Sensory Functioning/Stress

11. What type of cognitive responses might a nurse assess in a patient with sensory deprivation? A) uncoordinated movements, altered sense of smell B) decreased attention span, difficulty problem solving C) apathy, depression D) rapid mood changes, anxiety

B

13. An individual steps into a tub of very hot water and immediately jumps out again. What mechanism caused this response? A) inflammatory response B) reflex pain response C) general adaptation syndrome D) fight-or-flight response

B

13. What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU? A) use bright lights B) use limited light C) play loud music D) avoid touch

B

15. A nurse assesses a mother who rocks and cuddles her newborn son. What sense is the mother stimulating? A) auditory B) kinesthetic C) visual D) gustatory

B

16. A young mother tells the nurse, I cant stop smoking. That is what I do to make myself feel better. What is the term used to describe this behavior? A) defense mechanism B) coping mechanism C) caregiver burden D) crisis

B

20. Which of the following illnesses has been associated with long-term stress? A) bacterial infections B) cardiovascular disease C) renal disease D) fractures

B

23. Which of the following nonpharmacologic, independent nursing interventions may be used to promote relaxation without also causing sensory overload? A) talking with the patient B) playing music the patient chooses C) watching talk shows the nurse chooses D) watching television reality shows that visitors choose

B

30. A nurse teaches a patient deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique? A) meditation B) relaxation C) anticipatory guidance D) guided imagery

B

5. What is the term for the change that takes place in response to a stressor? A) rehabilitation B) adaptation C) positive movement D) negative movement

B

6. After assessing a patient, a nurse documents the state of awareness as confused. What part of the brain controls awareness? A) cranial nerves B) reticular activating system C) hypothalamus D) medulla

B

7. Various physiologic mechanisms within the body respond to internal changes to maintain relative constancy in the internal environment. The state that results is called: A) nirvana B) homeostasis C) fight-or-flight response D) anxiety

B

9. A student is preparing for her first patient care assignment. She wakes up at 4:00 a.m. with a pounding pulse and diarrhea. What type of adaptive response to stress is she experiencing? A) general adaptation syndrome B) mindbody interaction C) local adaptation syndrome D) coping or defense mechanism

B

12. A patient admitted to the hospital for major surgery is at risk for what type of sensory alteration? A) sensory deprivation B) sensory deficits C) sensory overload D) sensory stimulation

C

17. A nurse is assessing a patient on the first day after major abdominal surgery. Which of the following internal stimuli would be increased and affect patient responses? A) lights and noise B) visitors and caregivers C) intravenous lines, pain D) ambulating, coughing

C

19. A man has noticed bright red blood in his bowel movements for over a month. He says to himself, Oh, its just my hemorrhoids. What defense mechanism is the man using? A) rationalization B) repression C) denial D) compensation

C

2. What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs, independent of vision? A) stereognosis B) visceral C) proprioception D) sensory perception

C

21. A home care patient has both visual and hearing deficits. Although all of the following are important, what would be a high priority concern when planning and implementing care? A) nutrition B) comfort C) safety D) communication

C

22. A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crises is she experiencing? A) adventitious B) maturational C) situational D) emotional

C

22. A nurse asks the mother of a hospitalized 2-year-old patient to bring in his favorite blanket or stuffed animal. What sense is the nurse trying to stimulate with this intervention? A) gustatory B) visual C) tactile D) auditory

C

25. A nurse is teaching a lawn-care worker about the risk of hearing loss. What might be recommended? A) Listen to loud music with earphones while mowing. B) Just ignore the noise; you are too young for damage. C) Wear earplugs while using lawn equipment. D) Clean your ears with cotton-tipped applicators daily.

C

25. Which of the following groups of nurses experience the highest levels of stress in the work setting? A) obstetric nurses B) pediatric nurses C) new graduates D) aging nurses

C

27. A nurse is caring for a person who is delusional. What is important for the nurse to do while communicating with the patient? A) Touch the patient gently while talking. B) Avoid arguing about erroneous statements. C) Reinforce reality for delusional statements. D) Maintain eye contact at all times.

C

28. A nurse is caring for a patient who is unconscious. Which of the following is a recommended guideline for communication with this patient? A) Do not assume the person can hear you. B) Keep environmental noise level high to stimulate the patient. C) Be careful what is said in front of the patient as he or she might hear you. D) Touch the person before speaking to them.

C

28. A nurse is teaching a patient about the benefits of exercise in reducing stress. How often would the nurse recommend the patient exercise? A) 2 hours every day B) 1 hour once a week C) 30 to 45 minutes, most days of the week D) 60 to 75 minutes, four to five times a week

C

4. Cold temperatures and loud noises are stressors to one person but not another. Why does this occur? A) Although the perception is the same, the response is individualized. B) Both individuals will respond the same, depending on the situation. C) The perception and effects of stressors are highly individualized. D) The internal environment of one person is more selective.

C

6. A patient responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor? A) adaptation B) homeostasis C) coping mechanism D) defense mechanism

C

2. Which of the following are considered internal stressors? Select all that apply. A) loud noises B) pollution C) illness D) hormonal change E) fear F) cold stress

C,D,E

10. In which of the following healthcare settings is a patient more likely to be at risk for sensory deprivation? A) hospital newborn nursery B) community health center C) emergency department D) long-term care

D

11. What phase of the general adaptation syndrome is a patient in when he uses all of his adaptive mechanisms for dealing with stress, leaving no defense against the distress? A) alarm reaction stage B) fight-or-flight stage C) stage of resistance D) stage of exhaustion

D

14. If a nurse assessed the vital signs of a person who was in the initial alarm reaction stage (shock phase) of the GAS, what would be the expected findings? A) slow, deep breathing B) fatigue and lethargy C) hypotension D) hypertension

D

15. Which of the following group of terms best describes anxiety? A) cognitive, known threat, depression B) cognitive, visible threat, anger C) known source, prolonged, solely physical D) unknown cause, emotional, apprehensive

D

17. A nurse is preparing to teach a patient about care at home. On entering the room, she finds the patient pacing around the room, hyperventilating, and complaining of nausea. Based on these manifestations of severe anxiety, what would the nurse do? A) Provide both verbal and written information to the patient. B) Ignore the patient and teach the family the information. C) Modify the teaching plan to the patients anxiety level. D) Postpone implementation of the teaching plan.

D

18. A nurse assessing older adults in a long-term care facility is aware that which of the following may result in sensory alterations for these patients? A) constipation B) anorexia C) dry skin D) presbyopia

D

18. A woman who was assaulted in the street is brought to the emergency room for observation. A nurse documents that the woman has difficulty communicating verbally, is agitated, and complains of chest pain and a sense of impending doom. What type of anxiety is this patient experiencing? A) mild anxiety B) moderate anxiety C) severe anxiety D) panic

D

20. Which of the following nursing diagnoses describes disturbed sensory perception as the etiology? A) Altered environmental stimuli: excessive B) Altered sensory reception, transmission C) Impaired memory related to situational causes D) Ineffective Coping related to sensory overload

D

23. Which of the following is an example of developmental stress? A) a newborn who needs to be fed by bottle B) a school-aged child learning to read C) a teenager learning to drive a car D) a middle adult accepting signs of aging

D

26. Which of the following questions would be helpful in eliciting data about the effects of stress during a health history? A) Why are you having so much difficulty breathing at night? B) Why do you think smoking and drinking will calm you? C) Do you often drink too much and have hangovers? D) How does your body feel when you are upset?

D

29. What philosophy for handling stress can nurses encourage patients to adopt? A) One for all and all for one. B) Do today so that you do not have to do the same thing tomorrow. C) If you have too much to do, just get busy and do it. D) Accept what cant be changed, change what cant be accepted

D

4. Which of the following best describes a stimulus? A) a sense organ that receives a message and converts it into a nerve impulse B) conduction along a nerve pathway from the receptor to the brain C) reception and translation of an impulse into a sensation D) an act or agent that initiates a response by the nervous system

D

9. Which of the following hospital units is more likely to cause severe sensory alterations? A) general unit B) short-stay surgery C) eye clinic D) intensive care

D

10. A patient with an inflamed appendix is feeling pain in the stomach area. What is the term for this body response to stress? A) local adaptation syndrome B) general adaptation syndrome C) physiological homeostasis D) fight-or-flight response

A

12. A patient who is being seen at a physicians office states that he has bad headaches all the time. Diagnostic tests are normal. What is this type of response to stress called? A) psychosomatic disorder B) acute illness C) chronic illness D) pretend disorder

A

14. A patient tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition? A) sensory deficit B) sensory deprivation C) sensory overload D) sensory stimulation

A

16. Is it important for a nurse to consider a patients culture when providing physical care? A) Yes, culture dictates the amount of sensory stimulation considered normal. B) Yes, the nurses culture and the patients culture are often different. C) No, the nurse must provide needed physical care to all patients. D) No, the nurse is not required to consider culture when providing care.

A

19. A patient has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness. What would be the most appropriate nursing diagnosis? A) Acute Confusion B) Chronic Confusion C) Impaired Memory D) Disturbed Sensory Perception

A

21. The wife of a patient on hospice at home is diagnosed with caregiver burden. Which of the following best describes this syndrome? A) prolonged stress from caring for a family member at home B) inability to provide competent care for a family member C) insufficient funds to pay for medical care of a family member D) effect of the illness causing stress in siblings

A

24. A community health nurse is conducting a seminar on vision self-care. What might be one topic included in the teaching plan? A) Wear sunglasses when working outside. B) Close the eyes when working with chemicals. C) Use over-the-counter eye drops when necessary. D) When using aerosol sprays, spray toward self.

A

24. Of the following physiologic stressors, which one is a physical agent? A) heat B) drugs C) bacteria D) hypoxia

A

26. A nurse is making a home care visit to a patient with a hearing deficit. What can she do to facilitate communication with the patient? A) Ask for permission to turn off the television set during the visit. B) Talk in a loud tone of voice at all times during the visit. C) Use written communication rather than verbal communication. D) Reduce the time spent with the patient to decrease frustration.

A

27. Which one of the following diagnoses would be written for stress as the cause of the problem? A) Anxiety related to conflicts about values and goals in life B) Caregiver Role Strain related to long-term stress of care for a parent with Alzheimers disease C) Spiritual Distress related to inability to accept diagnosis of terminal illness D) Hopelessness related to presence of disabling physical injuries

A

3. A patient says, What is that awful smell? What sense is being used? A) olfactory B) gustatory C) tactile D) auditory

A

3. Which of the following best describes stress? A) a response to changes in the normal balanced state B) a perception that something is threatening C) a response to internal environment for homeostasis D) a localized response of a tissue or organ to a stressor

A

7. How would a nurse document the condition in which a patient has a normal state of awareness? A) Aware of self and environment, responsive, well-oriented. B) Easily distracted, alternates between drowsiness and excitability. C) Disoriented, restless, agitated, hallucinating. D) Cant be aroused and does not respond to stimuli.

A

8. A nurse documents the following on a patient chart: patient manifests difficulties with spatial orientation, memory language, and changes in personality. What state of arousal/awareness does this describe? A) delirium B) dementia C) confusion D) locked-in syndrome

A

8. Which of the following body systems are the primary controllers of homeostatic mechanisms? Select all that apply. A) autonomic nervous system B) endocrine system C) respiratory system D) cardiovascular system E) gastrointestinal system F) renal system

A,B

1. Which of the following accurately describe senses by which individuals maintain contact with the external environment? Select all that apply. A) vision B) hearing C) smell D) taste E) kinesthesia F) visceral

A,B,C,D

5. Which of the following are conditions that must be met for a person to receive the necessary data to experience the world? Select all that apply. A) A stimulus must be present. B) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. C) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. D) The stimulus must be recognized by the cardiovascular system and sent to the brain. E) The person must physically and mentally recognize the stimulus and accept or reject it in the brain. F) A particular area in the brain must receive and translate the impulse into a sensation.

A,B,C,F

1. According to Pender, Murdaugh, & Parsons, (2006), which of the following are major sources of stress in society? Select all that apply. A) interpersonal relationships B) physical threat C) performance demands D) religious affiliations E) environmental effects F) disease states

A,C