Choice A rationale
Experiencing poverty can indeed be a source of chronic stress due to the ongoing hardships and struggles associated with financial instability. However, it is not typically classified as an example of acute stress, which is usually associated with a specific event or situation that causes a sudden and intense reaction.
Choice B rationale
Being a victim of a crime is a prime example of an acute stressor. This is because it is a specific event that can cause immediate emotional and physiological reactions. The individual may experience intense feelings of fear, shock, or distress, and these reactions typically occur immediately after the event.
Choice C rationale
Being part of a dysfunctional family can lead to chronic stress due to ongoing family conflicts, communication problems, or other issues. While specific incidents within the family context (like a heated argument) could potentially trigger acute stress responses, the overall experience of living in a dysfunctional family is more commonly associated with chronic stress.
Choice D rationale
Experiencing racism can lead to both acute and chronic stress. Acute stress might occur in response to a specific incident of racial discrimination, while chronic stress could result from living in a society where racism is pervasive. However, without a specific incident mentioned, it is less likely to be considered an example of acute stress compared to being a victim of a crime.

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

Step 1 is to calculate the rate of fluid replacement. The formula for this is: Rate (mL/hr) = Total volume (mL) ÷ Time (hr) So, for this question: Rate (mL/hr) = 1000 mL ÷ 10 hr = 100 mL/hr.

Choice A rationale
While palliative care can indeed help improve a patient’s quality of life, it is not typically aimed at curing the disease or significantly prolonging life. Instead, the focus is on managing symptoms and improving comfort. Therefore, the statement “This treatment should help me live a little longer and give me hope for a cure” does not accurately reflect the goals of palliative care.
Choice B rationale
The statement “I will continue my strict dietary plan” does not necessarily indicate an understanding of palliative care. While maintaining good nutrition can be an important part of managing some conditions, palliative care is more focused on symptom management and improving quality of life. Strict dietary restrictions may not be necessary or beneficial in a palliative care context.
Choice C rationale
The statement “I am hoping this will limit my discomfort and give me the best quality of life for me” accurately reflects the goals of palliative care. Palliative care aims to manage symptoms, including pain and discomfort, and to improve the patient’s quality of life.
Choice D rationale
The statement “This is not working and I plan to stop treatment” does not necessarily reflect an understanding of palliative care. While a patient has the right to stop treatment at any time, this decision should be based on a thorough understanding of their condition and the potential benefits and drawbacks of continuing or discontinuing treatment.

Choice A rationale
While the thickness of the tympanic membranes can indeed change with age, it typically increases rather than decreases. Thickening of the tympanic membranes can contribute to hearing loss by reducing the ability of the ear to transmit sound vibrations.
Choice B rationale
Tinnitus, or ringing in the ears, is not typically decreased in older adults. In fact, tinnitus is often more common in older individuals and can be a sign of age-related hearing loss.
Choice C rationale
A decreased ability to hear high-frequency sounds is a common physiological change associated with aging. This is often one of the first signs of age-related hearing loss.
Choice D rationale
Decreased ear wax is not typically associated with aging. In fact, some older adults may produce more ear wax, which can contribute to hearing problems if it becomes impacted.

Choice A rationale
Chronic stress is a prolonged, often overwhelming feeling of stress that can negatively impact a person’s daily life. It can be caused by various factors, including high-pressure jobs, challenging relationships, and living in poverty. Living in poverty is a long-term situation that can cause chronic stress due to the constant worry about meeting basic needs such as food, shelter, and healthcare. This continuous worry and fear can lead to chronic stress.
Choice B rationale
A motor vehicle accident is typically an acute stress event. While it can cause significant stress at the moment, it is usually not a long-term stressor unless it results in severe injury or trauma that significantly impacts a person’s daily life.
Choice C rationale
Being a victim of a crime can indeed cause stress, but it is typically considered an acute stress event. However, if the crime results in long-term effects such as physical harm or psychological trauma, it could potentially lead to chronic stress.
Choice D rationale
The loss of a loved one can cause both acute and chronic stress. The initial loss can cause acute stress, and the subsequent grieving process can lead to chronic stress, especially if the individual has difficulty moving through the stages of grief. However, not everyone who loses a loved one will experience chronic stress.

Choice A rationale
The first physiological response that occurs during the General Adaptation Syndrome (GAS) is
the alarm reaction stage. This stage is the body’s initial response to stress, where the sympathetic nervous system is activated by the sudden release of hormones.
Choice B rationale
The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.
Choice C rationale
Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.
Choice D rationale
An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.

Choice A rationale
Increased joint stiffness is a common age-related change in older adults.
Choice B rationale
Increased muscle mass is not typically an age-related change. In fact, older adults often experience a decrease in muscle mass, a condition known as sarcopenia.
Choice C rationale
Increased calcification of bones is not a typical age-related change. Older adults are more likely to experience osteoporosis, a condition characterized by a decrease in bone density.
Choice D rationale
Decreased balance is a common age-related change, but it is not the correct answer for this question.

Choice A rationale
Restlessness is an observable behavior, making it an objective finding.
Choice B rationale
Pacing is also an observable behavior, so it is considered an objective finding.
Choice C rationale
Anxiety is a subjective finding because it is based on the patient’s personal experience and cannot be directly observed.
Choice D rationale
Alertness is an objective finding because it can be directly observed and measured.

Choice A rationale
Post-traumatic stress disorder (PTSD) is a stress-related disorder that can occur after a person experiences a traumatic event. Symptoms can include flashbacks of the traumatic event, which the patient reports experiencing.
Choice B rationale
Episodic acute stress is a type of stress that occurs in response to specific situations or events. It does not typically involve flashbacks of a traumatic event.
Choice C rationale
Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. While stress can exacerbate symptoms of IBS, it is not a stress-related disorder in the sense of being a psychological response to stress.
Choice D rationale
Acute stress disorder (ASD) is a stress-related disorder that can occur in response to a traumatic event. However, ASD symptoms occur immediately after the traumatic event and typically resolve within a month. Since the patient reports experiencing flashbacks of a traumatic event that occurred a year ago, ASD is not the correct answer.