Question 1

The nurse is aware that which function of antidiuretic hormone occurs when the hormone is released in the alarm stage of the general adaptation syndrome?

Accepted Answer

Antidiuretic hormone (ADH) promotes fluid retention by increasing the reabsorption of water by the kidney tubules, which is crucial for maintaining blood volume and pressure during stress responses such as the alarm stage of the general adaptation syndrome.

Question 2

An 18-year-old is accepted to nursing school in another state. The adolescent states to the parents, "I know I am going away to college, but I am nervous about going." Which type of stressor is the student most likely experiencing?

Accepted Answer

B

Question 3

The nurse is providing care for a patient who suddenly experiences a cardiac arrest. As the nurse responds to this emergency, which substance does the nurse's body secrete in large amounts to help prepare the nurse to react in this situation?

Accepted Answer

Epinephrine, also known as adrenaline, is secreted in large amounts in response to stress or emergency situations, preparing the body for a "fight or flight" response by increasing heart rate, blood pressure, and energy supplies.

Question 4

A client approaches the nurse in the health clinic and states, "I have been dealing with my spouse's illnesses for years. Now my children want me to start babysitting my grandchildren. I don't know whether I can handle all this." Which is the nurse's most accurate interpretation of the client's statements?

Accepted Answer

C) Many stressors or prolonged stressors make adaptation more likely to fail. This interpretation accurately reflects the situation described by the client, who is dealing with long-term stress from a spouse's illness and now faces additional stress from family expectations. This accumulation of stressors can overwhelm an individual's ability to adapt.

Question 5

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 general adaptation syndrome (GAS) does the nurse recognize the patient is most likely experiencing?

Accepted Answer

The patient's symptoms indicate that the body's adaptive mechanisms are overwhelmed, leading to the exhaustion stage of the general adaptation syndrome (GAS). This stage follows the initial alarm reaction and a period of resistance, where the body attempts to adapt to the stressor. If the stressor is too severe or persistent, and the body's adaptive mechanisms are depleted, the exhaustion stage ensues, characterized by a decrease in blood pressure and an increase in heart rate and respiratory rate, among other symptoms.

Question 6

The nurse is providing care for a patient who sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process does the nurse expect the patient to experience first?

Accepted Answer

The first step in the inflammatory process following an injury, such as a laceration, is the vascular response. This involves the immediate response of the blood vessels, which includes vasoconstriction followed by vasodilation, leading to increased blood flow to the area. This is a critical initial step to deliver immune cells and factors to the site of injury.

Question 7

The nurse is aware that after a patient has an argument with the patient's spouse, the patient becomes verbally abusive to the nurse who is providing care. Which coping mechanism does the nurse recognize the patient is exhibiting?

Accepted Answer

Displacement is a defense mechanism where an individual redirects emotional feelings, often anger, from the original source to another, safer target. In this scenario, the patient is redirecting anger from the argument with the spouse to the nurse, which is a classic example of displacement.

Question 8

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

Accepted Answer

The best response is to acknowledge the patient's feelings and invite them to share more about their experience. This approach validates the patient's emotions and encourages communication, which is essential in understanding and addressing their concerns.

Question 9

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

Accepted Answer

Decreased blood pressure is a common indicator of relaxation and reduced stress, suggesting that the guided imagery session was successful in promoting relaxation.

Question 10

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

Accepted Answer

Unresolved anger can lead to depression as individuals may internalize their anger and experience feelings of hopelessness or helplessness, contributing to depressive symptoms.

Question 11

The nurse is aware that when a patient becomes alarmed, the body will release a substance to promote a sense of well-being. Which substance is released?

Accepted Answer

Endorphins are released in response to stress and pain, acting as natural painkillers and promoting a sense of well-being.

Question 12

The nurse is counseling a patient about behaviors to reduce stress. Which goal should the nurse put on the care plan?

Accepted Answer

The answer of The nurse is counseling a patient about...

Question 13

The nurse is providing care for a patient who is in crisis. After assessing the situation, which action does the nurse perform first?

Accepted Answer

Ensuring the safety of both the nurse and the patient is the first priority in any crisis situation, as it addresses immediate risks and creates a secure environment for further assessment and intervention.

Question 14

A nurse identifies a patient's nursing diagnosis as "Diarrhea related to stress." Which nursing intervention does the nurse include in the nursing care plan to help the patient relieve the cause of the diarrhea?

Accepted Answer

C) Encouraging the patient to verbalize about stressors and anxiety directly addresses the identified cause of the diarrhea (stress), helping the patient to manage and potentially reduce the stress that is contributing to their condition.

Question 15

A patient 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?

Accepted Answer

The adaptive phase of crisis is characterized by the individual beginning to cope with the crisis, making adjustments, and feeling more positive about the situation, as seen in the patient's decision on a treatment plan and positive feelings about her prognosis.

Question 16

The nurse is providing care to a patient who expresses feeling of dread and of vague uneasiness. Nursing assessment reveals the patient's heart rate is elevated. Which nursing diagnoses is most appropriate for this patient?

Accepted Answer

The symptoms described, such as a feeling of dread and vague uneasiness, along with an elevated heart rate, are indicative of anxiety. Anxiety is characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure.

Question 17

The nurse asks, "Why do some of my patients get a headache when they have stress but others cry?" Which is the most appropriate response to the nurse's question?

Accepted Answer

The answer of The nurse asks, "Why do some of...

Question 18

Before entering the room of a patient who is angry and yelling, the nurse removes the stethoscope from around the neck. Which is the best rationale for the nurse's action?

Accepted Answer

The stethoscope could be used by the patient to hurt the nurse. In situations where a patient is angry and yelling, there is a potential risk for violence. Removing objects that could be used as weapons, such as a stethoscope, is a precaution to ensure the safety of the healthcare provider.

Question 19

The nurse is providing care for a patient with numerous physiological complaints. A family member shares that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. The nurse recognizes which somatoform disorder this patient is most likely experiencing?

Accepted Answer

Malingering is not considered a somatoform disorder; it involves the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding work, obtaining financial compensation, or evading criminal prosecution. In this scenario, the patient is pretending to have symptoms for a specific secondary gain (avoiding work), which aligns with malingering, rather than a somatoform disorder where symptoms are not intentionally produced.

Question 20

The nurse is presenting a workshop on stress and adaptation to adolescents at the local high school. A teenager tells the nurse, "Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think?" Which is the most appropriate response by the nurse?

Accepted Answer

A moderate amount of stress, like feeling your heart rate increase before a test, can actually enhance focus and performance. This is known as the Yerkes-Dodson law, which suggests there is an optimal level of stress for peak performance.

Quiz 12: Stress Adaptation