NURS 255 Exam 11 Flashcards
(68 cards)
1
Q
What is stress?
A
Stress is any disturbance to a persons normal balanced state.
2
Q
What happens to the Endocrine system in the alarm stage?
A
- Blood pressure increases
- Sense of wellbeing and pain reduction
- Metabolism increases
3
Q
What happens to the sympathetic nervous system during the alarm stage?
A
- Increase in mental alertness
- Pupils dilate
- More blood flow to the muscles
4
Q
What happens to the body when the alarm stage happens?
A
- Heart rate and force of contractions increase
- Blood flow to vital organs increases
- Blood volume and pressure increase
- Depth of respirations increases
- Glycogen to glucose
5
Q
What happens in the resistance stage of GAS?
A
- The body either adapts and returns to normal
- Or the body enters the third stage
6
Q
What happens in the Exhaustion or recovery stage of GAS?
A
- Exhaustion: decrease blood pressure, Increase in pulse and respirations, ends in injury or death
- Recovery: You recover to normal.
7
Q
What can cause the inflammatory response?
A
- Autoimune disorders
- Antigen-antibody response
- Chemical injury
- Ischemia
- Neoplasmic growth
- Pathogens
- Pathogens
- Physical agents
8
Q
What are the stages of the inflammatory response?
A
- Vascular response
- Cellular response
- Exudate formation
- Healing
9
Q
How does anxiety relate to stress?
A
- It is an anticipatory form of stress that is caused by worrying about something that may or may not be coming
10
Q
How are anxiety and fear different?
A
- Fear is related to a precipitating event and anxiety is future related
- The source of fear is easily identifiable
- Fear can be caused by physical or psychological events
11
Q
What 3 things can you do to assess Risk factors to stress?
A
- Determine whether the patient has a realistic or exaggerated perception of stressors
- Identify factors that increase the risk for future stresses.
- Identify interventions to reduce current stress and help avoid future stressors
12
Q
What Can be done to assess for physiological responses to stress?
A
- Measure vital signs
- General survey of patient
13
Q
What can be done to assess for emotional responses to stress?
A
- Observe nonverbal behaviours
- Check records for destructive behaviours
14
Q
What can be done to assess for cognitive responses to stress?
A
- Difficulty learning, thinking, judging, focusing, remembering
15
Q
What 3 main things can be done to help stressors?
A
- Remove stressors
- Support coping abilities
- Treat responses (help make diarrhea better)
16
Q
What is special about Judaism?
A
- They celebrate the Sabbath and work is forbidden from Friday to Saturday.
- Yom Kippur is for fasting
- No meat, pork or seafood or milk (Kosher)
- Women cover bodies and men cover head
- No contraceptives, no organ transplant
17
Q
What is special about Christianity?
A
- Baptism
- Many do not use alcohol and some do not eat meat on Fridays.
- Do not always agree on artificial births
18
Q
What is special about Islam?
A
- God is Allah
- Blood transfusions and organs are okay
- No pork, Halal meat only
- Ramadan means fasting during the day
- Must always wash hands before meals
- Women only treated by women
- No contraception
- No abortions
19
Q
What is special about hinduism?
A
- No beef, eggs.
- Wash in free flowing water, no showers.
- Practice Ayurvedic Medicine
- Blood transfusions and organs are okay
- Women only treated by women
- Believe in Karma
- Some wear a “Sacred Thread”
20
Q
What is Special about Buddhism?
A
- Believe in Karma
- Many are vegetarian
- Okay with contraception but not abortion
- Blood transfusions and transplants are okay
21
Q
What is special about native Americans?
A
- Note taking is forbidden with this religion
- Believe health is harmony
22
Q
What is special about Jehovah’s witnesses?
A
- They do not accept blood transfusions under any circumstances
23
Q
What are 5 barriers to spiritual care?
A
- Lack of general awareness of spirituality
- Lack of awareness of own spiritual belief
- Differences in spirituality between nurse and patient
- Fear that your knowledge base is insufficient
- Fear of where spiritual discussions may lead
24
Q
What is the HOPE spiritual assessment?
A
- H: Sources of hope
- O: Organized religion
- P: Personal spirituality/practices
- E: Effects on medical care and end of life issues
25
What is JAREL?
- Spiritual assessment well being scale for clients 65 and older
26
What is SPIRIT assessment?
- Spiritual religious belief system
- Personal spirituality
- Integration within a spiritual community
- Ritualized practices
- Implications for medical care
- Terminal events planning
27
What are the 6 Components of PRESENCE?
- Your actual presence at the bedside
- Being open to issues and concerns of patient
- Allowing the patient to lead discussions
- Sincere communication
- Being fully available to the client
- Listening to the patients stories about illness
28
Is it okay to pray for a client?
- Yes if you feel comfortable doing so but if not it may be best to ask another nurse or the Chaplin to take your place.
29
What are the 3 stages of grief according to George Engel
- Shock and disbelief
- Developing awareness to the loss
- Restitution and recovery
30
What are 4 phases of grief according to John Bowlby?
- Shock and numbness
- Yearning and searching
- Disorganization and despair
- Reorganization
31
What are the 3 stages of grief according to Theresa Rando?
- Avoidance
- Confrontation
- Accommodation
32
What are the 4 stages of grief according to William Worden?
- Accepting the reality of loss
- Working through the pain and grief
- Adjusting to the environment in which the deceased is missing
- Emotionally relocating the deceased and moving on with life
33
What are the 5 stages of grieving according to Elisabeth Kubler-Ross?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
34
What is Margaret Stroebes dual process model of grief?
- Loss-oriented response
- Restoration-oriented response
35
What did Dennis Klass believe about grief?
- Grief will always be felt to some degree and it is simply negotiation and renegotiation
36
What are factors that affect grief?
- Significance of the loss
- Support system
- Unresolved conflict
- Circumstances of the loss
- Previous or multiple losses
- Spiritual beliefs about loss
- Timeliness of death
37
What 3 things is end of life care defined by?
- The patient has a fatal condition
- Death is likely with the next exacerbation of disease
- The patient acknowledges the seriousness of the situation
38
What is palliative care?
- Aggressively planned comfort care that addresses end of life care concerns that include supporting families and caregivers, promoting continuity of care, ensuring respect for persons, addressing emotional concerns, managing symptoms and ensuring informed decision making.
39
What is hospice care?
- Hospice care is care that focuses on holistic care of patients who are dying or deliberated and not expected to improve
40
What are the two premises that hospice care is based upon?
- The quality of life is as important as the length of life
- Those who are terminally ill should be allowed to face death with dignity and while surrounded y the comfort of their homes and families
41
What are the 3 purposes of admitting a patient into hospice care?
- Provide a family with some respite for a period of time
- Stabilize a patient who requires symptom management
- Care for a patient who is in the end stage of a disease and needs a level of expert care that family members cannot provide at the home
42
What are the three requirements to receive medicare funds?
1. Educate patients and staff
2. Provide patients with information on their rights to accept or refuse treatment
3. Provide an opportunity for all patients to complete an advance directive.
43
What are the 2 types of advance directives?
- A living will
- A durable power of attorney (another person who is responsible for making decisions for someone who can't)
44
What should be done with a family after a family member passes?
- Encourage questions and respond to them
- Sit at the head of the bed and don't appear rushed
- Encourage family members to express feelings
- Ask what you can do to help
- Be sure everyone on the healthcare team understands the plan
- NEVER SAY YOU KNOW HOW THEY FEEL
45
What are 3 ways to help a family resolve grieving?
- Recall memories
- Find meaning in the families lives
- Bibliotherapy (reading to help)
46
What 3 things happen to a body after a person dies?
- Rigor mortis
- Algor mortis (Occurs when the blood stops)
- Livor mortis (Body begins to turn blue)
47
What is the main job of the nurse during postmortem care?
- Educate the family about the stages of grieving and be there if they need (IT IS OKAY TO ATTEND FUNERALS)
48
What are the 6 reasons sleep is important?
- Sleep affects every tissue in the body
- Sleep regulates metabolism
- Sleep improves learning and adaptation
- Sleep reduces stress and anxiety
- Sleep lessens the bodies perception of pain
- Sleep, rest and illness are interrelated
49
What factors affect sleep?
- Age
- lifestyle factors (caffeine, nicotine, medications)
- Illness
- Environment (light and dark rooms)
50
What is insomnia?
- Being unhappy with your sleep and not sleeping well due to anything.
51
What are sleep-wake schedule disorders?
- Changes in things like time zone, daylight saving times.
52
What is restless leg syndrome?
- A condition where someone feels like they have to move their legs just before or during sleep
53
What is Hypersomnia?
- Excessive sleeping
54
What is narcolepsy?
- Sudden uncontrollable urges to sleep, caused by the brain being unable to tell time of day properly.
55
What are parasomnias?
- Sleepwalking, sleepwalking, night terrors and a few others.
56
What substances should be avoided before sleep?
- Meals high in fat
- Nicotine
- Alcohol
- Opioids
- Beta blockers
- Antidepressants
57
Is it appropriate to wake someone up in the morning to take vitals?
- Only if they are critically ill
58
A nurse is preparing a presentation at a local collunity centre about sleep hygiene. Sort the following characteristics into either rapid eye movement sleep or non-rapid eye movement sleep.
A. Cognitive restoration occurs
B. Light sleep
C. 75% of time sleeping
D. Loss of muscle tone occurs
E. Vivid dreaming occurs
A. REM
B. NREM
C. NREM
D. REM
E. REM
59
A nurse is assessing a client who reports insomnia which of the following findings can contribute to a clients insomnia?
A. Irregular schedule
B. Stress
C. Warm Bath
D. Alcohol intake
E. Morning walk
A. Irregular schedule
B. Stress
D. Alcohol intake
60
The nurse is educating the client about ways to improve sleep. Which of the following recommendations should the nurse include?
A. Practice muscle relaxation techniques
B. Exercise each morning
C. Take two 30 min naps each day
D. Avoid heavy meals before bedtime
E. Limit fluid intake at least 1 hr before bedtime
A. Practice muscle relaxation techniques
B. Exercise each morning
D. Avoid heavy meals before bedtime
61
A nurse is instructing a client who has narcolepsy. Which of the following client statements indicates an understanding of the instructions?
A. "I will add plenty of carbohydrates to my meals"
B. "I will take a short nap when I feel sleepy"
C. "I will increase the heat in my office so I stay warm"
D. "I will limit alcohol intake to one drink per day"
B. "I will take a short nap when I feel sleepy"
62
A nurse is caring for a client who has terminal lung cancer. Match the client statement to the Kuber-Ross model stage of grief the client is experiencing.
A. "I am looking forward to our family reunion next year"
B. "This is so unfair why is this happening to me"
C. "I promise to go to church every day if I live through this"
D. "I have nothing to live for anyway"
E. "I have lived a good life"
A. "I am looking forward to our family reunion next year" (DENIAL)
B. "This is so unfair why is this happening to me" (ANGER)
C. "I promise to go to church every day if I live through this" (BARGIN)
D. "I have nothing to live for anyway" (DEPRESSION)
E. "I have lived a good life" (ACCEPTANCE)
63
A nurse is caring for a client who is expected to die within 24 hours. The client's family asks the nurse what physical changes to expect. Which manifestations should the nurse include?
A. Increase in urine output
B. Warm extremities
C. Decreased muscle tone
D. Periods of apnea
E. Bowel incontinence
C. Decreased muscle tone
D. Periods of apnea
E. Bowel incontinence
64
A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take?
A. Make sure the body is lying first
B. Remove dentures from the client
C. Place a clean gown on the clients body
D. Remove all equipment from the clients room
E. Dim the lights in the clients room
C. Place a clean gown on the clients body
D. Remove all equipment from the clients room
E. Dim the lights in the clients room
65
A nurse is caring for a client awaiting transport to the surgical suite for a coronary bypass graft, just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?
A. Exhaustion stage
B. Resistance stage
C. Alarm stage
D. Recovery stage
C. Alarm stage
66
A nurse is caring for a client whose partner passed away a month ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make?
A. "It takes time to get over the loss of a loved one"
B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
C. "Why don't you try something to take your mind off your troubles, like watching a funny movie."
D. "I might not share your exact situation, but I do know what people go through when they deal with loss"
B. "You are right. I cannot really understand. perhaps you'd like to tell me more about what you're feeling?"
67
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping and adherence to the treatment plan should the nurse initiate at this time?
A. Suggest coping skills for the client to use in this situation
B. Allow the client to provide input in the treatment plan
C. Assist the client with time management and address the clients priorities
D. Provide extensive instructions on the clients treatment regimen.
E. Encourage the client in the expression of feelings and concerns.
B. Allow the client to provide input in the treatment plan
C. Assist the client with time management and address the clients priorities
E. Encourage the client in the expression of feelings and concerns
68
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?
A. Prescribing tasks unilaterally
B. Delegating care to one member
C. Speaking to the primary client privately
D. Convening a family meeting
D. Convening a family meeting
