Chapter 12. Stress & Adaptation My Nursing Test Banks

Chapter 12. Stress & Adaptation

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____1.When released in response to alarm, which of the following substances promotes a sense of well-being?

1)

Aldosterone

2)

Thyroid-stimulating hormone

3)

Endorphins

4)

Adrenocorticotropic hormone

ANS:3

Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralocorticoids.

PTS:1DIF:ModerateREF:p. 253

KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

____2.After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?

1)

Alarm

2)

Resistance

3)

Exhaustion

4)

Recovery

ANS:3

Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place.

PTS:1DIFifficultREF:p. 254

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

____3.You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?

1)

Epinephrine

2)

Corticotrophin-releasing hormone

3)

Aldosterone

4)

Antidiuretic hormone

ANS:1

During the shock phase of the general adaptation syndrome, large amounts of epinephrine prepare the body to react in an emergency situation. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.

PTS: 1 DIF: Moderate REF: p. 252

KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application

____4.What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?

1)

Promotes fluid retention by increasing the reabsorption of water by kidney tubules

2)

Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle

3)

Increases the use of fats and proteins for energy and conserves glucose for use by the brain

4)

Promotes fluid excretion by causing the kidneys to reabsorb more sodium

ANS:1

Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.

PTS:1DIF:ModerateREF:p. 252

KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall

____5.A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first?

1)

Cellular inflammation

2)

Exudate formation

3)

Tissue regeneration

4)

Vascular response

ANS:4

Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate-formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase.

PTS:1DIF:ModerateREF:p. 254

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____6.A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?

1)

Anger

2)

Fear

3)

Anxiety

4)

Hopelessness

ANS:3

NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely feeling  anxious. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.

PTS:1DIF:ModerateREF:p. 256

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

____7.A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, I hate this place; nobody knows how to take care of me or Id be home by now. Which response by the nurse is best in this situation?

1)

You seem angry; whats going on that makes you hate this place?

2)

Im sorry that we arent caring for you according to your expectations.

3)

You were very sick; dont be angry; youre lucky to be alive.

4)

You shouldnt be angry with us; were trying to help you.

ANS:1

You seem angry; whats going on . . . encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry or you shouldnt be angry diminishes the patients right to be angry.

PTS:1DIF:ModerateREF:p. 266

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

____8.You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?

1)

Hypochondriasis

2)

Somatization

3)

Somatoform pain disorder

4)

Malingering

ANS:4

Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically.

PTS:1DIF:ModerateREF:p. 259

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

____9.After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?

1)

Reaction formation

2)

Displacement

3)

Denial

4)

Conversion

ANS:2

This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis.

PTS:1DIF:ModerateREF:p. 257

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

____10.A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?

1)

Precrisis

2)

Impact

3)

Crisis

4)

Adaptive

ANS:4

When a patient begins to think rationally and problem-solve, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase.

PTS: 1 DIF: Moderate REF: pp. 259-260

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

____11.A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?

1)

Monitor and record the frequency of stools on the graphic record.

2)

Administer prescribed antidiarrheal medications as needed.

3)

Encourage the patient to verbalize about stressors and anxiety.

4)

Provide oral fluids on a regular schedule.

ANS:3

The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea.

PTS: 1 DIF: Moderate REF: p. 259

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

____12.When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?

1)

The patient will limit his intake of fat to no more than 15% of the daily calories consumed.

2)

The patient will eat three meals per day at approximately the same time each day.

3)

The patient will limit his intake of sugar and salt, as well as sweet and salty foods.

4)

The patient will consume no more than three alcoholic beverages a day.

ANS:3

The nurse should advise the client to limit the intake of sugar and salt; limit the intake of fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals (not three meals a day); and consume no more than two alcoholic beverages per day but not necessarily every day.

PTS:1DIF:ModerateREF:p. 265

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____13.At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful?

1)

Decreased blood pressure

2)

Decreased peripheral skin temperature

3)

Increased heart rate

4)

Increased respiratory rate

ANS:1

Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate.

PTS:1DIF:ModerateREF:pp. 266-267

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension

____14.The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess?

1)

Depression

2)

Hypochondriasis

3)

Somatization

4)

Malingering

ANS:1

Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger.

PTS:1DIF:EasyREF:p. 256

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

____15.Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope

1)

Could be used by the patient to hurt her

2)

Might cause the patient not to trust her

3)

Would distract her from focusing on the patient

4)

Will function as another stressor for the patient

ANS:1

When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse should be removed before entering the patients room. It is unlikely that a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely dont even notice their presence.

PTS:1DIF:ModerateREF:p. 266

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

____16.A patient is in crisis. After assessing the situation, what should the nurse do first?

1)

Determine the imminent cause of the crisis.

2)

Intervene to relieve the patients anxiety.

3)

Decide on the type of help the patient needs.

4)

Ensure the safety of both the nurse and patient.

ANS:4

The first goal of crisis intervention is to assess the situation. Then ensure safety of self and patient, defuse the situation, decrease the persons anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost.

PTS:1DIF:ModerateREF:p. 269

KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Application

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____1.During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply.

1)

Rate of metabolism decreases.

2)

Liver converts more glycogen to glucose.

3)

Use of amino acids decreases.

4)

Amino acids and fats are more available for energy.

ANS:2, 4

The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: The rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of amino acids and mobilization of fats for energy.

PTS:1DIF:ModerateREF:pp. 252-253

KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitive level: Comprehension

____2.Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Choose all that apply.

1)

The wound is most likely infected.

2)

This is a vascular response to inflammation.

3)

Damaged cells are being regenerated.

4)

Exudate formation is occurring.

ANS:2, 4

During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonly appears at surgical incisions. When a wound becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here.

PTS:1DIF:ModerateREF:pp. 254-255

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

____3.A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is worrying herself to death about losing her aging husband and being all alone. You recognize this reaction as Anxiety rather than Fear because (choose all that apply)

1)

It concerns future or anticipated events

2)

It concerns anticipation of danger rather than a present danger

3)

There is no shakiness or tearfulness present

4)

There is a psychological rather than a physical threat

ANS:1, 2, 4

Anxiety is an emotional response related to future or anticipated events. Fear is a cognitive response to a present, usually identifiable, source. Anxiety results from psychological conflict, whereas fear can result from either a psychological or physical threat. Shakiness and tearfulness may occur in both anxiety and fear, which share several defining characteristics.

PTS:1DIF:ModerateREF:p. 256

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

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