ch12.doc

[Osborn] chapter 12

Learning Outcomes [Number and Title ]Learning Outcome 1 Differentiate between internal and external stressors, and provide

examples of each.Learning Outcome 2 Differentiate between theories of stress as a response, a stimulus, and a

transaction.Learning Outcome 3 Explain the physiological components of the general adaptation syndrome

(GAS).Learning Outcome 4 Explain the relationship of oxidative stress to the disease process.Learning Outcome 5 Explain ways in which a maladaptive response to stress can increase the

risk of illness and cause disease.Learning Outcome 6 Describe nursing assessment criteria for patients experiencing stress.Learning Outcome 7 Explain the nursing management of patients with physiological stress.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. While being assessed, a patient tells the nurse that she has many stresses in her life. Of these stresses, which of the following would be considered an external stressor?

1. Rigid rules on the job2. The need to please everyone3. Workaholic4. Use of caffeine

Correct Answer: Rigid rules on the job

Rationale: External stressors originate outside the body and are precipitated by changes in the external environment. They can be triggered by the actual physical environment, the social environment, the organizational environment, major life events, and by trauma. Daily hassles, such as commuting long distances, misplacing keys, and experiencing mechanical breakdowns, also act as external stressors. The need to please everyone, being a workaholic, and the use of caffeine are considered internal stressors.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 1


2. A patient tells the nurse that he is recently unemployed and has fears that he will never find another job. The nurse recognizes this patient’s internal stressor as being:

1. All-or-nothing thinking.2. Denial.3. A catastrophic event.4. A realistic expectation.

Correct Answer: All-or-nothing thinking.

Rationale: Internal stressors originate within a person. They include lifestyle choices, overloaded schedules, negative self-talk, and all-or-nothing thinking. Because of being recently unemployed, the patient believes he will never find employment again. This is an example of all-or-nothing thinking. This patient is not exhibiting denial. A catastrophic event is a trauma, fire, motor vehicle accident, or some other external stressor. Thinking that he will never be employed again would not be an example of a realistic expectation.



3. A patient tells the nurse that he should not have answered his cell phone because he just learned he has a major meeting to attend in an hour and he is not prepared. The nurse realizes this patient has had a sudden onset of ___________ stress.

1. External2. Internal3. External and internal4. Situational

Correct Answer: External

Rationale: This patient is experiencing external stress. External stressors originate outside of the body and include work-related events such as rules, regulations, and deadlines. Internal stressors originate inside of the body and include lifestyles choices, negative self-talk, and rigid thinking. Situational stressors are precipitated by situations such as illness or the death of a child.



4. A patient tells the nurse that when something happens out of the ordinary, she considers if the situation is good, bad, or means nothing. The nurse realizes this patient is describing which type of appraisal within the transactional theory of stress?

1. Primary2. Secondary3. Cognitive reappraisal4. Hassles and uplifts

Correct Answer: Primary

Rationale: Primary appraisal is the process of evaluating the significance of a transaction as it relates to a person’s well-being. During the primary appraisal, the person determines if the transaction is irrelevant, good, or stressful. The patient’s explanation of how she considers a situation is describing the primary appraisal within the transactional theory of stress. The secondary appraisal is the process of evaluating the significance of the transaction between the person and the environment as it relates to available coping resources and options. Cognitive reappraisal develops from the feedback of changes in the person−environment relationship and from reflection about the coping process. Hassles and uplifts are experiences of daily living that are either positive or negative.



5. While discharge planning, the nurse asks the patient if there is anything in particular the patient will need once she returns home. The patient states that she has everything she needs, considering she is returning home in better shape than when she arrived at the hospital. The nurse, using the transactional theory of stress, realizes this patient is describing which type of appraisal?

1. Cognitive 2. Primary3. Secondary4. Emotional

Correct Answer: Cognitive

Rationale: Cognitive reappraisal develops from the feedback of changes in the person−environment relationship and from reflection about the coping process. The patient reappraises her hospitalization and realizes her health has been improved from the hospitalization. Primary appraisal is the process of evaluating the significance of the transaction as it relates to the person’s well-being. This type of appraisal will find a stressor as being good, bad, or irrelevant. The secondary appraisal is the process of evaluating the transaction as it relates to available coping resources and options. There is not an emotional appraisal within the transactional theory of stress.



6. A patient scored 350 on the Holmes and Rahe Social Readjustment Rating Scale and is not demonstrating any physical or emotional signs of illness. The nurse realizes it is also important to assess:

1. Age, perception, and previous experiences.2. Education level.3. Employment status.4. Nutritional status.

Correct Answer: Age, perception, and previous experiences.

Rationale: Even though it was previously theorized that the greater the number of stressful life events occurring throughout a specific period of time, the greater the vulnerability to illness, the relationships can often be weak, as evidenced by this patient’s lack of physical or emotional illness. When this occurs, the nurse should assess additional factors such as age, perception, health, and previous experiences when considering life events as stressful. Educational level, employment status, and nutritional status are not typically assessed when trying to determine if an event is stressful to a patient.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 2


7. A patient with a history of dog bites is admitted with a new severe dog bite and tells the nurse that he feels fine except for the bite. The nurse realizes this patient is functioning within which phase of the general adaptation syndrome?

1. Resistance2. Alarm3. Transaction4. Exhaustion

Correct Answer: Resistance

Rationale: The resistance stage reflects the individual’s adaptation to the stressor. Ideally, the individual moves from the alarm stage to the resistance stage quickly so that physiological forces are used to increase the resistance to stress. At this time, adaptation may occur, involving mediation of the external and internal environments. Resistance is high at this time compared with the normal state. The body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it. The alarm stage is the first stage of the general adaptation syndrome and is where the fight-or-flight response is initiated. The exhaustion stage is the final stage and means that the adaptation the body made during the second stage cannot be maintained. This stage occurs only if the stress becomes overwhelming or is not removed. There is no transaction stage within the general adaptation syndrome.



8. The nurse is preparing a burn patient for surgery. Because of this patient’s amount of stress, the nurse realizes that the patient would benefit from:

1. An increased supply of protein.2. Fluid restriction.3. Antinausea medication.4. An increase in activity.

Correct Answer: An increased supply of protein.

Rationale: In the hypothalamus-pituitary-adrenal response to stress, the body stimulates the production of cortisol. Cortisol stimulates protein catabolism. The patient with burns undergoing surgery is experiencing a significant level of stress and would benefit from protein supplementation. Fluid restriction, antinausea medication, and increased activity will not be beneficial to the patient at this time.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 3


9. The nurse is reviewing the serum laboratory values of a patient admitted with traumatic injuries. Which of the following laboratory values might be abnormally elevated because of the trauma?

1. Glucose 2. Sodium3. Potassium4. Hemoglobin

Correct Answer: Glucose

Rationale: Stimulation of both the adrenal medulla and cortex in response to stress results in an increased blood glucose level. There is no evidence to support that traumatic injuries will cause an increase in sodium or potassium levels. The patient’s hemoglobin might be low depending upon the amount of blood loss from the injuries.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 3


10. A patient tells the nurse that she takes 400 IU of vitamin E every day. The nurse realizes this patient is:

1. Neutralizing oxygen free radicals.2. Overdosing on vitamin E.3. Increasing the chances of blood clotting.4. Taking a vitamin that is not necessary for health.

Correct Answer: Neutralizing oxygen free radicals.

Rationale: Free radicals are involved in many cellular functions and are a normal part of living. Although free radicals have useful functions in the body under controlled conditions, they are extremely unstable molecules that can damage cells if left uncontrolled. Normally, oxygen free radicals are neutralized by antioxidants such as vitamin E or enzymes such as superoxide dismutase. The nurse does not have enough information to know if the patient is overdosing on vitamin E. It is believed that too much vitamin E can cause bleeding, not blood clotting. Vitamin E is necessary for health.



11. A patient asks the nurse about free radicals and how they contribute to illnesses. Which of the following would be the nurse’s best response to this patient?

1. “Molecules that are paired are called reduced and cause the molecule to be unstable and cause damage to other cells.”

2. “Molecules that are unpaired are called reduced and cause the molecule to be unstable and cause damage to other cells.”

3. “Free radicals are bad and clog the liver so the liver cannot get rid of body toxins.”4. “Increasing oxygen consumption eliminates free radicals, so taking deep breaths helps remove

them from the body.”

Correct Answer: “Molecules that are paired are called reduced and cause the molecule to be unstable and cause damage to other cells.”

Rationale: Molecules that donate electrons and thereby become unpaired are called oxidized. When a molecule gains an electron and is paired, it is called reduced. The reduced molecules are the free radicals. Free radicals are able to react with other molecules to cause damage to other cells. Not all free radicals are bad, so the nurse should not encourage the patient to eliminate free radicals by saying they clog the liver. Increasing oxygen consumption does not impact the number of free radicals.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 4


12. A patient in the intensive care unit is demonstrating signs of acute respiratory distress syndrome. The nurse realizes that which of the following contributed to the development of this syndrome?

1. Oxidative stress2. Poor fluid balance3. Immobility4. Renal failure

Correct Answer: Oxidative stress

Rationale: Evidence-based research confirms the link between oxidative stress and syndromes such as acute respiratory distress syndrome. When the body is overwhelmed by increased production of oxidative agents, the ensuing damage contributes to cellular derangements, cell injury, and death. The nurse does not have enough information to know if poor fluid balance, immobility, or renal failure contributed to this patient’s onset of acute respiratory distress syndrome.



13. A patient tells the nurse that she has been trying to get pregnant but has not been successful. The nurse should assess _______________ in this patient.

1. Current and ongoing stressors2. The date of first menstrual period3. Regularity of menstrual cycles4. The number of siblings

Correct Answer: Current and ongoing stressors

Rationale: Reactions to stress may manifest as decreased fertility and a higher risk for miscarriage in pregnant women. Although the patient’s date of first menstrual period and regularity of menstrual cycles might be important, the nurse should first assess the patient’s current and ongoing stressors that could interfere with conception. The number of siblings a person has is not known to impact a person’s ability to conceive.



16. A patient tells the nurse that she never had “bowel problems” until she started a new job that is highly demanding. How should the nurse respond to this patient?

1. “The new job might be a trigger for a stress reaction to occur in your body, causing the new bowel problems.”

2. “Stress causes gastrointestinal problems.”3. “You might have had the bowel problems all along but didn’t realize it until recently.”4. “There really isn’t any connection between the new bowel problems and the new job.”

Correct Answer: “The new job might be a trigger for a stress reaction to occur in your body, causing the new bowel problems.”

Rationale: Stress can be a trigger to cause gastrointestinal problems, but stress does not cause gastrointestinal problems directly. The stress circuit influences the stomach and intestines and can lead to problems such as diarrhea, constipation, cramping, and bloating. Excessive stomach acid can lead to gastric burning. It would be misleading to tell the patient that stress causes gastrointestinal problems. The nurse does not have enough information to say that the patient has had bowel problems all along but did not realize it until the new job started. The nurse should not tell the patient that there is not any connection between the bowel problems and the new job, because she does not know for sure.



17. A patient tells the nurse that she is under a great deal of stress, and now the doctor tells her she has high cholesterol levels. The nurse realizes that the elevated cholesterol levels are indicative of:

1. The body’s response to stress by releasing fat into the bloodstream.2. The patient consuming foods high in fat content.3. The patient not having enough physical activity.4. The patient consuming too much protein.

Correct Answer: The body’s response to stress by releasing fat into the bloodstream.

Rationale: One way the body responds to stress is by releasing fat into the bloodstream. This release of fat will cause an increase in the cholesterol level. This increase might be temporary. The nurse should explain the cholesterol elevation to the patient. Without further assessment, the nurse has no way of knowing if the patient is consuming food high in fat, too much protein, or if the patient is not having enough physical activity.



18. A patient tells the nurse that she recently lost her job but is doing well because she has the time now to catch up with things at home and can search for a better job. The nurse realizes this patient is demonstrating:

1. Coping.2. Denial.3. Avoidance.4. Delusional thinking.

Correct Answer: Coping.

Rationale: Coping mechanisms help deal with stressful events. The patient recently lost her job but has found things to keep herself occupied while she searches for new employment. This patient views the stressful event as an opportunity to get caught up with home activities while being positive in a new job search. The patient is not denying the loss of a job or avoiding the need to find a new job. The patient is not demonstrating delusional thinking.



19. At the completion of an assessment, the nurse reviews the list of a patient’s stated and observed behaviors. Which of the following would indicate to the nurse that the patient is experiencing stress?

Select all that apply.

1. Patient stated inability to sleep more than 2 hours per night.2. Observed patient’s hands trembling.3. Patient asked for water for a dry throat.4. Patient sat quietly in chair, hands resting in lap.5. Patient commented on recent pleasant weather.

Correct Answers: 1. Patient stated inability to sleep more than 2 hours per night.2. Observed patient’s hands trembling.3. Patient asked for water for a dry throat.

Rationale:Patient stated inability to sleep more than 2 hours per night. Insomnia and other sleep disturbances are signs of stress. Observed patient’s hands trembling. Trembling and nervous tics are signs of stress. Patient asked for water for a dry throat. Dryness of the throat and mouth are signs of stress. Patient sat quietly in chair, hands resting in lap. A sign of stress is the inability to sit still. Patient commented on recent pleasant weather. Irritability and excitation are signs of stress.



20 . A patient, informed that he can return to work 1 week after being discharged from the hospital, tells the nurse that he is not sure that he can return so soon because of the physical expectations of the job. The nurse realizes the patient experiences:

1. Job-related health concerns.2. Work-overload stress.3. Pressure on the job.4. Time pressure.

Correct Answer: Job-related health concerns.

Rationale: Job-related health concerns include unhealthy work conditions, physical danger, and heavy physical tasks to complete. Work-overload stress includes inefficient coworkers and shortage of help at work. Pressure on the job includes the inability to complete tasks during an average day and too much supervision. Time pressure includes monotonous pace of work and not enough time for breaks or meals. The patient is experiencing a job-related health concern.



21. A patient becomes angry and verbally abusive when he learns that he needs shoulder surgery. Which of the following is the nurse’s best response to this patient?

1. Silently listen to the patient vent his anger.2. Leave the patient’s room immediately.3. Tell the patient that his verbal abuse is not necessary.4. Tell the patient that he is free to leave the hospital at any time.

Correct Answer: Calmly listen to the patient vent his anger.

Rationale: Many nurses become upset with an angry patient. The best response for the nurse to make is to keep silent and listen to the patient vent his anger. The nurse should not act to reduce her own stress level by leaving the room or telling the patient that his verbal abuse is not necessary. If the verbal rant escalates, the nurse will need to seek assistance to manage the situation. The patient is free to leave the hospital at any time, but this suggestion by the nurse is dismissive of the client and would preclude the ability of the nurse to quietly address the client’s underlying concerns.

Cognitive Level: ApplyingNursing Process: Implementation Client Need: Psychosocial IntegrityLO: 7


22. A patient with chronic pain tells the nurse that as soon as she returns home, she is going to be expected to “pick up where she left off,” which is causing her a great deal of stress. Which of the following would be the best instruction for this patient?

1. Learn how to prioritize tasks and modify role demands.2. Plan to take a vacation away from home to recuperate.3. Return to home and spend as much time as possible resting in bed.4. Take pain medication around the clock to control the pain while resuming her normal activities

of daily living.

Correct Answer: Learn how to prioritize tasks and modify role demands.

Rationale: The patient in pain will need to learn how to prioritize tasks and modify role demands; the tasks the patient is expected to resume need to be modified along with role demands. Suggesting that the patient take a vacation does not address the expectations once the patient returns home. Unless it is prescribed as an activity level, suggesting the patient spend time in bed does not help the patient address the cause of stress. The nurse should not instruct the nurse to take pain medication around the clock to control the pain while resuming her normal activities of daily living.



23. A patient tells the nurse that taking deep breaths usually works to reduce acute stress, but lately it has not been working very well. The nurse should do which of the following to help the patient?

1. Review a variety of other techniques, such as progressive relaxation, humor, or music therapy.2. Encourage the patient to continue to take deep breaths because that is one of the best ways to

reduce stress.3. Tell the patient that most stress reduction techniques do not work anyway.4. Ask the patient what physical activities she prefers since this is the only way to reduce stress.

Correct Answer: Review a variety of other techniques, such as progressive relaxation, humor, or music therapy.

Rationale: The nurse should help the patient understand that no single stress reduction method is always successful to reduce stress. The nurse should offer other techniques, such as progressive relaxation, humor, or music therapy. The nurse should not encourage the patient to continue a technique that is not working such as deep breathing. The nurse should also not falsely tell the patient that stress reduction techniques do not work. Even though physical activity is known to reduce stress, the nurse should not tell the patient that this is the only way to reduce stress.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 7


ch12.doc

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physiological stress

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theories of stress