Nokea
What would be the most appropriate nursing intervention?
- A. Put the primary onus for planning care on the patient herself.
- B. Assess and provide constructive outlets for anger and hostility.
- C. Assess the patients sources of social support.
- D. Encourage an attitude of realistic hope to help her deal with helpless feelings.
Correct Answer: D
Rationale: By encouraging an attitude of realistic hope, the patient will be empowered. This allows the patient to explore her feelings and bring about more effective coping patterns. The onus for care planning should not lie with the patient. The nursing diagnosis is related to feeling of helplessness, not anger and hostility. Social support is necessary, but does not directly address the feeling of helplessness.
You may also like to solve these questions
What is most important for the nurses to know about these coping behaviors?
- A. They are effective, but alternative, coping behaviors.
- B. They do not directly influence stress in the body.
- C. They are adaptive behaviors.
- D. They increase the risk of illness.
Correct Answer: D
Rationale: Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness. The use of drugs and alcohol as a means to reduce stress are not effective coping behaviors. They are maladaptive behaviors, even though they have a short-term effect on stress.
What is an example of a bodily function that restores homeostasis by negative feedback when conditions shift out of normal range?
- A. Body temperature
- B. Pupil dilation
- C. Diuresis
- D. Blood clotting
Correct Answer: A
Rationale: Negative feedback mechanisms throughout the body monitor the internal environment and restore homeostasis when conditions shift out of normal range. Body temperature, blood pressure, and acid-base balances are examples of functions regulated by these compensatory mechanisms. Blood clotting in the body involves positive feedback mechanisms. Pupil dilation and diuresis are not modulated by negative feedback mechanisms.
What principle of stress and adaptation should be integrated into the nurses plan of care for this patient?
- A. Adaptation often fails during stressful events and results in homeostasis.
- B. Stress is a part of all lives, and, eventually, this young woman will adapt.
- C. Acute anxiety and depression can be adaptations that alleviate stress in some individuals.
- D. An accumulation of stressors can disrupt homeostasis and result in disease.
Correct Answer: D
Rationale: Four conceptsâ??constancy, homeostasis, stress, and adaptationâ??are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis, and, if adaptation fails, the result is disease. If a person is overwhelmed by stress, he or she may never adapt. Acute anxiety and depression are frequently associated with stress.
What will be included in the nurses intervention?
- A. The use of progressive tensing and relaxing of muscles to release tension in each muscle group
- B. Using a positive self-image to increase and intensify physical exercise, which decreases stress
- C. The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations
- D. The use of music and humor to create a calm and relaxed demeanor, which allows escape from stressful situations
Correct Answer: C
Rationale: Guided imagery is the mindful use of a word, phrase, or visual image to distract oneself from distressing situations or consciously taking time to relax or reenergize. Guided imagery does not involve muscle relaxation, positive self-image, or humor.
What is the most appropriate nursing diagnosis for this patient?
- A. Self-esteem disturbance related to late diagnosis
- B. Ineffective individual coping related to reluctance to seek care
- C. Altered family process related to inability to obtain treatment
- D. Ineffective denial related to reluctance to seek care
Correct Answer: B
Rationale: Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case, the patient was unable to access health care even when she was aware the disorder could be life-threatening. Self-esteem Disturbance, Altered Family Process, and Ineffective Denial are all nursing diagnoses that are often associated with breast cancer, but the patients ineffective individual coping has created a significant safety risk and is, therefore, the most appropriate nursing diagnosis.