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A nurse has completed an assessment of a patient who is experiencing significant stress. The assessment revealed intense anger and acting out behaviors along with statements of negative emotions. Which nursing diagnosis would be most appropriate?
- A. Disturbed thought processes
- B. Low self-esteem
- C. Hopelessness
- D. Ineffective coping
Correct Answer: D
Rationale: Intense anger, acting out, and negative emotions indicate ineffective coping, as the patient struggles to manage stress adaptively. Disturbed thought processes, low self-esteem, and hopelessness may be present but are less directly tied to the described behaviors.
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A nurse is assessing a patient and uses the Recent Life Changes Questionnaire as part of the assessment. The nurse determines that the patient has experienced major life crisis with which score on the questionnaire?
- A. 150
- B. 250
- C. 350
- D. 450
Correct Answer: D
Rationale: The Recent Life Changes Questionnaire (based on the Holmes-Rahe Stress Scale) indicates a major life crisis with a score of 300 or higher, with 450 reflecting significant stress. Lower scores (150, 250) suggest moderate stress, and 350 is borderline but not definitive.
A nurse is reviewing the assessment findings of several patients. Which patient would the nurse identify as having a type D personality?
- A. A man who threatens the receptionist in the emergency department with bodily harm if a doctor does not see him right away
- B. A woman who sits quietly reading in a waiting room before seeing her doctor for her annual physical examination
- C. A quiet teen who drinks a six pack of beer against his better judgment because of peer pressure
- D. A man who reacts negatively to almost everything but never discusses his feelings with anyone
Correct Answer: D
Rationale: Type D personality is characterized by negative affectivity and social inhibition, as seen in the man who reacts negatively but suppresses feelings. Threatening behavior, quiet reading, or succumbing to peer pressure do not align with Type D traits.
A nurse is providing an in-service presentation on coping and adaptation. Which of the following would the nurse most likely include? Select all that apply.
- A. Most coping strategies are similar in their approach.
- B. Coping when effective leads to adaptation.
- C. Reappraisal occurs simultaneously with coping.
- D. The same coping strategy is used in each situation.
- E. Coping is a deliberate and planned effort to manage stress.
Correct Answer: B,C,E
Rationale: Effective coping leads to adaptation (B), reappraisal occurs with coping (C) as part of ongoing stress evaluation, and coping is deliberate and planned (E). Coping strategies vary (A is false), and different strategies are used per situation (D is false).
When describing the concept of allostatic load to a group of students, which of the following would the instructor identify as abnormalities of which of the following as indicative of the overall changes?
- A. Nuclear imaging studies
- B. Laboratory test results
- C. Bone radiographs
- D. Cardiac studies
Correct Answer: B
Rationale: Allostatic load reflects cumulative stress effects, often shown through abnormal laboratory test results (e.g., cortisol, inflammatory markers). Nuclear imaging, bone radiographs, and cardiac studies are less directly indicative of stress-related changes.
The nurse is caring for a patient who has been under severe stress while caring for her elderly mother who is in the advanced stages of Alzheimer?s disease. The nurse explains that the patient is adapting to the stress is she is experiencing because of which of the following?
- A. Ability to survive in the midst of severe stress
- B. Acceptance of others? help in caring for her mother
- C. Success at being able to solve problems
- D. Capability in setting reasonable personal goals
Correct Answer: B
Rationale: Accepting others? help indicates adaptive coping by leveraging social support to manage stress. Survival, problem-solving, and goal-setting are aspects of coping, but accepting help directly reflects adaptation in this caregiving context.