STRESS & ADAPTATION NCLEX QUESTIONS AND CORRECT ANSWER GRADE A+

STRESS & ADAPTATION NCLEX QUESTIONS AND CORRECT ANSWER GRADE A+ A client expresses to the nurse that she constantly feels irritated and loses her temper. During the course of the interview, the nurse finds that the client takes care of her mother who was confined to bed following a stroke. The client struggles to balance caring for her family and her mother. Which nrusing diagnosis would the nurse most likely identify for this client? a) Compromised family adjustment b) Caregiver role strain c) Ineffective coping d) Anxiety - CORRECT ANSWER-b) Caregiver role strain Explanation: The most appropriate nursing diagnosis is caregiver role strain because the client feels tired and fatigued by struggling to care for her mother and fulfilling family needs. Ineffective coping, compromised family adjustment, and anxiety would be inappropriate nursing diagnoses based on the information provided. A middle-aged woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are a) Stressors b) Demands c) Illnesses d) Stimuli - CORRECT ANSWER-Stressors Explanation: Stress is defined as any event or set of events, a stressor, that causes a response. Everyday triggers associated with work or social relationships, and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors. An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of a) Valuation b) Adaptation c) Evaluation d) Reaction - CORRECT ANSWER-Adaptation Explanation: Adaptation is generally considered a person's capacity to flourish and survive, even with diversity. You are the nurse caring for a 72-year-old female who is recovering from abdominal surgery on the Medical Surgical unit. The surgery was very stressful and prolonged and you note on the chart that her blood sugars are elevated yet she in not been diagnosed with diabetes. To what do you attribute this elevation in blood sugars? a) It is a result of antidiuretic hormone. b) She must have had diabetes prior to surgery. c) She has become a diabetic from the abdominal surgery. d) The blood sugars are probably a result of the "fight-or-flight" reaction. - CORRECT ANSWER-The blood sugars are probably a result of the "fight-or-flight" reaction. Explanation: During stressful situations, ACTH stimulates the release of cortisol from the adrenal gland, which creates protein catabolism releasing amino acids and stimulating the liver to convert amino acids to glucose, the result is elevated blood sugars. Option A is incorrect, antidiuretic hormone is released during stressful situations and stimulates reabsorption of water in the distal and collecting tubules of the kidney. Option B is incorrect; assuming the patient had diabetes prior to surgery demonstrates a lack of understanding of stress induced hyperglycemia. Option C is incorrect, there is no evidence presented in the question other than are elevated blood sugars that would support a diagnosis of diabetes. A nurse is assessing an obese teenager who is unhappy and stressed out because she has not lost weight despite working out at the gym. The physician asks the nurse to try the modeling intervention for stress management for the client. Which of the following actions should the nurse perform when adhering to the modeling intervention? a) Ask the client to undergo liposuction surgery. b) Ask the client to change her exercise regimen. c) Ask the client to cut down on her food intake. d) Introduce the client to someone with a positive attitude. - CORRECT ANSWERIntroduce the client to someone with a positive attitude. Explanation: The nurse should introduce the client to a person who demonstrates a positive attitude or behavior as this promotes the ability to learn an adaptive response. The nurse should not ask the client to change her exercise regime, cut down on her food intake, or undergo liposuction surgery as that could lead to further medical complications. Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome? a) Increased mental alertness b) Vasoconstriction c) The initiation of neuroendocrine activity d) Decreased blood pressure - CORRECT ANSWER-Decreased blood pressure Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS. You walk into your patients' room and find her sobbing uncontrollably. When you ask what the problem is your patient responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a nursing diagnosis of "Ineffective coping related to stress". What is the best outcome you can expect for this patient? a) Patient will avoid stressful situations. b) Patient will start anti-anxiety agent. c) Patient will adapt relaxation techniques to reduce stress. d) Patient will be stress free. - CORRECT ANSWER-Patient will adapt relaxation techniques to reduce stress. Explanation: Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the patient needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. The other options are incorrect because it is unrealistic to expect a patient to be stress free; avoiding stressful situations and starting an anti-anxiety agent are not the best answers as outcomes for ineffective coping. The nurse would recognize that short-term pharmacological treatment may be appropriate if an anxious patient's nursing diagnoses includes which of the following? a) Social isolation b) Decisional conflict c) Disturbed sleep pattern d) Defensive coping - CORRECT ANSWER-Disturbed sleep pattern Explanation: The nurse should recognize that diagnoses relating to conflict, coping, and decisional conflict are less amenable to pharmacologic treatment. Disturbances in sleep patterns, however, are often addressed by the appropriate use of hypnotic medications. When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem? a) Avoid doing petty jobs. b) Take control of the situation. c) Change jobs. d) Avoid people who dump tasks on him. - CORRECT ANSWER-Take control of the situation.