Questions I have missed and explanations
A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? You Selected: Guided imagery Correct response: Anticipatory guidance
ANTICIPATORY GUIDANCE Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. Nurses use this technique when they teach patients about procedures and the surgical experience. When patients know what to expect, their anxiety is reduced and their coping mechanisms are more effective Not GUIDED IMAGERY In guided imagery, a person creates a mental image, concentrates on the image, and becomes less responsive to other stimuli (including pain). RELAXATION Relaxation techniques are useful in many situations, such as childbirth, pain, anxiety, sleeplessness, illness, and anger, and other uses are being discovered. Relaxation promotes a body reaction opposite to that of the fight-or-flight response: respiratory, pulse, and metabolic rates, as well as blood pressure and energy use, can all be decreased using relaxation methods. Relaxation can be taught to individuals or groups. It is especially helpful because it allows people to control their feelings and behaviors. Various techniques can be used, but most involve rhythmic breathing, reduced muscle tension, and an altered state of consciousness MEDITATION 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 oneself in it while breathing slowly in and out. This exercise should be performed for 20 to 30 minutes twice a day. BIOFEEDBACK Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches. A measurement device (e.g., skin temperature sensors) is used, and the patient tries to control the readings through relaxation and conscious thought. Over a period of time, the feedback of the change in readings teaches the person to control physiologic functions that normally are considered involuntary responses.
A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that a contributor to this phenomenon is: You Selected: adrenal function. Correct response: estrogen levels.
Adrenals Medulla produces epinephrine and norepinephrine Cortex secretes mineralocorticoids, glucocorticoids, and androgens Prepares the person for emergencies; supports the sympathetic system Mineralocorticoid aldosterone regulates fluid and electrolytes Glucocorticoids (cortisol) raise glucose levels (for energy) and increase resistance to physical stress Androgens control the development and maintenance of male characteristics and are the primary precursor of natural estrogens
The nurse is caring for a client who is a teacher in a high school and states that there have been several issues with violence. What clinical manifestations during the client assessment would indicate that the client is experiencing physical manifestations of stress? Select all that apply. You Selected: an extra heart sound every fourth to sixth beat a blood pressure of 110/68 mmHg difficulty viewing objects more than 100 feet away Correct response: an extra heart sound every fourth to sixth beat report of frequent evening headaches relieved by sleep reports of nausea
Clinical manifestations could be subjective or objective The reports would be subjective, the pt is reporting it and the extra heart sound would be something the nurse observes. Low blood pressure would not be a response to stress and difficulty viewing objects would not be apart of the stress, that would be indicative of some type of physical trauma relating to the anatomy.
The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as: You Selected: health belief model. Correct response: high-level wellness.
Dunn (1977) described his model of high-level wellness as functioning to one's maximum potential while maintaining balance and a purposeful direction in the environment.
A community health nurse is providing care to several farming families in a rural community. Which concept would be most important for the nurse to integrate into the plans of care for these families? You Selected: All family types have similar problems regardless of their structure. Correct response: Family structures may change over time.
Environmental dimension Safety and security needs Housing Community/neighborhood Climate Sociocultural dimension Love and belonging needs Relationships with others Communications with others Support systems Being part of a community Feeling loved by others
The client asks the nurse to explain stress and its effect on the body. Which information will the nurse include? Select all that apply. You Selected: Stress is ever-present. Some forms of stress are positive events. Correct response: Stress begins in utero. Stress is ever-present. Some forms of stress are positive events.
If stress is ever present, then it will begin in utero.
1. A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? You Selected: Primary prevention Correct response: Tertiary prevention 2. The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion? You Selected: Primary Correct response: Tertiary
Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Secondary health promotion and illness prevention focus on screening for early detection of disease with prompt diagnosis and treatment of any found. Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning.
A nurse observes that a client who has pneumonia is in the recovery and rehabilitation stage of the illness. Which statement describes the client response that the nurse would expect at this stage of the illness? You Selected: The client assumes a dependent role. Correct response: The client gives up the dependent role.
STAGE 1: EXPERIENCING SYMPTOMS How do people define themselves as "sick"? The first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. Although pain is the most common symptom indicating illness, other common symptoms include a rash, fever, bleeding, or a cough. If the symptoms last for a short time or are relieved by self-care, the person usually takes no further action. If the symptoms continue, however, the person enters the next stage. STAGE 2: ASSUMING THE SICK ROLE The person now self-defines as being sick, seeks validation of this experience from others, gives up normal activities, and assumes a "sick role." At this stage, most people focus on their symptoms and bodily functions. Depending on individual health beliefs and practices, the person may choose to do nothing, may research symptoms on Internet sources, may buy over-the-counter medications, may try alternative remedies to relieve symptoms, or may seek out a health care provider for diagnosis and treatment. STAGE 3: ASSUMING A DEPENDENT ROLE This stage is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. The person may initially have difficulty conforming to the recommendations of the health care provider and may decide to seek a second opinion or deny the diagnosis. The lack of independence is more troubling for some people who, based on their diagnosis, often require assistance in carrying out activities of daily living, and need emotional support through acceptance, approval, physical closeness, and protection. If the disease is serious (such as a heart attack or stroke), the patient may enter the hospital for treatment. If the symptoms can be managed by the patient or family alone or with the assistance of home care providers, the patient is cared for at home. To facilitate adherence to the treatment plan, the patient needs effective relationships with caregivers, knowledge about the illness, and an individualized care plan. TAGE 4: ACHIEVING RECOVERY AND REHABILITATION Recovery and rehabilitation might begin in the hospital and conclude at home, or may be totally concluded at a rehabilitation center or at home. Most patients complete this final stage of illness behavior at home. In this stage, the person gives up the dependent role and resumes normal activities and responsibilities. If the care plan includes health education, the person may return to health at a higher level of functioning and health than before the illness.
Which outcome(s) will the nurse include in the plan of care for a client experiencing caregiver role strain? Select all that apply. You Selected: Client will demonstrate appropriate coping strategies. Client will eliminate all stress in a period of 6 months. Client will identify one or two stressors to eliminate. Client will identify support mechanisms to help with stress. Correct response: Client will demonstrate appropriate coping strategies. Client will identify support mechanisms to help with stress. Client will identify one or two stressors to eliminate.
Since the client is the caregiver, it is not likely to get rid of all the stressor, that would indicate the caregiver is abandoning her role. What is realistic however is that the client demonstrates healthy coping mechanisms, getting support to help with the stress, and possibly trying to reduce the amount of stressors, say for example being tired all the time. Perhaps the client can try and take cat naps when there is down time to help.
Question 13 See full question1m 34sReport this Question The nurse is taking care of a client who is scheduled for a mastectomy. The client tells the nurse that the client is apprehensive about the operation and asks the nurse to read a passage from the Koran to help prepare the client for surgery. Which action by the nurse is the most appropriate? You Selected: Ask the client whether it would be okay to call a minister to pray with client. Correct response: Read the Koran passage to the client.
TABLE 4-1 The Human Dimensions and Basic Human Needs BASIC HUMAN NEEDEXAMPLES Physical dimension Physiologic needs Breathing Circulation Temperature Intake of food and fluids Elimination of wastes Movement Environmental dimension Safety and security needs Housing Community/neighborhood Climate Sociocultural dimension Love and belonging needs Relationships with others Communications with others Support systems Being part of a community Feeling loved by others Emotional dimension Self-esteem needs Fear Sadness Loneliness Happiness Accepting self Intellectual and spiritual dimensions Self-actualization needs Thinking Learning Decision making Values Beliefs Fulfillment Helping others
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? You Selected: reaction formation Correct response: compensation
TABLE 42-2 Commonly Occurring Defense Mechanisms DEFENSE MECHANISMCAUSESEXAMPLE Compensation A person attempts to overcome a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area. A student who has difficulty with academics may excel in sports. Denial A person refuses to acknowledge the presence of a condition that is disturbing. Despite finding a lump in her breast, a woman does not seek medical treatment. Displacement A person transfers (displaces) an emotional reaction from one object or person to another object or person. An employee who is angry with a coworker kicks a chair. Dissociation A person subconsciously protects him- or herself from the memories of a horrific or painful event by allowing the mind to forget the incident. An adult cannot recall childhood memories surrounding the traumatic death of a sibling. Introjection A person incorporates qualities or values of another person into his or her own ego structure. This mechanism is important in the formation of conscience during childhood. An older sibling tells his preschool sister not to talk to strangers, expressing his parents' values to his younger sister. Projection A person attributes thoughts or impulses to someone else. A person who denies any sexual feelings for a coworker accuses him of sexual harassment. Rationalization A person tries to give a logical or socially acceptable explanation for questionable behavior ("behavior justification"). A patient who forgot to keep a health care appointment says, "If patients didn't have to wait 3 months to get an appointment, they wouldn't forget them." Reaction formation A person develops conscious attitudes and behavior patterns that are opposite to what he or she would really like to do. A married woman is attracted to her husband's best friend but is constantly rude to him. Regression A person returns to an earlier method of behaving. Children often regress to soiling diapers or demanding a bottle when they are ill. Repression A person voluntarily excludes an anxiety-producing event from conscious awareness. A father may not remember shaking his crying baby. Sublimation A person substitutes a socially acceptable goal for one whose normal channel of expression is blocked. A person who is aggressive toward others may become a star football player. Undoing A person uses an act or communication to negate a previous act or communication. A husband who was physically abusive to his wife may bring her an expensive present the next day.
The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take? You Selected: Notify the physician. Correct response: Position the client in a side-lying position.
The reason why we would not notify the physician is that it's a seizsure, meaning they have lost control of their body so putting them immediately in a side-lying position would be a physiological need. They could drown in their own spit and we need to prevent that.
An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of: You Selected: reaction. Correct response: adaptation.
The response is adaptation because the teen is using communication to cope and trying to adapt to the anxiety of a new environment.
The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action? You Selected: Arrange for a chaplain to visit with the client. Correct response: Advocate for the client's choice.
While both are correct, there is a chance that the chaplin may not agree with the client's wishes. With that being said, the nurse is always going to be the advocate for what the pt. wants and making sure those needs are met in our care, especially in a terminal situation.
The nurse is planning care for several clients in an outpatient clinic. Which client requires follow-up care due to a chronic condition? You Selected: A client diagnosed with diabetes mellitus (DM) who stubbed the great toe and now has a wound Correct response: A client with chronic obstructive pulmonary disease (COPD) who is wheezing and coughing
While both are having physical problems, remember ABC, Airway, Breathing and Circulation. The pt with the COPD is having issues breathing, he requires follow-up to make sure he is making progress The pt with DM may have a wound, however, that wound may heal on its own. This is not an immediate physical need.
