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 who performs preoperative assessments and teaching prepares patients for postoperative discomfort using anticipatory guidance. What interventions would this nurse use to decrease postoperative stress?
Correct Answer: C
Rationale: Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient knows what to expect through advanced explanation about discomfort, nausea, or pain and available relief measures, the patient's anxiety can be reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.
Question 2 of 5
A nurse in a medical practice has assessed a patient reporting abdominal pain, diarrhea, and anxiety. When the health care provider finds no identifiable cause for the symptoms, which actions would the nurse recommend? Select all that apply.
Correct Answer: A,C,D
Rationale: Keeping a diary of sources of stress can help identify the problem, which is the first step in stress management. The nurse can help the patient identify supports and their strengths. The nurse should recommend sleeping 7 to 9 hours nightly. The nurse would not infer there is a problem of abuse or a psychiatric condition as a cause of their symptoms.
Question 3 of 5
A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress?
Correct Answer: C
Rationale: The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development.
Question 4 of 5
A nurse in a long-term care facility is caring for patient with a spinal cord injury affecting their sensory and motor reflexes below the waist. Based on the patient's condition, what would be a priority intervention for this patient?
Correct Answer: A
Rationale: A patient with a damaged neurologic reflex arc has a diminished pain reflex response. This diminished sensation and motor response places the patient at risk for burns. All patients should be provided adequate pain relief, but this is not a priority.
Question 5 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.