Nokea
The nurse is assisting with a breast biopsy for an alert patient who has a lump in the right breast. Which relaxation technique will be best to use at this time?
- A. Massage
- B. Meditation
- C. Guided imagery
- D. Relaxation breathing
Correct Answer: D
Rationale: Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practise and learn.
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The nurse is caring for a hospitalized patient with diabetes who states to the nurse, 'I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.' Which response by the nurse is appropriate?
- A. It is probably just coincidental that your blood sugars are high when you are ill.
- B. Stressors such as illness cause the release of hormones that increase blood sugar.
- C. Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.
- D. Your diet is different here in the hospital than at home and that is the most likely cause of the increased glucose level.
Correct Answer: B
Rationale: The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.
When choosing music to help relax a patient who is having a painful dressing change, which action is best for the nurse to take?
- A. Use music composed by Mozart.
- B. Ask the patient about music preferences.
- C. Select music that has 60-80 beats/minute.
- D. Encourage the patient to use music without words.
Correct Answer: B
Rationale: Although music with 60-80 beats/minute, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.
A young adult arrives in the emergency department (ED) with multiple abrasions after a motor vehicle accident and has an initial blood pressure (BP) of 180/98. Which of the following interventions should the nurse implement?
- A. Discuss the need for hospital admission to control blood pressure.
- B. Change the dressing on the abrasions and discuss the risks associated with hypertension.
- C. Recheck the blood pressure in 15 minutes.
- D. Start an intravenous (IV) line to administer antihypertensive medications.
Correct Answer: C
Rationale: Because hypertension is expected when a patient has experienced an acute stressor, the nurse should plan to check the BP in a timely manner, which will provide a more accurate idea of the patient's usual blood pressure. Hypertension that occurs in response to acute stress does not increase risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.
Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient?
- A. Assess for bradycardia.
- B. Ask about gastrointestinal pain.
- C. Observe for decreased appetite.
- D. Check for elevated blood glucose levels.
- E. Monitor for a decrease in respiratory rate.
Correct Answer: B,C,D
Rationale: The physiological changes associated with the acute stress response can cause changes in appetite, increased gastrointestinal upset, and elevation of blood glucose. Stress causes an increase in respiratory and heart rates.
The nurse is teaching a hospitalized patient to use imagery as a relaxation technique. Which statement by the nurse is appropriate?
- A. Place your stress in the image of a form you can destroy.
- B. Think of a place where you feel peaceful and comfortable.
- C. Bring what you hear and sense in your present environment into your image of the scene.
- D. If your scene is stressful to you, continue visualizing until you can overcome the distress.
Correct Answer: B
Rationale: When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual patient environment. Imagery may be used to target a disease or pathology, but this type of imagery will not lead to relaxation.