Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation - Nurselytic

Correct Answer: A

Rationale: Cells or tissues of the body may be injured or killed by any agent (physical, chemical, infectious). When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the injury site. Inflammation is not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. Although bee stings may cause infection, the signs and symptoms (very painful, looks swollen and red) result from the acute inflammatory response. If the stinger were still in the wound, it would only be creating inflammation, not infection. Antibiotics are not indicated.

Correct Answer: D

Rationale: By encouraging an attitude of realistic hope, the patient will be empowered. This allows the patient to explore her feelings and bring about more effective coping patterns. The onus for care planning should not lie with the patient. The nursing diagnosis is related to feeling of helplessness, not anger and hostility. Social support is necessary, but does not directly address the feeling of helplessness.

Correct Answer: B

Rationale: Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case, the patient was unable to access health care even when she was aware the disorder could be life-threatening. Self-esteem Disturbance, Altered Family Process, and Ineffective Denial are all nursing diagnoses that are often associated with breast cancer, but the patients ineffective individual coping has created a significant safety risk and is, therefore, the most appropriate nursing diagnosis.

Correct Answer: C

Rationale: Guided imagery is the mindful use of a word, phrase, or visual image to distract oneself from distressing situations or consciously taking time to relax or reenergize. Guided imagery does not involve muscle relaxation, positive self-image, or humor.

Correct Answer: B

Rationale: An initial response to stress, as seen by the fight-or-flight response, is an increase in the patients heart rate and blood pressure. Vasoconstriction leads to the increase in blood pressure. Blood glucose levels increase, supplying more readily available energy, and pupils dilate.