Medical surgical nursing assessment and management of clinical problems 9th edition lewis test bank

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Chapter 7: Stress and Stress Management Test Bank MULTIPLE CHOICE 1. An adult patient arrived in the emergency department (ED) with minor facial lacerations after

a motor vehicle accident and has an initial blood pressure (BP) of 182/94. Which action by the nurse is most appropriate? a. Start an IV line to administer antihypertensive medications. b. Discuss the need for hospital admission to control blood pressure. c. Treat the abrasions and discuss the risks associated with hypertension. d. Recheck the blood pressure after the patient is stabilized and has received treatment.

ANS: D

When a patient experiences an acute stressor, the blood pressure increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient’s usual blood pressure. Elevated blood pressure that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.

DIF: Cognitive Level: Apply (application) REF: 95-96 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. A female patient who initially came to the clinic with incontinence was recently diagnosed

with endometrial cancer. She is usually well organized and calm but the nurse who is giving her preoperative instructions observes that she is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm patient and reinforce and repeat teaching about the surgery. d. Encourage the patient to have bladder repair at the same time as the hysterectomy.

ANS: C

Since behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her, but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken and/or discontinued before surgery, etc. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.

DIF: Cognitive Level: Apply (application) REF: 92 | 96 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

3. An adult patient who is hospitalized following a motorcycle accident when a car ran a red

light tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety b. Defensive coping c. Ineffective denial d. Risk prone health behavior ANS: A

The information about the patient indicates that anxiety is an appropriate nursing diagnosis.

The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.

DIF: Cognitive Level: Apply (application) REF: 88 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. A patient is extremely anxious about having a biopsy on a femoral lymph node in the groin

area. Which relaxation technique would be best for the nurse to use at this time? a. Meditation b. Yoga stretching c. Guided imagery d. Relaxation breathing ANS: D

Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn.

DIF: Cognitive Level: Apply (application) REF: 93-94 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient who suffers from frequent migraines tells the nurse, “My life feels chaotic and out

of my control. I will not be able to manage if anything else happens.” Which response should the nurse make initially? a. “Regular exercise may get your mind off the pain.” b. “Guided imagery can be helpful in regaining control.” c. “Tell me more about how your life has been recently.” d. “Your previous coping strategies can be very helpful to you now.”

ANS: C

The nurse’s initial strategy should be further assessment of the stressors in the patient’s life.

Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this.

DIF: Cognitive Level: Apply (application) REF: 95-96 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

6. A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse

knows that this is a painful procedure and wants to provide music to help the patient relax.

Which action is best for the nurse to take? a. Use music composed by Mozart. b. Ask the patient about music preferences. c. Select music that has 60 to 80 beats/minute. d. Encourage the patient to use music without words.

ANS: B

Although music with 60 to 80 beats/minute, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.

DIF: Cognitive Level: Apply (application) REF: 95 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse teaches a patient who is experiencing stress at work how to use imagery as a

relaxation technique. Which statement by the nurse would be most appropriate? a. “Think of a place where you feel peaceful and comfortable.” b. “Place the stress in your life in an image that you can destroy.” c. “Bring what you hear and sense in your present work environment into your image.” d. “If your work environment is stressful, continue visualizing to overcome the distress.”

ANS: A

Imagery is the use of one’s mind to generate images that have a calming effect on the body.

When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery can also be used to specifically target a disease, problem, or stressor.

DIF: Cognitive Level: Apply (application) REF: 94-95 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8. An overweight female patient who had enjoyed active outdoor activities is stressed because

she is limited in what she can do because she has osteoarthritis in her hips. Which action by the nurse will best assist the patient to cope with this situation? a. Ask the patient what activities she misses the most. b. Have the patient practice frequent relaxation breathing. c. Teach the patient to use imagery to decrease pain and decrease stress. d. Encourage the patient to think about how weight loss might improve symptoms.

ANS: D

For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.

DIF: Cognitive Level: Apply (application) REF: 93 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. A hospitalized patient with diabetes tells the nurse, “I don’t understand why I can keep my

blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating.” Which response by the nurse is most appropriate? a. “It is probably just coincidental that your blood glucose is higher when you are ill.” b. “Stressors such as illness cause the release of hormones that increase blood glucose.” c. “Increased blood glucose occurs because the liver is not able to metabolize glucose as well during stressful times.” d. “Your diet is different here in the hospital than at home and that is the most likely cause of the increased glucose level.”

ANS: B

The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

DIF: Cognitive Level: Apply (application) REF: 90 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. A middle-aged male patient with usually well-controlled hypertension and diabetes visits the

clinic. Today he has a blood pressure of 174/94 and a blood glucose level of 190 mg/dL. What additional patient information may indicate that an intervention by the nurse is needed? a. The patient indicates that he usually does blood glucose monitoring several times each day. b. The patient states that he usually takes his prescribed antihypertensive medications on a daily basis. c. The patient reports that he and his wife are getting divorced and are in a custody battle over their 12-year-old son. d. The patient states that the results are related to his family history because both of his parents have high blood pressure and diabetes.

ANS: C

The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels.

DIF: Cognitive Level: Apply (application) REF: 90 | 96 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. A patient who is taking antiretroviral medication to control human immunodeficiency virus

(HIV) infection tells the nurse about feeling mild depression and anxiety. Which additional information about the patient is most important to communicate to the health care provider? a. The patient’s blood pressure is 152/88 mm Hg. b. The patient uses over-the-counter St. John’s wort. c. The patient recently experienced the death of a close friend.

d. The patient expresses anxiety about whether the drugs are effective.

ANS: B

St. John’s wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient’s health.

DIF: Cognitive Level: Apply (application) REF: 96 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just

received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)? a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for decreased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D

The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.

DIF: Cognitive Level: Analyze (analysis) REF: 96 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity