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How should you best respond if it is found that the patients health patterns are not achieving their goals?
- A. Seek ways to promote balance in the patient.
- B. Refer the patient to social work.
- C. Identify alternative models of health care.
- D. Provide insight into the patients physiological failings.
Correct Answer: A
Rationale: The nurse has a significant role and responsibility in identifying the health patterns of the patient receiving care. If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote balance. The nurse is not obligated to refer to social work, identify alternative forms of care, or provide insight into the physiologic failings of the system if the patients health patterns are not achieving their goals.
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How should you best understand the concept of coping when attempting to meet this patients needs?
- A. Coping is a physiologic measure used to deal with change, and he will physically adapt.
- B. Coping is composed of the physiologic and psychological processes that people use to adapt to change.
- C. Coping is the human need for faith and hope, both of which create change.
- D. Coping is a social strategy that is used to deal with change and loss.
Correct Answer: B
Rationale: Indicators of stress and the stress response include both subjective and objective measures. They are psychological, physiologic, or behavioral and reflect social behaviors and thought processes. The physiologic and psychological processes that people use to adapt to stress are the essence of the coping process. Coping is both a physiologic and psychological process used to adapt to change.
What can the triage nurse teach the mother?
- A. The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.
- B. Bee stings frequently cause infection, pain, and swelling, and, with treatment, the infection should begin to subside late today.
- C. The infection was probably caused by the stinger, which may still be in the wound.
- D. The mothers assessment is accurate and the ED doctor will probably prescribe antibiotics to fix the problem.
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.
To what type of stressor has this patient been exposed?
- A. Physiologic
- B. Psychosocial
- C. Physical
- D. Psychiatric
Correct Answer: C
Rationale: Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. A chemical spill is neither a psychiatric nor a psychosocial phenomenon.
What would be the most complete statement by the students about the concept of steady state?
- A. The concept of steady state preserves life.
- B. The mechanisms of steady state work to maintain balance in the body.
- C. This concept compensates for biologic and environmental attacks on the body.
- D. Steady state is the same as adaptation.
Correct Answer: B
Rationale: Mechanisms for adjusting internal conditions promote the normal steady state of the organism and its survival. These mechanisms are compensatory in nature and work to restore balance in the body. Adaptation is a part of the concept of steady state; it is not the concept itself.
Which of the patients actions best demonstrates adaptively coping?
- A. Becoming controlling
- B. Reprioritizing needs and roles
- C. Using benzodiazepines as ordered
- D. Withdrawing
Correct Answer: B
Rationale: Adaptive ways of coping included seeking information, reprioritizing needs and roles, lowering expectations, making compromises, comparing oneself to others, planning activities to conserve energy, taking things one step at a time, listening to ones body, and using self-talk for encouragement. Becoming controlling or withdrawing are not ways to cope adaptively. Benzodiazepines are sometimes indicated, but these are not considered to be an adaptive coping behavior.