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What would be your best response?
- A. This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help.
- B. In children who are previously healthy, inflammation and infections usually resolve without the need for drugs.
- C. Ill make sure the doctor is made aware that youd like your son to have a course of antibiotics.
- D. Infection is not the same as inflammation. What your son has is inflammation.
Correct Answer: A
Rationale: Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration. As these changes take place, five cardinal signs of inflammation are produced: redness, heat, swelling, pain, and loss of function. Infections do not always resolve spontaneously. The nurse should teach the patients father about the reasons that antibiotics are unnecessary rather than simply deferring to the physician.
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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.
What could the nurse do to help the patient?
- A. Refer him to a consciousness-raising group.
- B. Refer him to a psychiatrist.
- C. Refer him to a support group.
- D. Refer him to a church or temple.
Correct Answer: C
Rationale: Being a member of a group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas. Psychiatry may or may not be necessary. Spiritual assessment would necessarily precede any referral to a specific religious setting. Consciousness-raising groups are not known to be a common source of social support.
What would the nurse recognize as the longest-acting phase of the womans physiologic response to stress and its cause?
- A. Sympathetic-adrenal-medullary response caused by persistent stress
- B. Hypothalamic-pituitary response caused by acute stress
- C. Sympathetic-adrenal-medullary response caused by acute stress
- D. Hypothalamic-pituitary response caused by persistent stress
Correct Answer: D
Rationale: The longest-acting phase of the physiologic response, which is more likely to occur in persistent stress, involves the hypothalamic-pituitary pathway, not the sympathetic-adrenal-medullary pathway.
Which of the following is an immediate physiologic response to stress the nurse would expect this patient to experience?
- A. Vasodilation of peripheral blood vessels
- B. Increased blood pressure
- C. Decrease in blood glucose levels
- D. Pupil constriction
Correct Answer: B
Rationale: An initial response to stress, as seen by the fight-or-flight response, is an increase in the patients heart rate and blood pressure. Vasoconstriction leads to the increase in blood pressure. Blood glucose levels increase, supplying more readily available energy, and pupils dilate.
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.