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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.
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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 preparing a health-promotion session on meditation for older persons at a community centre. Which of the following points should the nurse include in the session?
- A. Have patients bring earphones to the session.
- B. Breathing pattern to slowly increase speed.
- C. Allow a 10-20 minute time frame for meditation.
- D. Practise two to three times per week.
Correct Answer: C
Rationale: Guidelines for basic mediation include continuing it for 10-20 minutes, although even 5 minutes can be helpful. Patients won't bring earphones as the guideline is to find a quiet place with no distractions. The breathing pattern is to breathe slowly and consistently, relaxation breathing, not to speed up the rate. Meditation guidelines suggest that this be done once or twice a day.
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 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.