Chapter 42 Topic 9 1. A nurse is assessing a patient who complains of migraines that have become “unbearable.” The patient tells the nurse, “I just got laid off from my job last week and I have two kids in college. I don’t know how I’m going to pay for it all.” Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors 2. A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? a. The nurse teaches a patient rhythmic breathing to perform prior to the procedure. b. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. c. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. d. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain. 3. A nurse witnesses a street robbery and is assessing a patient who is the victim. The patient has minor scrapes and bruises, and tells the nurse, “I’ve never been so scared in my life!” What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a. Increased heart rate b. Decreased muscle strength c. Increased mental alertness d. Increased blood glucose levels e. Decreased cardiac output f. Decreased peristalsis 4. A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? a. An infant who learns to turn over b. A school-aged child who learns how to add and subtract c. An adolescent who is a “loner” d. A young adult who has a variety of friends 5. A nurse is caring for an older adult in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on the patient’s condition, what would be a priority intervention for this patient? a. Monitoring food and drink temperatures to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Providing meals high in carbohydrates to promote healing 6. A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a. Decreasing pulse b. Increasing sleepiness c. Increasing energy levels d. Decreasing respirations 7. A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, “I’m so worried that my husband will find me and try to make me go back home.” Which data would the nurse most appropriately document? a. “Patient displays moderate anxiety related to her situation.” b. “Patient manifests panic related to feelings of impending doom.” c. “Patient describes severe anxiety related to her situation.” d. “Patient expresses fear of her husband.” 8. A college student visits the school’s health center with vague complaints of anxiety and fatigue. The student tells the nurse, “Exams are right around the corner and all I feel like doing is sleeping.” The student’s vital signs are within normal parameters. What would be an appropriate question to ask in response to the student’s verbalizations? a. “Are you worried about failing your exams?” b. “Have you been staying up late studying?” c. “Are you using any recreational drugs?” d. “Do you have trouble managing your time?” 9. A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse “I would never be the type to get cancer; this must be a mistake.” Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression 10. A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother’s hair and clothing are unkempt and the house is untidy, and the mother states that she is “so busy with the baby that I don’t have time to do anything else.” What would be the priority intervention for this family? a. Arrange to have the infant removed from the home. b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse. d. Notify the care provider and recommend respite care for the mother. 11. A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for additional teaching? a. “I must breathe in and out in rhythm.” b. “I should take my pulse and expect it to be faster.” c. “I can expect my muscles to feel less tense.” d. “I will be more relaxed and less aware.” 12. A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery 13. A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student’s understanding of the process? a. “I need to identify the problem first.” b. “Listing alternatives is the initial step.” c. “I will list alternatives after I develop the plan.” d. “I do not need to evaluate the outcome of my plan.” 14. A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, “I worry all the time about being able to handle becoming a mother.” Which nursing diagnosis would be most appropriate for this patient? a. Ineffective Coping related to the new parenting role b. Ineffective Denial related to ability to care for a newborn c. Anxiety related to change in role status d. Situational Low Self-Esteem related to fear of parenting 15. A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be most appropriate for these patients? a. Discouraging oververbalization of fears and anxieties b. Focusing on the outcome as opposed to the details of the surgery c. Providing time alone for reflection on personal strengths and weaknesses d. Mutually determining expected outcomes of the care plan ANSWERS WITH RATIONALES 1. 2. 3. 4. 5. 6. 7. 8. a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress. c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient know what to expect—for example, when the nurse tells the patient about the pain he or she should expect to experience during a procedure, and describes related pain relief measures—the patient’s anxiety is reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. a, c, d. The sympathetic nervous system functions under stress to bring about the fight-orflight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest. c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development. a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services and U.S. Department of Agriculture. c. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. d. Fear is a feeling of dread in response to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation. a. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient’s level of stress and physiologic response to this stress. 9. b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing, in this case receiving a diagnosis of pancreatic cancer. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness. In the case described in question 9, the patient is not blocking out the fact that the diagnosis was made, the patient is refusing to believe it. 10. d. A person providing care at home for a family member for long periods of time often experiences caregiver burden, which may be manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker or arrange for respite care for the family. 11. b. No matter what the technique, relaxation involves rhythmic breathing, a slower (not a faster) pulse, reduced muscle tension, and an altered state of consciousness. 12. a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don’t have yet, but aspire to, such as parenthood. 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. 13. a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified. 14. c. The most appropriate nursing diagnosis is Anxiety, which indicates situational/maturational crises or changes in role status. Ineffective Coping refers to an inability to appraise stressors or use available resources. Ineffective Denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem refers to feelings of worthlessness related to the situation the person is currently experiencing, not to the fear of role changes. 15. d. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. The nurse should explain all procedures and sensations likely to be experienced during the procedures, and stay with the patient to promote safety and reduce fear.
