Adult Nursing - Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation - PrepU

A client who is going to have surgery is slightly nervous. What nursing intervention is most important for the nurse to perform? - progressive muscle relaxation - guided imagery - provide education - distraction

- provide education

Which type of healing occurs when the edges are not approximated and the wound fills with granulation tissue? - Cellular necrosis - First-intention - Second-intention - Third-intention

- Second-intention

Which of the following would a nurse least likely assess in a client experiencing anxiety? - Sleeping difficulties - Irritability - Positive self-talk - Muscle tension

- Positive self-talk

After teaching nursing students about substance abuse and its effects on individuals and families, the instructor determines that additional teaching is necessary when the students state which of the following? - "Substance abuse is widespread, occurring in all types of settings." - "Individuals frequently engage in substance use and abuse to enhance their decision-making ability." - "Substance abuse involves use of alcohol and illegal, prescribed, or over-the-counter drugs." - "People experiencing substance abuse problems often have difficulty using adaptive behaviors."

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

A nurse is interviewing a client for possible depression. What client statement will most likely reflect clinical depression? - "My life is worthless, and I don't know why I'm here." - "I've been feeling sad and down for the last couple of days." - "I slept poorly the last two nights." - "My work is so interesting lately, and I feel like I can add to the office."

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

A client with a foodborne illness is concerned his gastrointestinal tract will never be the same again. Which of the following would be an appropriate response from the nurse? - "Give it time. Don't worry." - "It's true. You may have to readjust your eating habits." - "New gastrointestinal cells replace damaged ones constantly." - "Gastrointestinal cells can adapt to the new environment created by the infection."

- "New gastrointestinal cells replace damaged ones constantly."

The nurse is instructing a community education class on stress. The nurse asks the participants, "Is all stress bad for you?" Which answer by the participants is most accurate? - "No, not all stress is bad, but all stress can make a person sick." - "No, the right amount of stress can be motivating to accomplish goals." - "Yes, all stress is bad but in varying degrees depending on the nature." - "Yes, all stress has negative effects on the body systems."

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

A client with diabetes whose husband recently died reports elevated blood glucose levels. She admits she is barely eating anything; she does not feel hungry. How will the nurse best respond to this client? - "Often with stress, glucose level increases because the body needs more energy." - "You probably do not realize all that you are eating during this stressful time." - "The body reacts in strange ways when we go through stressful times." - "Have you checked the batteries in your glucose monitor recently?"

- "Often with stress, glucose level increases because the body needs more energy."

A nurse is assessing a patient who has been diagnosed with post-traumatic stress disorder (PTSD). Which statements would the nurse identify as supporting this diagnosis? Select all that apply. - "Sometimes I feel like I'm looking from outside my body." - "I just can't seem to get anything done lately." - "I jump when I hear any loud noise, like a bang." - "I don't understand why I'm still alive when so many others died." - "I keep having nightmares about the incident."

- "Sometimes I feel like I'm looking from outside my body." - "I jump when I hear any loud noise, like a bang." - "I don't understand why I'm still alive when so many others died." - "I keep having nightmares about the incident."

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy? - "Yes. it is supposed to. This is a good thing." - "Swelling is a normal response from your body to prepare for healing." - "Let me look at that. We may need to have the doctor examine you." - "No need to worry. Soccer is a dangerous sport."

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

For a person to be clinically depressed, signs of a depressed mood or depressed interest in pleasurable activities must occur for at least - 3 days. - 10 days. - 2 weeks. - 1 week.

- 2 weeks.

Brain cell death may occur in as little as: - 5 minutes - 7 minutes - 1 minute - 3 minutes

- 3 minutes

Which of the following responses is most helpful to the client when in an emergency situation? - A response by the cardiovascular system - A response by the sympathetic nervous system - A response by the central nervous system - A response by the musculoskeletal system

- A response by the sympathetic nervous system

A nurse has developed a plan of care for a patient with a nursing diagnosis of "risk for spiritual distress." Which interventions would the plan most likely include? Select all that apply. - Actively listen to the patient. - Demonstrate acceptance of the patient. - Encourage the patient to avoid usual rituals. - Limit the amount of time spent with the patient. - Encourage the patient to talk about his or her faith.

- Actively listen to the patient. - Demonstrate acceptance of the patient. - Encourage the patient to talk about his or her faith.

A nurse is teaching a group of families who have members experiencing addiction about this problem. Which of the following, if stated by the families, indicates that the teaching was successful? - Addiction results from a defect in the person's character. - Addiction rarely results in the person experiencing relapse. - Addiction is not a result of a person having moral faults. - A single factor is usually responsible for development of addiction.

- Addiction is not a result of a person having moral faults.

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply. - Acceptance - Anger - Despair - Peacefulness - Ambivalence

- Anger - Despair - Ambivalence

The nurse is caring for a client with an infected surgical incision. Which signs demonstrating systemic inflammatory response does the nurse observe? Select all that apply. - Anorexia, malaise, and weakness - Subnormal body temperature caused by vasoconstriction - Loss of appetite and complaints of aching - Leukopenia owing to increased white blood cell production - A febrile state caused by the release of pyrogens

- Anorexia, malaise, and weakness - Loss of appetite and complaints of aching - A febrile state caused by the release of pyrogens

A client is experiencing difficulty speaking and numbness on his right side. His wife calls a neighbor who is a nurse for help. Upon arrival at the scene, the nurse calls 911 immediately. Which of the following displays the nurse's critical clinical judgement? - Brain cells without oxygen die in approximately 3 to 6 minutes. - This man needs to develop collateral circulation immediately. - The blood supply to the heart is reduced. - A decreased hemoglobin count lowers blood supply to the brain.

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

A nursing instructor is discussing death and dying with a group of students as part of a clinical conference. Which of the following would the instructor identify as the current cause of most deaths? - Trauma - Chronic illness - Mental health problems - Cancer

- Chronic illness

A nurse assesses that a patient is at increased risk for depression based on which of the following? - Sporadic alcohol ingestion - Male gender - Co-existing medical problems - Supportive family

- Co-existing medical problems

A nurse is working with a family that is under stress. Which trait would the nurse emphasize in the plan of care as being most useful to the family's coping? - Individual talents - Communication skills - Cognitive abilities - Emotional strengths

- Communication skills

The nurse is working with a client who is in a stressful situation. The nurse evaluates the client's resiliency by assessing the client's ability to do what? - Respond with strong emotions - Admit past mistakes - Continue to function well - Verbalize feelings of anger

- Continue to function well

Nursing students are reviewing information about depression. The students demonstrate understanding of the information when they state which of the following? - Depression is commonly underdiagnosed and undertreated. - Elderly clients often demonstrate specific symptoms of depression. - Depression is more common in men than in women. - Individuals with depression often seek treatment for it.

- Depression is commonly underdiagnosed and undertreated.

Which of the following conditions triggers the general adaptation syndrome? - Eustress - Distress - Helplessness - Placebo effect

- Distress

The nurse is performing an assessment to determine the patient's social support systems. What question is important for the nurse to ask? - Does the patient belong to a group that is mutually dependent and communicative? - Does the client have an exercise plan to stay motivated? - Does the client regularly attend a support group? - What is the client's current employment status?

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

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter? - Glutamate - Dopamine - Acetylcholine - Serotonin

- Dopamine

Which of the following would be the priority when providing care to a client with posttraumatic stress disorder (PTSD)? - Establishing a trusting nurse-client relationship - Teaching the client appropriate methods for coping - Helping the client address the trauma experienced - Assisting the client in working through the trauma

- Establishing a trusting nurse-client relationship

A nurse is developing a plan of care for a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following would be the priority? - Teaching coping skills for self-care - Administering prescribed drug therapy - Establishing a trusting nurse-patient relationship - Assisting the patient to work through the traumatic experience

- Establishing a trusting nurse-patient relationship

Which of the following would least suggest emotional health? - Acceptance of reality - Realistic sense of hopelessness - Pursuit of personal goals - Management of every day challenges

- Realistic sense of hopelessness

The nurse is conducting a community education program on stress. The nurse includes which information? - Stressors elicit a state of homeostasis. - Short-term stress increases susceptibility to disease. - Effective stress adaptation is a disease precursor. - Excessive stress response increases susceptibility to illness.

- Excessive stress response increases susceptibility to illness.

Which of the following factors are implicated in the development of heart disease? - Frequent activation of the sympathetic nervous system - Brain pathology - Result of imbalances in serotonin - Excess and low levels of dopamine

- Frequent activation of the sympathetic nervous system

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

- Hyperplasia

When approaching health care holistically, which of the following would the nurse do? - Foster the use of technological advances in care - Include physical, emotional, and social elements - Focus on complementary and alternative practices - Emphasize the client's strengths with passive participation

- Include physical, emotional, and social elements

A client has gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the client experience with this inflammatory infection? - Increased body temperature - Redness of the anus - Stomatitis - Intestinal inflammation

- Increased body temperature

After educating a class about depression, the instructor determines that additional class time is needed for teaching when the class identifies which of the following as an indicator of depression? - Feelings of worthlessness - Increased concentration - Sleep disturbances - Increased thoughts about death

- Increased concentration

Which condition is a sympathetic-adrenal medullary response to stress? - Mental confusion - Constricted pupils - Increased heart rate - Decreased blood glucose level

- Increased heart rate

The nurse is caring for a patient with a fever. Care for this patient should be based on what body responses? (Select all that apply.) - Increased nutrient catabolism, which influences the body's caloric needs - Vasodilation of surface blood vessels, which prevents excessive heat loss - Increased heart rate, which helps to meet increased metabolic demands - Decrease in cellular metabolism, which decreases metabolic demand - Diaphoresis, which is a compensatory mechanism that cools the body

- Increased nutrient catabolism, which influences the body's caloric needs - Increased heart rate, which helps to meet increased metabolic demands - Diaphoresis, which is a compensatory mechanism that cools the body

A nurse is assessing a patient with posttraumatic stress disorder (PTSD) who is exhibiting physiologic manifestations. The nurse interprets these manifestations as being the result of which of the following? - Decreased urinary epinephrine levels - Decreased plasma catecholamine levels - Increased parasympathetic activity - Increased sympathetic activity

- Increased sympathetic activity

Students are reviewing information about substance abuse and its effects on individuals and families. The students demonstrate understanding of this topic when they identify which of the following? - Individuals with substance abuse often have difficulty using adaptive behaviors. - Individuals use substances to enhance their decision-making ability. - Substance abuse is most frequently seen in outpatient settings. - Substance abuse applies primarily to the use of illegal drugs.

- Individuals with substance abuse often have difficulty using adaptive behaviors.

Which nursing intervention is required when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements? - Obtain a baseline weight - Encourage daily exercise - Avoid providing liquid sleep medications - Avoid providing foods that contain alcohol

- Obtain a baseline weight

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

- Socialization

When assessing a client for manifestations of posttraumatic stress disorder (PTSD), which of the following would the nurse expect to assess? Select all that apply. - Muscle flaccidity - Focused concentration - Strong startle response - Lack of impulse control - Nightmares

- Strong startle response - Lack of impulse control - Nightmares

An instructor is preparing for a class discussion on family health and the effects of illness on it. Which of the following would the instructor incorporate into the discussion? - Families, when faced with illness, typically respond in similar ways. - The primary focus of care is on intervening in the illness cycle. - The provision of direct care is more important than teaching the family. - The health of the family often affects the family's ability to function.

- The health of the family often affects the family's ability to function.

When describing the term "grief" to a group of students, which of the following would the instructor include? - A part of the life cycle in the form of change, growth, and transition - Feelings of apprehension or worry in response to a situation - The response experienced by anyone who has suffered a loss - A feeling of connectedness with one's self and others

- The response experienced by anyone who has suffered a loss

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

- Viruses

During assessment, a client states, "I don't know why God is punishing me like this." What coping strategy will the nurse offer the client? - offering to watch television with the client - assistance with a warm shower - a discussion of current events - a telephone call to a spiritual leader

- a telephone call to a spiritual leader

A nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques: - are helpful because they distract the client from focusing on claudication pain. - haven't proven useful in clients with peripheral vascular disease. - are helpful because stress stimulates the release of vasoconstricting catecholamines. - are helpful only because they assist in smoking cessation.

- are helpful because stress stimulates the release of vasoconstricting catecholamines.

What physiologic events may happen in the alarm phase of General Adaptation Syndrome? - constriction of the bronchi - increased sympathetic nervous system stimulation - decreased blood pressure - decreased cortisol response

- increased sympathetic nervous system stimulation

The nurse is using progressive muscle relaxation with a client to reduce stress. What will the nurse teach the client to do? - tense and relax specific muscles - imagine a pleasant scene - repeat a word or phrase while bending at the waist - use a weight and lift in sessions of 10 movements

- tense and relax specific muscles