A girl quickly withdraws her hand from a stream of hot tap water. A woman's impending job interview has prompted the activation of her fight-or-flight response. A man is experiencing moderate anxiety before meeting with an important client. A man has a sudden urge for a bowel movement before undergoing thoracentesis.
A girl quickly withdraws her hand from a stream of hot tap water. The local adaptation syndrome (LAS) is a localized response of the body to stress. It involves only a specific body part (such as a tissue or organ) instead of the whole body. The reflex pain response is a response to physiologic stress that is a component of the local adaptation syndrome (LAS). Psychological anxiety and the activation of the fight-or-flight response are not considered to be manifestations of the local adaptation syndrome. The sudden urge for a bowel movement involves the entire gastrointestinal system and not a tissue or organ.
Which nurse is most likely to experience the greatest amount of stress related to his or her position as a nurse? A graduate nurse working on a telemetry unit A nurse with 2 years of experience working on an oncology unit A nurse with 10 years of experience working as a nurse educator A nurse who is an editor of a nursing journal
A graduate nurse working on a telemetry unit Stress is the body's way of responding to any kind of demand or threat. Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care. A nurse with 2 or 10 years has less stress because over time the nurse learns to use knowledge and skills learned to care for a variety of clients. A nurse who is an editor of a nursing journal is also a nurse with clinical experience and is now transitioning into a nursing office job.
A client was at home alone when a tornado struck and damaged the structure. What type of crisis does the nurse address in the care of this client? Adventitious Developmental Situational Maturational
Adventitious There are three types of crises: maturational, situational, and adventitious. Adventitious crises are accidental and unexpected events, resulting in multiple losses and major environmental changes, such as fires, hurricanes, earthquakes, and floods. Maturational crises occur during developmental events that require role change. Situational crises occur when a life event disrupts a person's psychological equilibrium, such as loss of a job or loved one. Developmental crisis does not exist.
Which outcome(s) will the nurse include in the plan of care for a client experiencing caregiver role strain? Select all that apply. Client will demonstrate appropriate coping strategies. Client will identify support mechanisms to help with stress. Client will identify one or two stressors to eliminate. Client will confront those responsible for additional stress. Client will eliminate all stress in a period of 6 months.
Client will demonstrate appropriate coping strategies. Client will identify support mechanisms to help with stress. Client will identify one or two stressors to eliminate. Demonstrating, not only naming, coping strategies is essential for caregivers who are experiencing role strain. Identifying support mechanisms (family, friends, community resources) is helpful in decreasing stress for the caregiver trying to do everything oneself. Identifying one or two stressors to eliminate is realistic, helpful, and can assist the client with feeling some control over the situation. Blaming and confronting others is not a healthy coping mechanism and will likely add to the caregiver's stress. Expecting the caregiver to eliminate all stress is an unrealistic goal that, when unmet, can cause additional stress due to a feeling of failure.
A 15-year-old student is on the high school soccer team. She tells a nurse how she has really started to take a leadership role on the team. When the nurse talks with the client's mother, the mother tells the nurse that her daughter's best friend is a natural leader and may be voted team captain next year. The client's behavior is an example of what defense mechanism? Introjection Projection Denial Lying
Introjection Introjection is when an individual adapts a characteristic of someone else.
A client is using prayer to assist in relieving stress. How would the nurse respond when entering the room to administer medication? Leave and allow the client to continue for as long as needed. Softly alert the client it is time for medication. Place the medication on the hospital tray and return to ensure it has been taken. Ask if there is anything the nurse can do to make this activity more comfortable.
Leave and allow the client to continue for as long as needed. Prayer and meditation aid the client in physical relaxation, connection with the inner self, and accessing higher power. Because prayer and meditation are highly personal, some clients may wish for the nurse to participate with them, while others may not. The nurse should allow the client to complete this activity without interruption. The nurse should not leave medication in the room for the client to be responsible to take on one's own. After the client has completed the prayer, then the nurse may ask if there is anything that can be done to help make this practice more comfortable in the future.
Which client would the nurse expect to have negative coping skills? a 19-year-old diagnosed with schizophrenia who is heading off to college a 13-year-old diabetic who joins a softball league a 37-year-old factory worker who is laid off for the summer a 72-year-old retiree who needs to take an expensive new chemotherapeutic agent
a 19-year-old diagnosed with schizophrenia who is heading off to college All of these clients will be facing stressors and need to develop adaptation skills. The client with schizophrenia, a chronic but manageable psychiatric illness, is most at risk for reacting negatively to the new life stressor. Clients with mental illness may have decreased physiologic reserve with which to effectively cope and adapt.
In contrast to anxiety, fear is characterized by: a cognitive response to a known threat. the creation of an action plan to deal with a perceived threat. a real, rather than perceived, threat. short-term resolution.
a cognitive response to a known threat. Fear is a cognitive response to a known threat, while anxiety is the emotional response to that threat. Fear does not necessarily resolve in the short term, and an action plan may or may not be formulated by the individual. The fact that fear involves the identification of a known threat does not necessarily mean that the object of fear is objectively real.
A client informs the nurse that headaches started when marital problems began. The client reports that each time they have a fight, a headache develops and loss of appetite occurs for several days. What does the nurse identify as the physiologic symptoms? a somatic disorder anxiety fear a coping mechanism
a somatic disorder A somatic disorder is a real illness caused by psychological influences. The client's fight with her husband causes emotions that lead to physical symptoms. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fear is a cognitive response to a known threat. Anxiety is often managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety.
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.
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.
The parents of an infant who requires cardiac surgery inform the nurse they are not anxious about the surgery and "will leave the outcome in God's hands." Which intervention(s) will the nurse use to support the parents' spiritual beliefs? Select all that apply. Give the parents directions to the hospital chapel Give the parents a pamphlet for the nurse's church Tell the parents denial is a common coping mechanism Ask the parents if they would like to speak to the chaplain Ask the parents if they have been praying on a regular basis
Give the parents directions to the hospital chapel Ask the parents if they would like to speak to the chaplain Giving the parents directions to the hospital chapel provides an opportunity for them to be alone and practice spiritual beliefs in a quiet place. Offering the chaplain's assistance is appropriate because talking to another person is an emotion-focused coping mechanism. It is inappropriate for the nurse to offer his or her beliefs or religion to the parents. It is inappropriate and demeaning for the nurse to tell the parents they are in denial. Asking the parents about specific religious practices is inappropriate and prying.
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 client has been diagnosed with breast cancer. Which will the nurse suggest to the client to assist her in engaging in a healthy lifestyle during treatment? Participating in a cancer survivors 5K walk/run Giving away personal possessions Going to happy hour every day after work Missing a chemotherapy appointment to attend a wedding
Participating in a cancer survivors 5K walk/run Adaptation is the process by which individuals use coping mechanisms to balance out the level of stress they are under so they can maintain homeostasis. Joining a support system such as a cancer group's charity event can turn negative stress to positive. Giving away possessions is anticipatory grieving. Drinking and missing appointments are avoidance behaviors and are not healthy behaviors.
A client is dealing with the death of a spouse 10 days ago. The client tells the nurse about not feeling like eating and struggling to get food in. What does the nurse identify is occurring with the client? This is part of the normal sympathetic stress response. This is a form of maladaptive coping. This is a personal coping style. This is an example of the resolution of loss.
This is part of the normal sympathetic stress response. Some individuals lose their appetite during stressful situations. This is actually part of the normal sympathetic stress response that diminishes appetite and digestive function. Sympathetic nervous system (SNS) activity, however, should be short-term, and a person's appetite should return.
While conducting the physical assessment of a client, the nurse notes an increase in the blood glucose level. Upon inquiry, the client discloses that lately he has been under a lot of stress at work. Which stage of stress is the client experiencing? alarm stage resistance stage exhaustion stage tertiary stage
alarm stage The client is most likely in the alarm stage of stress if the blood glucose level is increasing rapidly. This occurs when the body is responding to a stressor by raising the blood glucose as a reserve for meeting increased energy requirements. The stage of resistance is characterized by restoration of normalcy. Physiologic exhaustion occurs when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor. There is no tertiary stage; however, tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease.
Which behaviors represent effective coping mechanisms? Select all that apply. setting limits with family members who upset you learning relaxation techniques taking a vacation sleeping 14 hours a night sleeping 3 hours a night denying responsibility for a DUI conviction
setting limits with family members who upset you learning relaxation techniques taking a vacation Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective.
An adolescent expresses concern that a friend is under "a lot of stress" with home life, classes, clubs, community service, and part-time work. The adolescent asks the nurse what medication the friend should take to "calm down." Which response by the nurse will be supportive of the client? "What medication is your friend taking now? I can recommend something, but we need to make sure there will not be an interaction with something else." "It sounds like your friend is in too many extracurricular activities. Can you convince your friend to drop out of some of those clubs?" "Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives." "Is your friend passing classes? Did you tell your friend's parents this was happening?"
"Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives." The most therapeutic approach would be to enlist the adolescent's help in getting the friend to sit down and discuss what is happening with someone trained in therapeutic communication. Decreasing the activities may help but may be unacceptable to the friend. Directing attention to the friend's academic problems, asking the client about another's health issues and medications, and asking about parental involvement at this stage may damage the trust relationship the nurse has with the client and the friend.
A nurse is assessing a client for anxiety. Which questions should the nurse ask to elicit subjective data related to anxiety? Select all that apply. "Have there been any changes in your appetite?" "Has your heart felt like it was racing or skipping a beat?" "Do you feel like you get angry or upset easily?" "Do you wake easily from sleep?" "How often do you have sex?"
"Have there been any changes in your appetite?" "Has your heart felt like it was racing or skipping a beat?" "Do you feel like you get angry or upset easily?" Anxiety can manifest in different ways. To obtain subjective data the nurse should ask about appetite, changes in heart rhythms or breathing, and anger or sadness issues. Anxiety usually causes a lack of sleep, not waking easily from sleep. Changes in sexual desire may be a reaction to anxiety, but asking how often one has sex does not gather the needed information about anxiety.
A client newly diagnosed with type 2 diabetes mellitus states, "I just can't seem to win. Every time I turn around, I am being thrown a curve ball." Which questions should the nurse ask to determine the client's current ability to adapt to this new diagnosis? Select all that apply. "Where were you born?" "How long have you felt like this?" "Do you have any other health problems?" "How do you usually cope with life problems?" "Have you told your doctor how you are feeling?'
"How long have you felt like this?" "Do you have any other health problems?" "How do you usually cope with life problems?" "Have you told your doctor how you are feeling?' Answering "How long have you felt like this?" will allow the nurse to determine whether the illness or situation is chronic or acute. The question "Do you have any other health problems?" points to the client's health status, which could help determine how the client's body will react to the illness or situation. Answering the question, "How do you usually cope with life problems?" identifies the client's coping strategies, which could tell how well the client adapts to stress. "Have you told your doctor how you are feeling?" is a question that is used to assess how well the client is able to express emotion. Asking a client "Where were you born?" is insignificant, as it does not indicate how an individual will response to stress.
A client informs the nurse that they have a well-paying job but that it is demanding and causes a great deal of anxiety. What statement made by the client indicates that the client has a coping mechanism to deal with anxiety produced by this situation? " Everyone feels sorry for me, and I find comfort in that." "I am going to tell my manager that I just can't deal with the stress." "I am going to have to start taking medication for this anxiety." "I am actively seeking job opportunities in a less stressful environment."
"I am actively seeking job opportunities in a less stressful environment." The person may respond by limiting his emotional response, taking direct action to solve a problem, or using defense mechanisms. Medications are not considered to be coping mechanisms.
A Red Cross volunteer has recently returned from assisting families who survived a devastating forest fire. The volunteer is having trouble sleeping and has returned to smoking cigarettes. Which statement by the volunteer leads the nurse to suspect the nursing concern of role strain related to stress from being a caregiver during their disaster volunteer activities? "I cannot 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 cannot seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." This volunteer is exhibiting a physiologic response to stress while also returning to a negative coping solution to diminish the symptoms. Reliving the events that were stressful is commonly reported by people when experiencing anxiety. The other statements do not demonstrate the burden of role strain.
A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement? "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer." "I am bringing him to the orientation so he can meet his teacher and some classmates." "It's so hard to get them into a routine after summer break. I go through this every year with all my kids." "We've all been talking to him about what school will be like; his brother had the same teacher and really liked her."
"I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer." Each developmental stage includes tasks that must be achieved so that normal growth and development can occur, but change can be stressful. In a school-age child, starting school and being around strangers can be challenging. One way to counteract the anxiety is to introduce them to others in social situations, and teach acceptable social behaviors, before they start school.
Which statement made by the client indicates a need for further teaching regarding stress management? "I manage my stress by taking antianxiety medication." "I manage my stress with occasional alcohol and alprazolam." "I manage my stress by going out with friends for an occasional drink." "I manage my stress by exercising once a week."
"I manage my stress with occasional alcohol and alprazolam." Taking alprazolam with alcohol can produce a temporary relaxation; however, this can result in physical impairment and drug dependence. It is appropriate to manage stress with antianxiety medication, as prescribed by a health care provider, and exercise. It is also appropriate to manage stress by socializing, and alcohol use in moderation does not require further teaching.
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.
The emergency department nurse suspects that an older adult client who fell and broke her hip is using a defense mechanism when the client states: "They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight." "I'm so clumsy. I'm surprised it hasn't happened before this." "Does this mean I have to stay here in the hospital?" "Can you call my next-door neighbor for me? I'm so worried that my cat, Clancy, won't have any food or water."
"They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight." Defense mechanisms are psychological tools individuals use to deal with high levels of anxiety from stressors. Clients under extreme stress may self-protect by using denial and rationalization; they may convince themselves that the problem didn't happen or was not caused by them, or that it must have resulted from someone else's mistake. Additionally, the denial may be nonacceptance of the developmental stressors of aging.
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.
The nurse is caring for a client with chronic pain. Which long-term coping strategies may be helpful in this situation? Smoking and walking briskly Accepting the pain will never go away Deep breathing and meditation Take a tepid sponge bath during pain episodes
Deep breathing and meditation Long-term coping mechanisms are positive, constructive ways of dealing with stress and can be effective over long periods. Long-term coping strategies include deep breathing exercises and meditation, as these promote relaxation. Smoking is detrimental to health and should never be used as a coping strategy. Accepting that the pain will never go away is not a coping strategy and may indicate feeling of hopelessness. Taking a tepid sponge bath is done to lower body temperature and may actually worsen discomfort.
A client tells the nurse about feeling depressed and low. Further assessment reveals that the client has difficulty verbalizing his feelings and needs, often feeling manipulated by others. Which action would the nurse suggest to the client to help relieve stress? Enroll in a class or workshop in assertiveness training. Practice rephrasing thoughts that are negative or irrational. Be realistic about how much you can accomplish. Gain control over self-defeating thoughts.
Enroll in a class or workshop in assertiveness training. The nurse should suggest that the client enroll in a class or workshop in assertiveness training. Assertive behavior enables people to act in their best interests, to stand up for themselves, to express their feelings openly and honestly, and to exercise their rights without infringing on the rights of others. Practicing rephrasing thoughts that are negative or irrational, being realistic about how much he can accomplish, and gaining control over self-defeating thoughts are inappropriate coping strategies.
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.
What is a general task for a client adapting to acute and chronic illness? Maintain self-esteem Handle pain Carry out medical treatment Confront family problems
Maintain self-esteem Adaptation to acute and chronic illness or to traumatic injury involves two sets of adaptive tasks: 1. General tasks (as in the case of any situational stress) involve maintaining self-esteem and personal relationships while preparing for an uncertain future. 2. Illness-related tasks include such stressors as losing independence and control, handling pain and disability, and carrying out the prescribed medical regimen.
An older adult client assumed care of a parent with dementia and had to decrease work hours to stay and home and care for the parent. Due to the decrease in hours, it is difficult to meet financial obligations. What actions by the nurse would be appropriate for this client? Select all that apply. Make a referral to the case manager to determine available resources. Inform the client that the parent needs to go into a long-term care facility. Have the client make an appointment with social services to assist with financial resources. Suggest the client join a support group for caregivers of parents with dementia. Encourage the client to find another family member to care for the parent.
Make a referral to the case manager to determine available resources. Have the client make an appointment with social services to assist with financial resources. Suggest the client join a support group for caregivers of parents with dementia. Caring for a family member with dementia can be a very stressful life event but can also be rewarding. Determining what available resources can be used, such as social, financial, and physical assistance; is an appropriate intervention that can make life much easier. Support groups are also a positive intervention and the client may find resources available through that avenue. It is not the nurse's role to have the client ask another family member to care for the parent or suggest that they would be better off in a long-term care facility.
The spouse of a client on hospice at home is diagnosed with "caregiver burden." Which intervention(s) will the nurse use to assist the caregiver? Select all that apply. Problem solve with the spouse to create a plan for respite Discuss support mechanisms available for the spouse Offer the spouse ideas for emotional coping mechanisms Provide the name of a local caregiver support group Suggest ways the spouse can maximize time and effort
Problem solve with the spouse to create a plan for respite Discuss support mechanisms available for the spouse Offer the spouse ideas for emotional coping mechanisms Provide the name of a local caregiver support group Suggest ways the spouse can maximize time and effort Caring for a family member at home for long periods can cause prolonged stress. The nurse can assist by helping the spouse create a plan to find respite for oneself. Support mechanisms are an example of emotion-focused coping mechanisms. A support group is a good way for the spouse to bond with other caregivers as a coping mechanism. Suggesting ways the souse can maximize one's time and effort are possible long-term coping mechanisms.
The client has just been informed about having a terminal illness. Which should the nurse anticipate when taking the client's current vital signs? Pulse oximetry: 100% Heart rate: 64 beats/min Blood pressure: 108/56 mm Hg Respiratory rate: 10 breaths/min
Pulse oximetry: 100% In times of stress, norepinephrine and epinephrine have similar, not opposing, physiologic functions. These include increased heart rate and contractility, bronchial dilation, heightened awareness, and pupil dilation. A pulse oximetry reading of 100% is expected due to bronchial dilation. A heart rate of 64 beats/min is within normal range; during times of stress, the physiologic response is tachycardia, which is greater than 100 beats/min. A blood pressure reading of 108/56 mm Hg is quite low; during times of stress, there is increased heart contractility, leading to increased blood pressure. A respiratory rate of 10 breaths/min is normal; during times of stress, there is an increase in respirations to increase oxygenation to the vital organs.
The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client? Refer the client to a consciousness-raising group Refer the client to an encounter group Refer the client to a support group Refer the client to a religious support group
Refer the client to a support group Being a member of a support group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas. The religious support group may focus on religion and not the loss that the client needs to discuss. An encounter group is a group of people who meet to gain psychological benefit through close contact with one another. This is different from the support group, as the attendees are gaining psychological benefit and not expressing feelings and ideas. A consciousness-raising group is a group of people attempting to focus the attention of a wider group of people on some cause or condition. An example of this is raising awareness of increased suicides among those who experience the death of a loved one.
The nurse is assessing a client who was involved in a neighborhood shooting. The client's vital signs show that his body is attempting to adapt to the stressor. What stage of the general adaptation syndrome is this client experiencing? Alarm reaction Resistance Exhaustion Homeostasis
Resistance The general adaptation syndrome (GAS) describes the body's general response to stress, a concept essential in all areas of nursing care. Having perceived a threat and mobilized its resources, the body attempts to adapt to the stressor during the resistance stage; vital signs, hormone levels, and energy production return to normal during this stage. The alarm reaction is initiated when a person perceives a specific stressor and various defense mechanisms are activated. Exhaustion results when the adaptive mechanisms can no longer provide defense. Homeostasis is when the body's internal environment is in a balanced state.
A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in? Alarm reaction Exhaustion Resistance Reflex pain response
Resistance This client's situation is an example of the resistance stage of the GAS. Stress is continuing, but the client is maintaining homeostasis. Alarm is the initial stage when major stress is encountered. Exhaustion is when homeostasis can no longer be achieved. The reflex pain response is part of the local adaptation syndrome.
A client who has been working with an organization for several years did not get a promotion. As a result, the client has gone into depression. Which suggestion should the nurse make in order to help the client with his stress? Change the job. Accept the changes. Take a break from the job. Seek professional help.
Seek professional help. The client should seek professional help, where he can talk freely about his anger and sense of betrayal. The client should then explore other options in a calmer frame of mind. Changing jobs, compromising, or taking a break from the job will not help the client solve the problem.
The nurse is facilitating an evening meditation and deep breathing class for breast cancer survivors. Which outcome will the nurse anticipate occurring after performing deep breathing with the clients? Lethargy Restlessness Shallow breathing Slowed heart rate
Slowed heart rate Breathing is an important element of the relaxation response. When a person is relaxed, breathing slows and deepens and the heart rate returns to normal. As stress and tension mount during the day, breathing becomes shallow and irregular and the heart rate accelerates. Poorly oxygenated blood contributes to lethargy, tension, restlessness, and depression.
A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation? Adaptation often fails during stressful events and results in homeostasis. Stress is a part of our lives and eventually this young woman will adapt. Acute anxiety and depression are seldom associated with stress. Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease.
Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease. Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease. If a person is overwhelmed by stress, that person may never adapt. Acute anxiety and depression are frequently associated with stress.
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 is discussing methods of relaxation for a client diagnosed with anxiety and panic attacks. When informing the client about the benefits of meditation, what conditions does the nurse include that must be present to be effective for a state of relaxation? Select all that apply. The client should have a passive attitude. The client should identify a word or mental image on which to focus. The client should be in a quiet area. The client should have food present to snack on during meditation. The client should be in a comfortable position that can be maintained.
The client should have a passive attitude. The client should identify a word or mental image on which to focus. The client should be in a quiet area. The client should be in a comfortable position that can be maintained. Meditation has four components: quiet surroundings, a passive attitude, a comfortable position, and a word or mental image on which to focus. A person practicing meditation sits comfortably with closed eyes, relaxes the major muscle groups, and repeats the selected word silently with each exhalation. Alternatively, a person may focus on a pleasant scene and mentally place himself or herself in it while breathing slowly in and out. This exercise should be performed for 20 to 30 minutes twice a day. Focus is required and snacking may be a significant distraction.
The client is a parent who has just been notified their son was in a motor vehicle accident. The nurse assesses the following reactions of the client over time. Place the reactions in the order of the stages of the general adaptation syndrome (GAS). The client's pupils are measured at 5 mm from original 3 mm. The client's heart rate decreases from 116 to 84 beats/min. The client reports a feeling of exhaustion. The client states she feels rested after sleeping.
The client's pupils are measured at 5 mm from original 3 mm. The client's heart rate decreases from 116 to 84 beats/min. The client reports a feeling of exhaustion. The client states she feels rested after sleeping. The stages of the general adaptation syndrome start with the threat (notification of the son being in the motor vehicle accident). Alarm reaction occurs, and one of the signs of this stage is dilated pupils. The next stage is the stage of resistance, in which neuroendocrine activity returns to normal. This may be exhibited by the heart rate returning to a normal level. The third stage is one of exhaustion. The client may recover following the stressor, and this client reports feeling rested.
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.
Many families are sheltering in the local middle school gymnasium during a severe tornado outbreak. Many homes have been destroyed and lives lost. The community health nurse expects to see negative stress reactions to the crisis, such as: a young wife asking everyone repeatedly if they know where her husband is. an older adult couple staying near each other constantly. a young boy asking everyone if they need some water or food. a man enlisting others to help him look for lost pets.
a young wife asking everyone repeatedly if they know where her husband is. Disasters are considered adventitious crises. Those who are affected will utilize coping skills, good or bad, to maintain homeostasis. Positive coping might involve supporting loved ones and helping others adapt. Negative coping might include denial, anger, withdrawal, and panic.
An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of: adaptation. evaluation. reaction. valuation.
adaptation. Adaptation is generally considered a person's capacity to flourish and survive, even with in times of adversity.
A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of: appraisal. secondary appraisal. buffering. adaptation.
adaptation. Adaptation is the process of adjusting to, or accommodating, a stressor. Appraisals involve the subjective evaluation of a potential stressor. Buffering is something that reduces the intensity of stress.
A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client? cocaine use projection exercise alcohol use
alcohol use Alcohol use is a common altered coping pattern for individuals with poor coping skills. It is legal and easily accessible. Phrases such as "I just cannot cope" and "I need to numb the pain" are common among those who misuse alcohol.
Which response to long-term stress may present itself in clients? Select all that apply. alcoholism peritonitis hypertension bulimia diplopia
alcoholism hypertension bulimia Stress that becomes a chronic problem over time can lead to maladaptive coping and further evidence of disease. It has been linked to eating disorders, substance use, cardiovascular disease, cancer, and immune system dysfunction. Diplopia (double vision) and peritonitis are not within this constellation of pathologies.
A freshman college student who lives on campus comes to the health clinic reporting insomnia and difficulty concentrating in class. The student has three red, scaly patches of skin on their arms and chest. The nurse identifies the primary problem-based nursing concern as: sleep deprivation related to change in living arrangements. altered skin integrity related to psoriasis. altered thought processes related to increased scholastic workload. anxiety related to stress of achievement in school.
anxiety related to stress of achievement in school. This student, new to college, is demonstrating classic anxiety symptoms stemming from high stress levels. The nurse should identify the nursing concern of anxiety. Sleep deprivation, altered skin integrity, and disturbances of thought are applicable, but these concerns do not address the primary problem.
A nursing student is engaging in a conversation with a nursing instructor whom the student intensely dislikes. Which nursing student behavior is consistent with reaction formation? imitating the speech of the nursing instructor accusing the nursing instructor of being prejudiced being extremely nice to the nursing instructor developing stomach pain during each conversation with the nursing instructor
being extremely nice to the nursing instructor Reaction formation involves acting just the opposite of one's true feelings; thus, being extremely nice to the nursing instructor is the opposite of what the student feels. Imitating the speech of the nursing instructor is consistent with identification. Accusing the nursing instructor of being prejudiced is consistent with projection. Developing stomach pains when talking with the nursing instructor reflects somatization.
An intensive care unit (ICU) nurse with 11 years of experience has been frequently absent or late for shifts, has been verbally abusive with coworkers she feels are unskilled at the technological tasks of the job, and cursed under her breath at a distraught family member today. The nurse manager is threatening to suspend her if it happens again. The ICU nurse may be experiencing: burnout. allostatic load. repression. sleep deprivation.
burnout. Burnout is the term used to describe behaviors that occur when a person is overwhelmed with the demands of a situation and is similar to the exhaustion stage of anxiety. This is commonly seen in nurses who work in high-stress environments. The individual in this scenario may have a great allostatic load and/or sleep deprivation, but there is no evidence of this in the given scenario. Repression is when a person copes by unconsciously denying the occurrence of a stressful event.
Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with: clear identification of the relevant problem. presentation of clear, achievable, and evidence-based solutions. careful and objective analysis of different proposed options. comparison of the family's situation to other similar situations.
clear identification of the relevant problem. Crisis intervention is a problem-solving technique that begins with the identification of the problem. This precedes the identification of options and assessment of proposed solutions. Once the problem is identified by the client and the crisis team is way, interventions should be then be developed by the team members. The crisis intervention is very individualized and should not be compared to other families. Analysis is the last step of the process.
A client is having a stress response related to a recent accident while boating. What does the nurse identify will be excreted from the adrenal cortex in response to this reaction? cortisol insulin epinephrine thyroxine
cortisol Cortisol is the main glucocorticoid hormone from the adrenal cortex. Cortisol affects glucose metabolism, which is necessary for increased energy expenditure.
The client is a single mother of two children who attends college and works full time. She is seeing the college nurse due to a crying outburst in class. The last step of crisis intervention that the nurse employs is: determining if the outcome has been achieved. outlining several solutions to the crisis with the client. asking the client, "What would happen if you did this solution?" having the client select an acceptable solution to her problem.
determining if the outcome has been achieved. Crisis intervention is a five-step problem-solving technique. The last step is to evaluate outcome achievement. The other options precede evaluation.
A client has experienced the loss of a loved one and is in the grieving process. The grief following this stressful event may be documented as what type of event? chaos. coping. distress. adaptation.
distress. Stress is unavoidable. The resulting feelings of angst and grief are sometimes labeled distress.
A client with diabetes mellitus is experiencing acute stress. The nurse identifies that the client will be secreting excess levels of cortisol. What should the nurse monitor the client for related to the increased levels of cortisol? depression elevated glucose levels elevated potassium levels cardiac arrythmias
elevated glucose levels Under acute stress, cortisol is released and can raise glucose levels. In a client with diabetes, the elevations in glucose levels can be detrimental. The nurse does not need to monitor for depression, elevated potassium, or cardiac arrythmias in relation to the elevated cortisol levels.
In human beings, the physiologic response to a stressor includes the: sympathetic nervous system slowing the heart rate. hypothalamus secreting adrenocorticotropic hormone. hypothalamus secreting thyroid-stimulating hormone. epinephrine increasing the blood-glucose level.
epinephrine increasing the blood-glucose level. Homeostasis in physiologic systems is maintained within a narrow range around a set point through continual changes in internal processes. Adjustments in heart rate, blood pressure, body temperature, fluid and electrolyte balance, blood glucose concentration, and blood oxygen level occur automatically to maintain proper system functioning and survival.
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.
A client who has a history of sexual abuse is demonstrating repression. What client behavior does the nurse expect? blaming others for the sexual abuse having no memory of the sexual abuse refusing to believe that the sexual abuse occurred behaving like a young child
having no memory of the sexual abuse Repression is forgetting about the stressor or removing the experience from the subconscious. Blaming others is a sign of displacing anger. Refusal to believe is a sign of denial. Childish behavior is demonstrative of regression.
The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize? angry outbursts lack of interest in sex difficulty falling asleep impaired concentration
impaired concentration Impaired concentration is consistent with a cognitive symptom associated with stress. Difficulty falling asleep and lack of interest in sex are physical symptoms associated with stress, and angry outbursts are emotional symptoms associated with stress.
The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize? angry outbursts lack of interest in sex difficulty falling asleep impaired concentration
impaired concentration Impaired concentration is consistent with a cognitive symptom associated with stress. Difficulty falling asleep and lack of interest in sex are physical symptoms associated with stress, and angry outbursts are emotional symptoms associated with stress.
A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms? type 2 diabetes obstructive sleep apnea moderate anxiety herniated lumbar disc
moderate anxiety This client may have increased anxiety from adjusting to retirement, a significant life stressor. There are not enough data to identify any of the other disorders as being present.
A client is being admitted to a health care facility for abdominal pain of undetermined origin. The client states, "I have never been hospitalized before. What is going to happen to me?" The nurse notes the client's respirations are 28 breaths/minute, heart rate is 102 beats/minute, and blood pressure is 120/86 mm Hg. The client's muscles are tense. What action(s) will the nurse take to reduce the client's anxiety? Select all that apply. introduce self to client by name and title provide information about diet, activity, and diagnostic tests hold information about policies and routines until the client's anxiety is reduced discuss past experiences involving the health care system with the client ask the client about available support systems and enlist his or her support
introduce self to client by name and title provide information about diet, activity, and diagnostic tests discuss past experiences involving the health care system with the client ask the client about available support systems and enlist his or her support The client, exhibiting signs of moderate anxiety, acknowledges this is the first hospitalization and asks for information. The nurse would first introduce himself or herself to the client by name and title. The nurse completes an assessment that would include information about past experiences with the health care system and available support systems. The nurse would provide information to the client about diet, activity, and diagnostic tests. The client asked for this information with the aim of knowing what to expect.
A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? tell the family they are causing too much stress limit the family visits to once daily explain that family visits and support are important do not intervene and allow the client to work out the family issue
limit the family visits to once daily When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor.
A nurse is teaching a client regarding effective coping strategies. Which teaching will the nurse include? Select all that apply. making an appointment with a counselor writing a list of pros and cons sleeping during the day avoiding crowds and social activity practicing yoga and relaxation turning to a higher power
making an appointment with a counselor writing a list of pros and cons practicing yoga and relaxation turning to a higher power Making an appointment with a counselor is an appropriate step in positive coping. Writing a list of pros and cons is a problem-solving technique used in positive coping. Practicing yoga and relaxation is similar to progressive relaxation, which is a positive coping strategy. Turning to a higher power can also be a sign of positive coping. Excessive sleeping and social avoidance are signs of maladaptive coping.
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.
An occupational health nurse at an oil refinery on the Gulf Coast of Texas performs client education with an adult client. The client is being seen after having suffering a chemical burn in an accident at the refinery. Which type of stressor has this client been exposed to? physiologic psychosocial maturational socioeconomic
physiologic Physiologic stressors include chemical agents (drugs, poisons), physical agents (heat, cold, trauma), infectious agents (viruses, bacteria), nutritional imbalances, hypoxia, and genetic or immune disorders. Psychosocial stressors include both real and perceived threats. Environmental stressors are items found in our surroundings, such as noise and crowds. Socioeconomic stressors relate to income and home life (such as low household income and low occupational status of the householder).
A middle-aged adult discusses the loss of a job due to frequent illness. Which will the nurse discuss with the client to assist in problem-solving the loss? practicing meditation or yoga drinking a glass of wine each night with dinner searching for a job with adequate health insurance obtaining a prescription for antianxiety medication
practicing meditation or yoga Coping is the process of applying thoughts and actions to deal with stressful events. There are various mechanisms to coping. An example of a normal, long-term coping mechanism is learning and practicing meditation or yoga. A short-term and possibly unhealthy coping mechanism is drinking alcohol or "pill popping" (e.g., taking aspirin or tranquilizers). Searching for a job with adequate health insurance does not address the client's current issue and the job search may add more stress.
The nurse is making preparations for a group of clients who have been experiencing some stressful events in their lives. Which nursing strategies should the nurse use to assist these clients? Select all that apply. ignoring the stressors preventing additional stressors assessing the client's response to stress implementing stress management techniques assisting in maintaining a network of social support
preventing additional stressors assessing the client's response to stress implementing stress management techniques assisting in maintaining a network of social support Preventing additional stressors will eliminate the cumulative effects of other stressors. Assessing the client's response to stress will help indicate how well the client is adapting to the stressors. Implementing stress management techniques will provide strategies to assist the clients in mitigating further stressors. Maintaining a network of social support will provide the clients with other individuals to share their concerns with. Ignoring the stressors will just add to the cumulative effect or other stressful life events; it will not remove the stress.
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.
After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify? rationalization denial repression suppression
rationalization Rationalization is relieving oneself of personal accountability by attributing responsibility to someone or something else. By claiming the exam is written poorly, the student is relieved of the personal responsibility. Denial is simply rejecting information. Repression is forgetting about the stressor. Suppression is purposeful avoidance of the topic or issue causing stress.
A new graduate is having difficulty coping with the role transition from student to registered nurse (RN). Which defense mechanism is being exhibited when the nurse states, "I hate going in to work on weekends. The aides are lazy, the clients are all complaining, and the families are all crazy!" denial projection displacement reaction formation
reaction formation New RNs are often faced with a tremendous challenge—adapting to the "real world." While wanting to maintain the compassion, empathy, and altruism that caused them to choose health care as a profession, the realities of day-to-day conflict and stress at work are difficult to accept and may be even more difficult to resolve. Sometimes the new nursing graduate will cope by using reaction formation—developing attitudes that are opposite to what the nurse really would prefer to do (or needs to do) in the situation.
A client who is a single parent of two small children is working two part-time jobs. The client comes into the clinic for an appointment looking disheveled and fatigued. Which health promotion activities would this client benefit from? Select all that apply. reduction of stressors perfection reduction using aggressiveness cognitive behavioral therapy antianxiety medications
reduction of stressors perfection reduction Assertiveness, not aggressiveness, is a preferred health promotion strategy. CBT is a treatment, not health promotion. Medications are also a treatment.
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 has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing? alarm stage exhaustion stage resistance stage primary stage
resistance stage The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress. The primary stage is not related to stages of stress and is applicable for stress prevention.
The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as: mild. moderate. severe. panic.
severe. Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.
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.
The nurse is obtaining data for a client experiencing a sympathetic response to a medication. Which symptom(s) will the nurse document that will correlate with the medication effects? Select all that apply. pupils are constricted and pinpoint heart rate is 58 beats/min skin is pale bowel sounds are hypoactive in all quadrants urine output is decreased to less than 30 ml/h
skin is pale bowel sounds are hypoactive in all quadrants urine output is decreased to less than 30 ml/h Pinpoint or constricted pupils and bradycardia indicate a parasympathetic response. In a sympathetic response to a medication, the heart rate will be rapid and the pupils will be dilated. Pale skin is a sympathetic response due to constriction of blood vessels. Digestive motility is decreased which will be indicated in the slowing of peristalsis and hypoactive bowel sounds. The detrusor muscle is inhibited which suppresses urination and limits flow.
Which data is most appropriate for the nurse to include when assessing an older adult client's capacity to adapt to current stressors? advanced age, number of children, and network of social factors social losses, network of social factors, and advanced age level of education, religious belief, and social losses expectations of life, attitudes, and advanced age
social losses, network of social factors, and advanced age Advanced age, loss of social network, and social losses is correct, because these can diminish older adults' ability to cope and may provoke the onset of physical or emotional disorders. Religious belief and one's attitude is incorrect, because these vary as to how older adults adapt to stress. Numbers of children, level of education, and life expectations do not determine how older adults adapt to stress.
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.
The nurse determines that a client understands instruction regarding progressive relaxation when the client states that the technique requires: tensing and relaxing various muscle groups. using a mantra in a relaxed position. focusing on pleasant images. using a biofeedback machine.
tensing and relaxing various muscle groups. Progressive relaxation consists of systematically tensing and relaxing various muscle groups from head to toe. Progressive relaxation provides a method of identifying particular muscle groups and distinguishing between sensations of tension and tranquility.
