Question 1

What is the priority for the nurse to address in the adolescent client's plan of care once physiologic stabilization occurs after a myasthenic crisis?

Accepted Answer

Answer reason: After stabilization from a myasthenic crisis, the priority is preventing future exacerbations. Stress is a common trigger in adolescents; teaching stress-management strategies is key. Plasmapheresis is an acute treatment, temperature avoidance is helpful but less central, and medication administration is ongoing but not the priority focus for crisis prevention in this context.

Question 2

A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, "Sometimes she is more than we can manage." Based on the mother's statement, the most appropriate nursing diagnosis is?

Accepted Answer

Answer reason: The mother's statement indicates difficulty handling ongoing care demands for an adult child with schizophrenia, reflecting caregiver burden and stress; thus caregiver role strain is the most appropriate diagnosis.

Question 3

The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?

Accepted Answer

Answer reason: Encouraging sibling visitation helps reduce anxiety, supports coping, and maintains understanding and connection during hospitalization. The other statements are not generally true of siblings’ reactions.

Question 4

A client who has been drinking for 5 years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The client is using alcohol as a way to deal with?

Accepted Answer

Answer reason: He reports drinking when upset by unemployment and life problems, indicating alcohol is being used as a maladaptive coping mechanism for stressors.

Question 5

An appropriate goal for a client with anxiety would be to?

Accepted Answer

Answer reason: Teaching self-help coping strategies empowers the client to manage anxiety. Ventilating feelings is a short-term intervention, establishing contact with reality applies to psychosis, and desensitization targets phobias/trauma rather than general anxiety goals.

Question 6

Which behavior MOST strongly indicates effective stress management in a nurse working rotating shifts?

Accepted Answer

Answer reason: Incorporating short, intentional relaxation strategies helps regulate stress responses and supports sustained performance. Avoidance, missed meals, and stimulant reliance worsen stress over time.

Question 7

A client reports chronic stress related to caregiving responsibilities and poor sleep. Which intervention is MOST appropriate to address long-term stress reduction?

Accepted Answer

Answer reason: Long-term stress reduction is best supported by skills that improve coping and restorative sleep. Sedatives and avoidance do not address underlying stressors, and screen time impairs sleep.

Question 8

Which outcome BEST indicates that a stress management plan is effective for a client with work-related stress?

Accepted Answer

Answer reason: Effective stress management improves functioning and adaptive coping rather than eliminating all stress. Avoidance and escalating medication needs suggest ineffective management.

Question 9

Which sign MOST suggests maladaptive stress management in a client working long hours?

Accepted Answer

Answer reason: Using substances to cope with stress is a maladaptive strategy that can worsen sleep, mood, and health. Adaptive strategies include movement, relaxation techniques, and boundary setting.

Question 10

A client experiencing acute stress reports muscle tension and rapid breathing. Which nursing intervention is MOST appropriate initially?

Accepted Answer

Answer reason: Acute physiologic arousal is best addressed first with techniques that reduce sympathetic activation. Diaphragmatic breathing can quickly lower muscle tension and respiratory rate.

Question 11

Which client outcome BEST reflects effective stress management over time?

Accepted Answer

Answer reason: Effective stress management is reflected by improved functioning and routine use of adaptive coping skills. Eliminating all stress or relying on avoidance or medications indicates poor coping.

Question 12

Teaching relaxation techniques fulfills?

Accepted Answer

Answer reason: Relaxation techniques are coping strategies that reduce stress and anxiety. In Maslow’s hierarchy, safety and security needs include freedom from fear and anxiety and a sense of stability. Teaching relaxation directly addresses this safety need, not basic physiologic needs, esteem, or self-actualization.

Question 13

An adult patient who is hospitalized following a motorcycle accident when a car ran a red light tells the nurse, I didnt sleep last night because I worried about missing work at my new job and losing my insurance coverage. Which nursing diagnosis is appropriate to include in the plan of care?

Accepted Answer

Answer reason: The patient reports excessive worry about job and insurance and inability to sleep, which are classic defining characteristics of anxiety. There is no evidence of maladaptive defense mechanisms such as denial (refusing to acknowledge the situation) or defensive coping (distorted appraisal with self-protective behaviors). “Risk prone health behavior” is not supported by the scenario because the accident occurred due to another driver running a red light, not a pattern of risky choices. Therefore, the most appropriate nursing diagnosis is Anxiety.

Question 14

A primigravida client is in active labor and states she feels "overwhelmed" by the process. Her contractions are becoming more intense and frequent, and the nurse notes she is "shaking" and "anxious" while trying to coordinate her breathing. Which of the 5 P's is most directly impacted by the client's current state and requires immediate nursing assessment and intervention?

Accepted Answer

Answer reason: The findings describe acute anxiety and feeling overwhelmed, which can impair coping and effective participation in labor (e.g., difficulty coordinating breathing). Heightened stress increases catecholamine release that can reduce uterine perfusion and may negatively affect labor progress and maternal-fetal oxygenation. Immediate nursing interventions include calm coaching, reassurance, focused breathing/relaxation techniques, and continuous support to reduce anxiety and improve coping. The other P’s (power/position/passenger) are not the primary issue reflected by the client’s current behavioral and emotional state.

Question 15

A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data?

Accepted Answer

Answer reason: Life-change scores estimate stress load but do not by themselves predict who will develop illness. Individual appraisal, coping skills, resilience, and availability of social supports strongly influence outcomes after major losses. A score of 110 suggests some increased stress exposure, but it is not sufficient to label the client as having severe distress or a specific illness risk without a psychosocial assessment. The nurse should further assess coping strategies, support systems, and current symptoms to determine risk and needed interventions.

Question 16

Eight months ago, a client was in a hotel fire and was the last person to be rescued from the roof. The client watched the client's spouse burn to death from the helicopter. The client continues to have nightmares and is fearful that the client will die in a fire. An appropriate nursing diagnosis for the client is?

Accepted Answer

Answer reason: The data provided directly supports a problem-focused diagnosis centered on impaired sleep due to recurrent nightmares. The other options use inaccurate etiologies or inappropriate psychiatric terminology (e.g., conversion reaction, illusions) and do not align with the client’s primary observable complaint pattern. Prioritizing sleep disturbance also targets a modifiable symptom that affects daily functioning and can be addressed with nursing interventions such as sleep hygiene, coping strategies, and referral for trauma-focused care when indicated.

Question 17

A client has been diagnosed with posttraumatic stress disorder (PTSD) after a house fire. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Peer support groups provide normalization of trauma responses, shared coping strategies, and encouragement to engage in treatment, which can reduce symptoms and improve functioning. This intervention is directly within nursing scope and can be implemented promptly while reinforcing safety and ongoing follow-up. In contrast, returning-to-work planning or focusing on future plans may be helpful later but does not address core trauma-related hyperarousal, avoidance, and re-experiencing as immediately as structured social support does.

Question 18

A client with a panic disorder is participating in panic control treatment. Which action indicates to the nurse that the client is using techniques to control panic reactions?

Accepted Answer

Answer reason: Using slow, deep breathing aligns directly with panic-control training and is an active coping strategy the nurse can reinforce. Pacing reflects escalating anxiety and increased psychomotor agitation rather than control of symptoms. Lying down with eyes closed or isolating in a chair may indicate avoidance or withdrawal and does not specifically demonstrate use of a taught panic-management skill.

Question 19

A client is participating in cognitive-behavioral therapy for symptoms of anxiety. During an episode of anxiety, the nurse assesses the effectiveness of this therapy as successful when the client makes which statement?

Accepted Answer

Answer reason: CBT is effective when the client can recognize anxious thoughts/physiologic sensations as symptoms of anxiety and apply a coping strategy to reduce arousal. This statement shows insight (identifying the episode as anxiety) and immediate use of a self-regulation technique (controlled breathing). In contrast, catastrophizing and dyspnea-focused panic language reflects ongoing escalation rather than cognitive reframing. Attributing anxiety to a fixed personality trait with avoidance indicates maladaptive coping that CBT aims to replace.

Question 20

A nurse is creating a plan of care prior to working with a client learning to cope with anxiety and stress. Which outcome does the nurse include in the plan of care for the client?

Accepted Answer

Answer reason: Effective coping outcomes focus on improving the client’s appraisal of stress and strengthening adaptive responses, not eliminating stressors entirely. Stress and anxiety are normal parts of life, so plans of care should set realistic, measurable goals centered on recognizing triggers and using coping strategies to modify responses. Attempting to limit major stressors or avoid stressful situations is often unrealistic and can reinforce avoidance behaviors that worsen anxiety over time. Goals framed as avoiding anxiety “at all costs” are unattainable and may increase distress by setting the client up for failure rather than building resilience.

Question 21

A psychiatric-mental health nurse counsels a client experiencing anxiety. Which maladaptive response may result if the anxiety is not controlled for the client?

Accepted Answer

Answer reason: This ongoing muscle contraction, especially in the scalp, neck, and shoulders, can lead to tension-type headaches as a stress-related somatic complaint. By contrast, relaxation and imagery are adaptive coping strategies that help decrease arousal rather than reflect maladaptation. Baseline vital signs describe a normal assessment state and do not represent a maladaptive response to anxiety.

Question 22

When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?

Accepted Answer

Answer reason: Slow diaphragmatic breathing activates parasympathetic tone, lowering sympathetic arousal (heart rate, muscle tension) and helping the client regain a sense of control. It requires no equipment, minimal coaching, and can be performed while awaiting surgery without interfering with preop care. Biofeedback typically needs training and equipment, making it impractical 1 hour before surgery, and distraction/imagery can help but are more variable and often need more sustained coaching to be effective quickly.

Question 23

A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

Accepted Answer

Answer reason: Parents commonly become distressed by the newborn’s scalp swelling and may fear brain injury, making education about the condition’s benign course and what to report (e.g., increasing jaundice, pallor, lethargy) central to nursing care. Addressing anxiety improves adherence to follow-up and helps parents accurately observe the infant at home. An intracranial hemorrhage is a different, more serious diagnosis with neurologic signs and is not implied by an isolated cephalhematoma.

Question 24

A client is hospitalized for treatment of severe hypertension. Captopril (Capoten) and alprazolam (Xanax) are prescribed. The client quickly finds fault with the therapeutic regimen and nursing care. What does the nurse determine as the probable cause of this behavior?

Accepted Answer

Answer reason: The prescription of alprazolam also supports that the client is experiencing significant anxiety that may be driving hypervigilance and dissatisfaction. Cerebral anoxia would be expected to cause acute confusion, altered level of consciousness, or neurologic deficits rather than a patterned critical stance toward care. Adverse effects of captopril (e.g., cough, hypotension, hyperkalemia, angioedema) do not typically manifest primarily as hostile or fault-finding behavior.

Question 25

Which problem is most commonly encountered by adolescent females with scoliosis?

Accepted Answer

Answer reason: Visible asymmetry (uneven shoulders/hips) and treatments like bracing can increase embarrassment, social withdrawal, and reduced confidence. Significant respiratory compromise is uncommon unless the curvature is severe (typically large thoracic curves), making it less common than psychosocial effects. Appetite and renal function are not typical direct problems associated with scoliosis in otherwise healthy adolescents.

Question 26

Psychologic conditioning to increase resistance to stress focuses on?

Accepted Answer

Answer reason: Stress resistance is strengthened by adaptive coping and cognitive appraisal, where a person’s perceived self-efficacy and self-worth reduce the intensity of the stress response. Psychological conditioning targets internal coping resources such as confidence, mastery, and positive self-concept to improve resilience. Building physical resources and exercise are primarily physiologic or lifestyle strategies rather than psychological conditioning. Decreasing assertiveness undermines healthy boundary-setting and problem-focused coping, which would worsen stress management.

Question 27

Which factor is most accurately linked to stress?

Accepted Answer

Answer reason: Stress is strongly associated with reduced perceived well-being and poorer quality of life because sustained physiologic arousal and maladaptive coping interfere with relationships, sleep, work performance, and mood. This makes decreased life satisfaction a common and accurate psychosocial correlate of stress across populations. In contrast, increased immunologic functioning is generally not linked with chronic stress, which more typically suppresses immune response. “Breakdown disorder” is not a standard, clearly defined clinical outcome compared with the well-established association between stress and reduced life satisfaction.

Question 28

The primary mode of intervention for stress management consists of?

Accepted Answer

Answer reason: Stress management interventions are commonly framed as primary (preventing stress by reducing or eliminating stressors), secondary (reducing physiologic/psychological responses), and tertiary (treating consequences and restoring function). The primary approach focuses on modifying the environment or situation to prevent the stress response from being triggered in the first place, which aligns with reducing exposure to stress-provoking triggers. Avoidance of all stress is unrealistic and can be maladaptive because some stressors are unavoidable and some stress can be motivating. Conditioning methods aimed at physiologic arousal reduction are better categorized as secondary prevention techniques (e.g., relaxation training) rather than primary prevention.

Question 29

Acutely ill clients often experience high levels of physiologic and psychologic stress. Sources of physiologic stress in the acutely ill client are?

Accepted Answer

Answer reason: Physiologic stress refers to stressors that directly trigger bodily stress responses (e.g., sympathetic activation, increased cortisol, tachycardia, elevated BP). Uncontrolled discomfort is a primary physiologic stressor in acute illness and can worsen oxygen demand, sleep disruption, and overall recovery. In contrast, learning new concepts and paying bills are predominantly psychological/social stressors rather than direct physiologic triggers. Staffing level may affect care quality and anxiety, but it is not a direct physiologic stressor in the way nociceptive pain is.

Question 30

A client tells the nurse that he is stressed by his job but enjoys the challenge. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Therapeutic nursing responses support adaptive coping and build skills rather than offering premature, directive life changes. The client reports manageable stress with positive meaning (“enjoys the challenge”), so the priority is to reinforce healthy coping and provide resources to manage stress effectively. A structured stress-management program can teach evidence-based techniques (relaxation training, time management, cognitive reframing) that reduce distress while preserving the aspects of work the client values. Suggestions like changing jobs, changing family time, or avoiding working from home are overly prescriptive and not individualized to the client’s stated goals or needs. This option best promotes coping without escalating the situation or minimizing the client’s experience.

Question 31

A client newly diagnosed with genital herpes is crying and wringing her hands as the nurse approaches her. Which nursing diagnosis is the most appropriate to this situation?

Accepted Answer

Answer reason: The priority nursing diagnosis should reflect the most prominent current assessment findings rather than potential physical problems that are not described. While genital herpes can cause pain and lesions, no pain behaviors or tissue findings are provided here to support those diagnoses. Knowledge deficits may exist, but the visible, urgent problem is heightened apprehension requiring support, reassurance, and coping-focused interventions.

Question 32

The nurse anticipates that which therapeutic modality will be used to treat an individual diagnosed with hypochondriasis?

Accepted Answer

Answer reason: Relaxation training is a common behavioral strategy that decreases sympathetic activation and helps the client tolerate benign sensations without escalating health-related worry. Suicide precautions are not routinely indicated unless there is clear suicidal ideation or severe comorbid depression. ECT is reserved for severe mood disorders or catatonia, and aversion therapy is used for specific maladaptive behaviors (e.g., some substance use/paraphilias), not health anxiety.

Question 33

An example of external family coping strategies include?

Accepted Answer

Answer reason: External coping strategies are those that involve seeking resources and support outside the immediate family system. Reaching out to relatives, friends, and neighbors reflects use of the social support network, which can buffer stress and improve adaptation during crises. By contrast, joint family problem-solving and using humor/stress-management tactics are primarily internal strategies occurring within the family unit or within individuals. Limiting leisure activities is not a healthy coping strategy and may worsen stress and reduce resilience.

Question 34

An educational forum about relaxation techniques is provided for college students preparing for their final exams. Which relaxation technique is most effective to counteract anxiety?

Accepted Answer

Answer reason: This option directly targets the stress response through focused attention and relaxation, making it a primary, evidence-supported strategy for situational test anxiety. Music and dance can be helpful adjuncts, but they are generally less direct and less consistently taught as a structured anxiolytic technique in brief educational forums. Reality orientation is intended for confusion/delirium or dementia and does not address anticipatory anxiety in cognitively intact students.

Question 35

The nurse is assessing a 40-year-old client who is scheduled to have elective facial surgery later in the morning and notes a pulse rate of 130 beats/minute. The nurse suspects the increased pulse rate is the result of which of the following?

Accepted Answer

Answer reason: An elective surgery setting with an otherwise unexplained pulse of 130 beats/min strongly supports an acute stress response. Age at 40 does not physiologically cause marked tachycardia at rest. Exercise would require recent activity history, and pain can cause tachycardia but would typically be accompanied by a report or signs of discomfort rather than being the most likely assumption in this context.

Question 36

Which nursing diagnosis is the most appropriate to include in a familycentered plan of care when caring for an infant newly diagnosed with hypoplastic left heart syndrome?

Accepted Answer

Answer reason: Hypoplastic left heart syndrome requires staged surgeries and carries significant morbidity/mortality risk, making caregiver fear about the infant’s survival a high-likelihood, high-impact concern that affects bonding, decision-making, and coping. This diagnosis directs nursing care toward emotional support, clear information, coping strategies, and referrals (e.g., social work, chaplain, support groups), which are immediate needs at diagnosis. By contrast, growth/development concerns and activity intolerance may become relevant over time but are not the most immediate family-centered priority at the point of a new diagnosis.

Question 37

Which statement made by a client with a pain disorder shows the nurse that the goal of stress management was attained?

Accepted Answer

Answer reason: " Stress-management goals are met when the client can demonstrate reduced physiologic arousal and reports benefit from a coping technique. Progressive muscle relaxation is a specific stress-reduction strategy, and the client’s report of bodily relaxation reflects immediate therapeutic effect (decreased tension). Ongoing pain complaints alone do not show improved coping or decreased stress response. Statements reflecting dependence or lack of insight suggest unmet psychosocial goals rather than successful stress management.

Question 38

A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first?

Accepted Answer

Answer reason: Nonpharmacologic sleep promotion is the safest first-line nursing action for insomnia related to anxiety, and relaxation techniques directly reduce sympathetic arousal that interferes with sleep onset. Progressive muscle relaxation is an evidence-based strategy that the nurse can implement immediately and teach for ongoing self-management of panic symptoms at bedtime. Contacting a psychotherapist is not an urgent first step for an acute sleep complaint and does not provide immediate symptom relief. Requesting sedative medication is generally not first because it adds adverse-effect and dependence risk, and watching television can worsen sleep latency by increasing stimulation and disrupting sleep hygiene.

Question 39

The mother of an infant client appears anxious when the infant cries and says, “I can’t handle this.” Which strategy should the care plan include early in the client’s hospital stay?

Accepted Answer

Answer reason: Teaching concrete soothing and safe responses to crying (e.g., feeding cues, diapering, swaddling, calming techniques, and placing the baby in a safe sleep space if overwhelmed) directly addresses the mother’s stated inability to cope. This approach also helps prevent escalation to frustration and potential unsafe handling by providing actionable steps and support. More global coping work can follow, but early targeted education and support around crying is the most immediately therapeutic and protective intervention.

Question 40

Guided imagery is a form of alternative therapy. Guided imagery can frequently be used by the nurse to decrease stress, pain, and anxiety. Additional benefits of guided imagery include?

Accepted Answer

Answer reason: Mind–body interventions can reduce perceived stress and pain, which often decreases the amount of analgesics or anxiolytics needed. With lower medication exposure, patients may experience fewer medication-related adverse effects such as sedation, nausea, constipation, or dizziness. This fits the expected nursing outcome of using nonpharmacologic techniques as adjuncts to symptom control. The other options describe negative outcomes that are not typical benefits of relaxation-based therapies.

Question 41

The nurse is teaching a client about stress management. Which rationale by the nurse best explains the reason for using stress management?

Accepted Answer

Answer reason: Stress activates neuroendocrine responses (e.g., sympathetic nervous system and cortisol release) that can impair immune function, worsen inflammation, and negatively affect cardiovascular and metabolic health. Stress-management strategies are therefore justified as preventive and therapeutic measures to reduce the physiologic burden of chronic stress and its downstream health effects. The other options are weak rationales because they rely on generalization, popularity, or vague appeals to tradition rather than the clinically relevant mind–body impact. This option provides the most accurate, patient-centered explanation for why learning stress management matters.

Question 42

Which nursing intervention is most appropriate for helping parents to cope with a child newly diagnosed with neonatal chronic lung disease (bronchopulmonary dysplasia)?

Accepted Answer

Answer reason: Coping interventions should begin with assessment so the nurse can identify the parents’ current emotional state, coping capacity, and immediate support needs. A new diagnosis of a chronic neonatal condition commonly triggers acute stress, anticipatory grief, and anxiety that can impair learning and decision-making, so evaluating these levels guides timely, individualized support and referrals. Once distress is identified and addressed, education and planning become more effective and realistic. Referrals and teaching may be appropriate later, but without first assessing psychosocial status, the nurse risks missing severe anxiety, depression, or inadequate coping that requires prompt intervention.

Question 43

During a yearly physical examination, a client tells the nurse that the client “is stressed to the max” by work and family obligations. First, the nurse?

Accepted Answer

Answer reason: Initial nursing care for self-reported stress in an otherwise routine assessment prioritizes supportive interventions that build coping skills and reduce physiologic/psychological strain. Exploring and teaching practical strategies (e.g., relaxation breathing, sleep hygiene, activity scheduling, social support, and boundary setting) is within nursing scope and can be initiated immediately. Referral to a provider or medication discussion may be appropriate later if symptoms suggest a disorder or impairment, but it is not the first-line response to uncomplicated stress. Advising a major life change is premature and risks being nontherapeutic without assessment of coping resources and readiness.

Question 44

A cardiac catheterization has been scheduled for an 8-year-old child. Prior to the procedure, what would be the most appropriate nursing intervention for the child and his parents?

Accepted Answer

Answer reason: A guided tour provides visual and experiential information that helps the child and parents anticipate what will happen, which improves coping and cooperation. A simple map is less effective because it does not demystify the procedure area or equipment. Teaching that fasting is required for 1 to 2 days is inaccurate and could increase fear; NPO is typically limited to the hours before sedation/anesthesia, not days afterward.

Question 45

Which intervention would be most appropriate for a nurse to perform when the parents of a child with cystic fibrosis tell her they are having difficulty coping?

Accepted Answer

Answer reason: Parents reporting difficulty coping benefit most from interventions that strengthen coping resources and social support. A disease-specific support group provides peer normalization, practical strategies, and emotional support that are associated with improved caregiver adjustment and reduced isolation. Teaching chest physiotherapy addresses technical care needs but does not directly target the parents’ emotional coping distress. Offering reassurance about longevity may provide hope, but it is less effective than connecting the family to ongoing, structured support.

Question 46

A father arrives in a busy emergency department and is upset with his wife for bringing their 2-year-old child with epiglottitis in for treatment. Which intervention by the nurse is most appropriate?

Accepted Answer

Answer reason: Acute pediatric emergencies often provoke fear that can surface as anger or blame, and the nurse’s priority is to use therapeutic communication to de-escalate while supporting the family. Validating the emotion and reframing it as a coping response helps reduce defensiveness and opens the door to constructive problem-solving without escalating conflict. Leaving the room abandons needed support and may worsen the confrontation, while calling security is premature unless there is a clear safety threat. Sending both parents away is nontherapeutic and may increase distress and impede calming, which is especially important in epiglottitis where agitation can worsen airway compromise.

Question 47

The nurse is preparing the peritoneal dialysis treatment for the 10-year—old. To promote a sense of control, what should the nurse allow the child to do?

Accepted Answer

Answer reason: Offering a limited menu of acceptable fluids allows participation without compromising sterile technique or treatment safety. Allowing the child to cleanse the abdomen risks contamination and peritonitis because aseptic preparation should be performed by trained staff. Toys or dolls can help with coping and distraction, but giving concrete choices about care-related preferences is the most direct strategy to enhance perceived control in this scenario.

Question 48

During a home visit to the client with Alzheimer’s disease, the nurse assesses the stress level of the client’s spouse, the primary caregiver. Which question is most appropriate for assessing the spouse’s stress level?

Accepted Answer

Answer reason:  Assessing caregiver stress starts with an open-ended exploration of daily demands, role strain, sleep disruption, and available support. This broad question invites the spouse to describe routines and challenges without assuming stress or steering the answer, allowing the nurse to identify specific stressors and coping gaps. In contrast, asking about stress relief jumps to coping strategies before fully assessing stressors, and offering to arrange help is an intervention rather than assessment. The leading statement about caregiving being stressful can bias the response and is less therapeutic.

Question 49

A client recently diagnosed with colon cancer tells the nurse that he’s been having trouble sleeping and is preoccupied with thoughts of how his life will change after surgery. Which is the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: Trouble sleeping and persistent preoccupation about future changes after surgery are classic manifestations of anticipatory anxiety. This diagnosis is broader and more immediately explanatory than focusing only on the sleep disturbance, which is typically secondary to the underlying emotional state. “Ineffective coping” would require clearer evidence of maladaptive behaviors or inability to manage stressors beyond worry and rumination. “Powerlessness” is less directly supported because the client expresses concern and fear, not a loss of control or inability to influence outcomes.

Question 50

A school nurse is called to assess a preadolescent Vietnamese girl attending a new school. A teacher tells the nurse the student sits in the back of the class and won’t speak when spoken to, although her parents confirmed the student speaks English. Which assessment finding is most likely?

Accepted Answer

Answer reason: Abrupt withdrawal, silence, and avoidance in a new environment commonly reflect an acute stress response to unfamiliar social norms, expectations, and fear of negative evaluation during cultural transition. Cultural shock often presents with anxiety, decreased interaction, and reduced participation even when language ability is adequate. The behavior described is not evidence of building support or successful adjustment; those patterns would typically increase engagement and communication over time. A “socialization period” is vague and does not specifically capture the culturally driven stress and adaptation challenge highlighted in the stem.

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