ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 43 : Stress and Adaptation Questions
Question 1 of 5
A nurse in the emergency department receives a patient rescued from a building fire. The firefighter giving the handoff report tells the nurse the building collapsed immediately after they removed the patient from the building. The nurse notes the patient is experiencing the alarm phase of the fight-or-flight response. What assessment findings support the nurse's observation? Select all that apply.
Correct Answer: A,C,E
Rationale: The sympathetic nervous system initiates the fight-or-flight response, preparing the body to fight a stressor or run from it. This phase of the alarm reaction, called the shock phase, is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. Hypotension and withdrawn demeanor represent the countershock phase.
Question 2 of 5
Nurses working in a trauma intensive care unit state they experience a high level of stress. Which stressor are they likely to encounter?
Correct Answer: D
Rationale: Incivility encompasses rude or discourteous actions that negatively affect others. Incivility can escalate to bullying, which is defined as repeated, ongoing actions that intend to harm another person.
Question 3 of 5
A college student visits the school's health center reporting extreme fatigue and slight restlessness. The student states, "Exams are right around the corner, and all I feel like doing is sleeping." There are no abnormal physical assessment findings. How does the nurse best help the student frame their desire to sleep?
Correct Answer: D
Rationale: Fatigue and mild anxiety are often handled without conscious thought through the use of coping mechanisms, such as sleeping. These coping mechanisms are protective behaviors used to decrease stress and anxiety.
Question 4 of 5
A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse, "I'm a vegetarian. I'm not the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating?
Correct Answer: B
Rationale: Denial, a coping mechanism, occurs when a person refuses to acknowledge the presence of a condition that is disturbing. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness.
Question 5 of 5
A visiting nurse is assessing a family that includes a young couple and their infant who has cerebral palsy. The nurse notes that the mother is unkempt, the house is untidy, and the mother states she is "so busy with the baby that I don't have time to do anything else." What priority intervention would the nurse set for this family?
Correct Answer: D
Rationale: A person providing care at home for a family member for long periods of time often experiences caregiver burden, manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses. The nurse could recommend a consultation with a social worker or suggest community resources including possible respite care for the parent(s).