MEDICAL SURGICAL NURSING ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEMS, 10TH EDITION

Chapter 06: Stress and Stress Management Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? a. Start an IV line to administer antihypertensive medications. b. Recheck the blood pressure after the patient has been assessed. c. Discuss the need for hospital admission to control blood pressure. d. Teach the patient about the stroke risk associated with uncontrolled hypertension. This study source was downloaded by from CourseH on :40:24 GMT -05:00 MEDICAL SURGICAL NURSING ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEMS, 10TH EDITION ANS: B When a patient experiences an acute stressor, the BP 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 BP 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: 80 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 the patient 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 the patient before repeating any information about the surgery. d. Encourage the patient to combine the hysterectomy with surgery for bladder repair. ANS: C Because 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 or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy. DIF: Cognitive Level: Apply (application) REF: 81 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. An adult patient who is hospitalized after a motorcycle crash 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 c. Ineffective denial b. Defensive coping d. Risk prone health behavior This study source was downloaded by from CourseH on :40:24 GMT -05:00 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: 78 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching c. Relaxation breathing b. Guided imagery d. Mindfulness meditation ANS: C 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: 83 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not 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 resources can be helpful to you now.” This study source was downloaded by from CourseH on :40:24 GMT -05:00 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: 86 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 try providing music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Play music that does not have words. c. Ask the patient about music preferences. d. Select music that has 60 to 80 beats/minute. ANS: C Although music with 60 to 80 beats/min, 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.