1 of 139
Term
A patient reports, "I am overwhelmed by stress." Which question by
the nurse would be most important to use in the initial assessment of
this patient?
a. "Tell me about your family history. Do you have any relatives who
have problems with stress?"
b. "Tell me about your exercise. How much activity do you typically
get in a day?"
c. "Tell me about the kinds of things you do to reduce or cope with
your stress."
d. "Stress can interfere with sleep. How much did you sleep last
night?"
Give this one a try later!
B C
, A C.
Don't know?
2 of 139
Term
A child was placed in a foster home after being removed from
abusive parents. The child is apprehensive and overreacts to
environmental stimuli. The foster parents ask the nurse how to help
the child. Which interventions should the nurse suggest? (Select all
that apply.)
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.
Give this one a try later!
A
Stress reaction is a withdrawal symptom that can occur when detoxing too
quickly. DTs are usually associated with alcohol withdrawal. Overdose of
alprazolam would present with extreme drowsiness, confusion, muscle weakness,
and loss of balance or coordination. The effects of alprazolam are dizziness,
drowsiness, dry mouth, and lightheadedness.
, A,B,E
The child has moderate anxiety. A calm manner will calm the child. A simple,
structured, predictable environment is desirable to decrease anxiety
provoking and reduce stimuli. Calm, simple explanations that reinforce
reality validate the environment. Repetition is often needed when the
individual is unable to concentrate because of elevated levels of anxiety.
A Opportunities for play and exercise should be provided as avenues to
reduce anxiety. Physical movement helps channel and lower anxiety. Play
helps experiencing
Individuals by allowing the childto
severe topanic-level
act out concerns
anxiety require a safe environment
that is quiet, nonstimulating, structured, and simple. A room with a desk and two
chairs provides simplicity, few objects with which the patient could cause self-
harm, and a small floor space in which the patient can move about. A small,
empty storage room without windows or furniture would feel like a jail cell. The
nurse's office or a room with an examining table and instrument cabinets may be
over-stimulating and unsafe
b,c,d
The physiologic changes associated with the acute stress response can cause
changes in
appetite, increased gastric acid secretion, and elevation of blood glucose levels.
Stress
causes an increase in the respiratory and heart rates
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3 of 139
Term
A patient who had been experiencing significant stress learned to
use progressive muscle relaxation and deep breathing exercises.
When the patient returns to the clinic 2 weeks later, which finding
most clearly shows the patient is coping more effectively with
stress?
a. The patient's systolic blood pressure has changed from the 140s to
the 120s mm Hg.
, b. The patient reports, "I feel better, and that things are not
bothering me as much."
c. The patient reports, "I spend more time napping or sitting quietly
at home."
d. The patient's weight decreased by 3 pounds
Give this one a try later!
A
Objective measures tend to be the most reliable means of gauging
progress. In this case, the patient's elevated blood pressure, an indication
of the body's physiological response to stress, has diminished. The patient's
report regarding activity level is subjective; sitting quietly could reflect
depression rather than improvement. Appetite, mood, and energy levels
are also subjective reports that do not necessarily reflect physiological
changes from stress and may not reflect improved coping with stress. The
patient's weight change could be a positive or negative indicator; the
blood pressure change is the best answer
D
In this case, the nurse lacks information about what stressors the patient is
coping with or about what coping skills are already possessed. Further
assessment is indicated before potential solutions can be explored. Suggesting
exploration of the stress facing the patient is the only option that involves further
assessment rather than suggesting a particular intervention.
C
A
The onset of delirium occurs acutely. The degree of disorientation does not
differentiate between delirium and dementia. Increasing confusion for several
years is consistent with dementia. Fragmented and incoherent speech may occur
with either delirium or dementia
Term
A patient reports, "I am overwhelmed by stress." Which question by
the nurse would be most important to use in the initial assessment of
this patient?
a. "Tell me about your family history. Do you have any relatives who
have problems with stress?"
b. "Tell me about your exercise. How much activity do you typically
get in a day?"
c. "Tell me about the kinds of things you do to reduce or cope with
your stress."
d. "Stress can interfere with sleep. How much did you sleep last
night?"
Give this one a try later!
B C
, A C.
Don't know?
2 of 139
Term
A child was placed in a foster home after being removed from
abusive parents. The child is apprehensive and overreacts to
environmental stimuli. The foster parents ask the nurse how to help
the child. Which interventions should the nurse suggest? (Select all
that apply.)
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.
Give this one a try later!
A
Stress reaction is a withdrawal symptom that can occur when detoxing too
quickly. DTs are usually associated with alcohol withdrawal. Overdose of
alprazolam would present with extreme drowsiness, confusion, muscle weakness,
and loss of balance or coordination. The effects of alprazolam are dizziness,
drowsiness, dry mouth, and lightheadedness.
, A,B,E
The child has moderate anxiety. A calm manner will calm the child. A simple,
structured, predictable environment is desirable to decrease anxiety
provoking and reduce stimuli. Calm, simple explanations that reinforce
reality validate the environment. Repetition is often needed when the
individual is unable to concentrate because of elevated levels of anxiety.
A Opportunities for play and exercise should be provided as avenues to
reduce anxiety. Physical movement helps channel and lower anxiety. Play
helps experiencing
Individuals by allowing the childto
severe topanic-level
act out concerns
anxiety require a safe environment
that is quiet, nonstimulating, structured, and simple. A room with a desk and two
chairs provides simplicity, few objects with which the patient could cause self-
harm, and a small floor space in which the patient can move about. A small,
empty storage room without windows or furniture would feel like a jail cell. The
nurse's office or a room with an examining table and instrument cabinets may be
over-stimulating and unsafe
b,c,d
The physiologic changes associated with the acute stress response can cause
changes in
appetite, increased gastric acid secretion, and elevation of blood glucose levels.
Stress
causes an increase in the respiratory and heart rates
Don't know?
3 of 139
Term
A patient who had been experiencing significant stress learned to
use progressive muscle relaxation and deep breathing exercises.
When the patient returns to the clinic 2 weeks later, which finding
most clearly shows the patient is coping more effectively with
stress?
a. The patient's systolic blood pressure has changed from the 140s to
the 120s mm Hg.
, b. The patient reports, "I feel better, and that things are not
bothering me as much."
c. The patient reports, "I spend more time napping or sitting quietly
at home."
d. The patient's weight decreased by 3 pounds
Give this one a try later!
A
Objective measures tend to be the most reliable means of gauging
progress. In this case, the patient's elevated blood pressure, an indication
of the body's physiological response to stress, has diminished. The patient's
report regarding activity level is subjective; sitting quietly could reflect
depression rather than improvement. Appetite, mood, and energy levels
are also subjective reports that do not necessarily reflect physiological
changes from stress and may not reflect improved coping with stress. The
patient's weight change could be a positive or negative indicator; the
blood pressure change is the best answer
D
In this case, the nurse lacks information about what stressors the patient is
coping with or about what coping skills are already possessed. Further
assessment is indicated before potential solutions can be explored. Suggesting
exploration of the stress facing the patient is the only option that involves further
assessment rather than suggesting a particular intervention.
C
A
The onset of delirium occurs acutely. The degree of disorientation does not
differentiate between delirium and dementia. Increasing confusion for several
years is consistent with dementia. Fragmented and incoherent speech may occur
with either delirium or dementia
