Hondros Nur 163 Exam 2 with 100%
Correct Answers 2023
Eustress – Correct Answer-Positive stress
Distress – Correct Answer-Negative stress
Parasympathetic – Correct Answer-Rest and digest
Sympathetic response – Correct Answer-Fight or flight. Increased HR, BP, cardiac
output, blood glucose. Dilation of bronchial airways, pupil dilation.
Cardiovascular signs of strss – Correct Answer-Racing/ pounding heart, increased
pulse, increased BP, cold/ clammy hands and feet, increased blood glucose
Respiratory signs of stress – Correct Answer-Increased rate and depth of respirations,
possible hyperventilation with tingling in extremities. Faintness, dizziness, possible
seizures.
Musculoskeletal signs of stress – Correct Answer-Increased blood glucose to provide
energy to muscles, increased muscle tension in back, neck and head. Tension
headaches, teeth grinding, and back aches.
Gastrointestinal signs of stress – Correct Answer-Decreased production of gastric
enzymes, loss of appetite, nausea, abdominal distinction, vomiting, heartburn, ulcers.
Decreased peristalsis resulting in excess gas and constipation, but diarrhea is also
common.
Urinary signs of stress – Correct Answer-Decreased urinary output but increased urinary
frequency.
Psychological and emotional response to stress – Correct Answer-Anxiety, depression,
anger, irritability, frustration, overreaction, memory loss, lack of concentration, insomnia
Physiological response to stress – Correct Answer-Muscle tension, headache,
stomachache, acid reflux, tachycardia, hyperventilation, elevated BP
Behavioral response to stress – Correct Answer-Smoking, overeating, substance abuse
Major risks associated with stress – Correct Answer-Angina, heart rhythm abnormalities,
heart attack, stroke, infections, ulcers, GERD, IBS, sleep problems, headaches, muscle
spasms.
Eustress
Positive stress
Distress
Negative stress
Parasympathetic
Rest and digest
Sympathetic response
Fight or flight. Increased HR, BP, cardiac output, blood glucose. Dilation of bronchial airways, pupil dilation.
Cardiovascular signs of strss
Racing/ pounding heart, increased pulse, increased BP, cold/ clammy hands and feet, increased blood glucose
Respiratory signs of stress
Increased rate and depth of respirations, possible hyperventilation with tingling in extremities. Faintness, dizziness, possible seizures.
Musculoskeletal signs of stress
Increased blood glucose to provide energy to muscles, increased muscle tension in back, neck and head. Tension headaches, teeth grinding, and back aches.
Gastrointestinal signs of stress
Decreased production of gastric enzymes, loss of appetite, nausea, abdominal distinction, vomiting, heartburn, ulcers. Decreased peristalsis resulting in excess gas and constipation, but diarrhea is also common.
Urinary signs of stress
Decreased urinary output but increased urinary frequency.
Psychological and emotional response to stress
Anxiety, depression, anger, irritability, frustration, overreaction, memory loss, lack of concentration, insomnia
Physiological response to stress
Muscle tension, headache, stomachache, acid reflux, tachycardia, hyperventilation, elevated BP
Behavioral response to stress
Smoking, overeating, substance abuse
Major risks associated with stress
Angina, heart rhythm abnormalities, heart attack, stroke, infections, ulcers, GERD, IBS, sleep problems, headaches, muscle spasms.
Stressor activates what
Hypothalamus response
Hypothalamus response to stress
Secretes corticotropin-releasing factor
Corticotropin-releasing factor activates what
Sympathetic nervous system, anterior pituitary and posterior pituitary glands
Activation of the sympathetic nervous system
Causes the release of catecholamines (epi, norepi, dopamine)
Activation of the anterior pituitary gland
Causes the release the ACTH which causes release of aldosterone and cortisol
Activation of the posterior pituitary gland
Causes release of ADH increasing water retention
Problem-focused coping
Evaluating a situation and taking action to manage or change the situation associated with the stressor. Goal is to eliminate or reduce underlying cause.
Emotion-focused coping
Emphasizes the regulation of emotional response that occurs in a given situation. No attempt is made to address the stressor but instead to control the emotional response.
Meaning-focused coping
A process where the individual draws on values, beliefs, and goals to modify the personal interpretation and response to a problem.
Evidence of poor coping behaviors
Anger, anxiousness, sadness, and hopelessness
Reframing
A positive coping strategy characterized by purposeful cognitive thoughts whereby the individual identifies positive aspect of the situation.
Confrontational problem solving method
Continuing to face the stressor and live with the consequences
Escape problem solving method
Completely leaving the situation EX: changing jobs
Avoidance problem solving method
Decrease contact with the stressor
Emotional distancing problem solving method
Consciously working to change ones attitude toward the stressor
Cardiovascular consequences of immobility
Reduced cardiac capacity, decreased cardiac output, othostatic hypotension, venous stasis, DVT
Respiratory consequences of immobility
Reduced lung expansion, atelectasis, pooling of respiratory secreations, possible pneumonia
Muscuskelatal consequences of immobility
Reduced muscle mass and atrophy, contracture, bone demineralization
Gastrointestinal consequences of immobility
Reduced peristalsis, comstipation
Urinary consequences of immobility
Renal canculi, urinary stasis, infection
Causes of immobility
Inadequate gas exchange, poor nutrition, pain, impaired perfusion
Oseoarthritis
Caused by gradual degenerative changes of the joint. Causing pain, swelling and reduced mobility of the joint.
Rheumatoid arthritis
Systemic autoimmune condition with genetic predisposition that creates an inflammatory process in the synovial membranes on the joints and other body tissues. Over time this leads to erosion of the membrane and cartilage causing pain, swelling, and joint deformity.
Agility
The ability to move quickly and smoothly, decreases with age.
Dexterity
The ability to perform fine manipulative skills that were perfected when younger such as playing an instrument or sewing.
Recommended weekly exercise for older adults
Should participate in 150 minutes of aerobic physical activity each week plus muscle-strengthening activities that work every major muscle group, twice a week.
Preventing hypertension during exercise
Breathe through mouth (valsalva maneuver)
Primary prevention of stress
Maintaining a positive attitude through counseling, health education, nutrition counseling, and exercise.
Secondary prevention of stress
Using screening tools to determine stress levels.
Which type of exercises should the elderly/cardiac patients not take part in?
Isometric/isotonic exercises due to vagal response
When giving diuretics, which electrolyte do you supplement due to the smallest margin of error?
potassium
Which system controls stress on the body, or the Fight or Flight instinct?
parasympathetic system
stress on the body/mind
negative emotions, insomnia, alertness
stress causes: pupils
dilate
stress causes: GI
mouth is dry, dec. peristalsis, dec. appetite, N/V, ulcers, heart burn
stress causes: heart
inc. HR, inc. BP
stress causes: lungs
inc. respirations, dilate bronchioles, hyperventilation -> resp. alk.
stress causes: blood glucose
increased
stress causes: insulin production
decreased
stress causes: sex drive
dec. libido
stress causes: urinary
dec. output
stress causes: musculoskeletal
tension, headache, backache, sore muscles
stress causes: immune system
dec. WBC count -> cancer
stress causes: skin/hair
acne, eczema, psoriasis, hair loss
Relaxation Techniques for Stress Management
exercise, art therapy, music, prayer, meditation, reiki, breathing exercises, massage
What is a challenging stressor?
Manageable, but requires mobilization of sources
What is a neutral stressor?
taxes existing resources
What is a threatening stressor?
Exceeds existing resources and personal capabilities
Primary prevention
Efforts to prevent an injury or illness from ever occurring; educating and vaccinations
Secondary prevention
screening and early detection
Tertiary prevention
actions taken to manage damage once a disease or disability has progressed beyond its early stages
T/F Stress is a concept with psychological, physiological, and behavioral components
True
T/F Children with chronic stress may show s/s of failure to thrive
True
T/F Stress is experienced daily by people of all ages
True
T/F Stress that is severe, prolonged, and chronic is likely to result in disability and dysfunction
True
T/F A perceived stress event initiates a response in the peripheral nervous system
False, CNS
T/F Stress activates the limbic system
True
T/F Untreated stress is associated with chronic conditions such as coronary artery disease, tension headaches, insomnia, and depression
True
T/F Decreased respiratory rate is a result of the release of norepinephrine and epinephrine
False; increased
T/F Bronchoconstriction is a result of the release of norepinephrine and epinephrine
False; bronchodilation
T/F Increased blood glucose level is a result of the release of norepinephrine and epinephrine
True
T/F Decreased BP is a result of the release of norepinephrine and epinephrine
False; increased
T/F Increased HR, contraction, and cardiac output is a result of the release of norepinephrine and epinephrine
True
Which intervention would be most beneficial for a patient experiencing frequent headaches related to muscle tension? behavioral skills training, health education, biofeedback, or meditation?
Biofeedback
what are the defining characteristics of stress overload?
Anger, impatience, inability to make decisions
T/F If a person experiences a positive event, such as winning the lottery, the person experiences stress because he/she is encountering a significant life change
True
What is the fight or flight response?
a predictable range of physiologic responses in the face of danger
What life event is considered most stressful?
The sudden death of a child
Why would someone be experiencing constipation during a stressful event?
decreased peristalsis
T/F mild stress is bad
False; mild stress causes increased alertness, which is good, in moderation
T/F Depression can occur because of high levels of stress
True
Biofeedback is:
making the pt aware of physiologic responses to stress in an attempt to gain control over those responses
T/F Suppression is making generalizations to avoid disturbing thoughts
False; emotion-focused strategy
repression
removal of anxiety-producing thoughts or experiences from conscious awareness
denial
refusing to acknowledge some painful painful aspect of external reality that is obvious to others
rationalization
creating an acceptable explanations for unacceptable thoughts or actions
intellectualization
making generalizations to avoid avoid disturbing thoughts or feelings
displacement
transferring emotions about one situation or person onto another
suppression
avoiding thinking about distressing situations
projection
Attributing one’s own thoughts, feelings, or motives to another
sublimation
channeling negative energy into socially acceptable behaviors
substitution
keeping so busy with activities that there is no time to think about stressors
Which systems does immobility affect?
All body systems
Immobility complications
depression, f/e imbalance, a/b imbalance, dec. perfusion -> DVT, dec. peristalsis, dec. C.O., skin breakdown -> pressure ulcers, pneumonia -> resp. acid., inc. risk for infection, edema, atrophy, bone demineralization -> kidney stones and osteoporosis
Immobility interventions
ambulate, wt. bearing exercises, SCD’s, ted hose, ankle pumps, turn Q 2 hrs, float heels, Ca++ Vit. D/Calcitonin, moon boots, hot/cold therapy, pre-med before exercise, referral to: social workers, PT, OT, DT
What can you delegate to a UAP?
anything that doesn’t involve assessment, medications, or nursing treatments (examples include: ambulation, ROM, moon boots, float heels, hot/cold therapy (unless assessment is needed), wt. bearing exercises)
What natural changes associated with aging affect activity in older adults?
increased joint degeneration
T/F By limiting physical mobility with restraint, the patient has a decreased risk for falls
False; increased risk
What can you do to help an older adult if pain is the common cause of decreased activity?
pre-medicate within an hour before exercising
T/F Risk factors for activity intolerance include exertional dyspnea
True
T/F Self-care deficits can negatively affect self-esteem
True
T/F When mobility decreases with age, older adults often display signs and symptoms of isolation
True
How would the nurse improve oxygenation for adequate exercise in a bedridden pt?
clear secretions and teach effective couging
What disorder would require a pt to use assistive devices such as padded eating utensils?
Hemiplagia
T/F Impaired physical mobility is a state in which a person has a limitation in physical mobility
True
deconditioned
a loss of physical fitness; used for pts who experienced extended immobility such as prolonged bedrest
Why are older adults at increased risk for bone fractures?
bone density decreases and bones become more brittle
T/F Immobility results in dec. cardiac output
True
T/F Immobility results in secondary hypertension
False
T/F Immobility contributes to the formation of DVT
True
T/F Immobility causes inc. calcium resorption into skeletal bones
False; aides in demineralization
T/F Immobility contributes to the development of pressure ulcers
True
T/F immobility has been linked to increased verbal and decreased nonverbal communication in individuals
False
T/F Psychological effects associated with immobility are more concerning for older adults than any other age group
False; children are more concerning
T/F Immobilization in children can interfere with intellectual and psychomotor functioning
True
T/F Immobility can hamper physical growth and development in children
True
T/F For adults, being unable to work or perform ADL’s due to immobility often causes a loss of self-worth
True
What kind of diagnostic test would be used for a pt with significant pain in the lower right leg after falling off a ladder?
x-ray
T/F The best reason bed exercises should be encouraged for pts on bedrest is to minimize atrophy ad maintain joint movement
True
T/F Muscle relaxants aren’t classified as analgesics
True
An otherwise strong, healthy pt with a lower leg cast is learning to ambulate with crutches. Which gait would he/she use?
3-point gait
Where do the patients feet stop when performing the swing-through crutch gait?
past the crutch tips
The nurse is teaching a pt who has crutches how to sit down in a chair. Which hand should the patient hold both crutches?
The hand on the injured side
Forearm crutches are generally used by pts with which types of conditions?
general weakness or paraplegia
A pt requiring minimal assistance with ambulation would use which type of device?
a cane
When preparing to safely transfer a pt from a bed to a wheel chair using a transfer belt, what would a nurse do first?
Assess the patient’s physiological capacity to transfer.
T/F When assisting a pt who is able to help transfer themselves from the bed to a wheel chair using a transfer belt, you would have the pt push down on the mattress with both hands and rock to stand on the count of 3.
True.
What would be the first action to perform just before moving a pt to the side of the bed?
Raise the head of the bed 30 degrees.
The nurse is preparing to transfer a pt with left sided weakness from the bed to a wheel chair using a transfer belt. Which position would the nurse instruct the pt to assume?
Place your stronger leg forward and your weaker leg back.
Why does the nurse cup one hand around the pt’s elbow and support the forearm and wrist during the ROM exercises?
To ensure stability while exercising the joint.
The nurse notes that the pt’s left elbow is resistant to extension and flexion while performing ROM exercises. What is the appropriate nursing action?
Omit all of the ROM exercises until the healthcare provider is notified.
Why would the nurse ask the physical therapist to perform passive ROM exercises on a pt with lower extremity injuries sustained in a car crash?
The pt has orthopedic trauma
When caring for a pt with Alzheimer’s, why would the nurse would cover the catheter?
to reduce pt access
How many people are needed to transfer a pt from a bed to a stretcher?
3
What would the nurse do first before transferring from bed to stretcher?
lock the brakes
T/F Crutches should be placed 6 inches in front, and 6 inches to the side of the feet
True
Four-point gait
used when both legs can bear some weight; right crutch, left foot, left crutch, right foot
Three-point gait
used when only one leg can bear weight (ex: broken leg or sprained ankle)
Two-point gait
matches the crutch to the opposite foot, moving them together like walking, where the crutches move with the natural swing of the arms
swing to gait
both crutches are advanced together and then both legs are lifted and placed down again on a spot behind the crutches.
swing through gait
both crutches are advanced then the legs swing past the crutches
Walker
used by pts who are able to bear partial weight
cane
used for people who need minimal assistance; place cane on strong side -> move cane and strong foot forward at the same time, landing the strong leg past the cane -> move weak leg to meet strong leg and repeat