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The nurse is caring for a patient who has been hospitalized following a heart attack and tells the nurse, 'I didn't sleep last night because I worried about missing work and losing my insurance coverage.' Which nursing diagnosis is appropriate to include in the plan of care?
- A. Anxiety
- B. Defensive coping
- C. Ineffective denial
- D. Risk prone-health behaviour
Correct Answer: A
Rationale: The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk-prone health behaviour as problems for this patient.
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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.
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.
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.
An overweight patient who enjoys active outdoor activities develops arthritis in the knees. Which action by the nurse is most appropriate to assist the patient in coping with the diagnosis?
- A. Ask the patient to discuss feelings about the diagnosis.
- B. Have the patient practise frequent relaxation breathing.
- C. Educate the patient on the use of imagery to decrease pain and decrease stress.
- D. Encourage the patient to think about how weight loss might improve symptoms.
Correct Answer: D
Rationale: For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with the diagnosis, but they will not be as helpful as a problem-oriented strategy.
A hospitalized patient whose wife describes him as usually well organized and calm is receiving diabetic teaching after being newly diagnosed with diabetes. He states, 'I'm feeling distracted because I'm just getting used to my new diagnosis'. Which action should the nurse take?
- A. Ask the health care provider for a psychiatric referral.
- B. Administer the PRN sedative medication every 4 hours.
- C. Suggest the use of a home caregiver to the patient's family.
- D. Plan to reinforce and repeat teaching about diabetes management.
Correct Answer: D
Rationale: Since behavioural responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.