Nokea
A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, 'Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done.' The nurse should document the patient's comment in which section of the assessment?
- A. Physical
- B. Spiritual
- C. Financial
- D. Psychological
Correct Answer: B
Rationale: Stress can be evident in a person's spirituality. This patient's comment indicates questioning of one's place in the universe and consequences for wrongdoing, both are elements of spirituality. Stress can be related to psychological, physical, or psychosocial well-being, but spirituality is the best answer.
You may also like to solve these questions
Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? (Select all that apply.)
- A. An 8-year-old child watches an R-rated movie with both parents.
- B. A young adult jumps from a bridge with a bungee cord with a best friend.
- C. An adolescent is kidnapped and held for 2 years in the home of a sexual predator.
- D. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment.
- E. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.
Correct Answer: C,D,E
Rationale: PTSD usually follows a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture or kidnapping, military combat, sexual assault, and natural disasters such as floods, tornados, earthquakes, and tsunamis; human disasters such as a bus or elevator accident or crime-related events such being taken hostage are additional examples. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumping by adolescents is part of the developmental task and might be frightening but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.
A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2014. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)?
- A. Immediately upon return to the United States from Afghanistan
- B. Before departing Afghanistan to return to the United States
- C. Two years after returning from Afghanistan
- D. Screening should be ongoing
Correct Answer: D
Rationale: PTSD can have a long lag time?months to years. Screening should be ongoing.
A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?
- A. Thalamus
- B. Parietal lobe
- C. Hypothalamus
- D. Pituitary gland
Correct Answer: C
Rationale: The individual will find this experience stressful. The hypothalamus functions as the command-and-control center when receiving stressful signals. The hypothalamus responds to signals of stress by engaging the autonomic nervous system. The parietal lobe is responsible for the interpretation of other sensations. The thalamus processes messages associated with pain and wakefulness. The pituitary gland may be involved in other aspects of the person's response but would not stimulate the autonomic nervous system.
A person with a fear of closes spaces enters into an elevator. Which division of the autonomic nervous system is stimulated in response to this experience?
- A. Limbic system
- B. Peripheral nervous system
- C. Sympathetic nervous system
- D. Parasympathetic nervous system
Correct Answer: C
Rationale: The autonomic nervous system is made up of the sympathetic (fight-or-flight response) and parasympathetic (relaxation response) nervous systems. In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with the experience of driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.
A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, 'We had planned to start a family, but now he won't talk about it. He won't even look at children.' The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)?
- A. Re-experiencing
- B. Hyperarousal
- C. Avoidance
- D. Psychosis
Correct Answer: C
Rationale: Physiological reactions to reminders of the event include a persistent avoidance of the stimuli associated with the trauma; the individual avoids talking about the event or avoids activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. No evidence suggests that this soldier is having a hyperarousal reaction or is re-experiencing war-related traumas. Psychosis is not evident.