A client is brought to the emergency department after a motorcycle accident.
The client is alert, responsive, and diagnosed with a broken leg.
The client's vital signs are pulse 72 and respiration 16. After being informed surgery is required for the broken leg, which vital sign readings would be expected?
Pulse 72 and respiration 16.
Pulse 90 and respiration 22.
Pulse 58 and respiration 14.
Pulse 70 and respiration 16.
The Correct Answer is B
Choice A rationale
When an individual is faced with a stressful situation, such as an impending surgery, the sympathetic nervous system is activated, initiating the "fight or flight" response. This response involves the release of catecholamines, primarily adrenaline and noradrenaline. These hormones increase the heart rate (tachycardia) and respiratory rate (tachypnea) to prepare the body for a perceived threat.
Choice B rationale
The sympathetic nervous system activation due to anxiety and stress from the impending surgery would cause an increase in both pulse and respiratory rate. A normal adult pulse rate is 60-100 beats per minute, and a normal respiratory rate is 12-20 breaths per minute. A pulse of 90 and respiration of 22 are elevated and consistent with the physiological stress response.
Choice C rationale
A pulse of 58 and a respiration rate of 14 are within or below the normal ranges. A decrease in heart rate (bradycardia) and respiratory rate (bradypnea) is not a typical response to acute stress. These vital signs would indicate a parasympathetic nervous system response, which promotes rest and relaxation, not the physiological stress response seen before surgery.
Choice D rationale
While a pulse of 70 and a respiration of 16 are within the normal range, they do not reflect the expected physiological response to acute stress. The client's initial baseline vitals were a pulse of 72 and respiration of 16. A stressful event like an impending surgery would trigger a sympathetic response, causing an increase in these values, not a maintenance of the baseline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response minimizes the client's experience by suggesting her observations are biased. Prolonged stress and negative emotions directly impact the immune system's function. The HPA axis and sympathetic nervous system are activated, leading to the release of cortisol and catecholamines. These hormones suppress the immune system, making the body more susceptible to infections like shingles and the flu. Suggesting it's just a matter of "noticing more" disregards this established physiological link.
Choice B rationale
This statement is scientifically inaccurate. The nervous system is a complex, integrated network. The sympathetic and parasympathetic divisions, part of the autonomic nervous system, directly influence physiological responses, including the immune system. The hypothalamic-pituitary-adrenal (HPA) axis, a key component of the neuroendocrine system, is a prime example of the interconnectedness of emotions, stress, and physical health, proving that these systems do not travel on separate tracts.
Choice C rationale
This rationale is not a correct reflection of current scientific knowledge. Extensive research in psychoneuroimmunology (PNI) has demonstrated a clear and well-documented connection between psychological stressors and physiological health outcomes. The field studies how the central nervous system, endocrine system, and immune system interact, showing that chronic stress leads to a compromised immune response, increasing susceptibility to illness. The link is not unclear.
Choice D rationale
Stressors, both psychological and physical, activate the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. This activation leads to the release of hormones such as cortisol and epinephrine. Cortisol, in particular, is a potent immunosuppressant that, when chronically elevated, reduces the number and activity of white blood cells, such as lymphocytes and natural killer cells, thereby weakening the body's ability to mount an effective immune response against pathogens.
Correct Answer is A
Explanation
Choice A rationale
Primary prevention aims to stop a problem from ever happening by targeting populations at risk before any illness or disease manifests. Leading a psychoeducational group in a community care home is an example of primary prevention because it provides education and skills to prevent mental health issues before they arise in a vulnerable population. This proactive approach focuses on reducing risk factors and enhancing protective factors.
Choice B rationale
Helping a client practice mindfulness for anxiety is an example of tertiary prevention. Tertiary prevention is aimed at reducing the negative impact of an already established disease by restoring function and reducing disease-related complications. In this case, the client already has anxiety, and mindfulness is being used to manage the symptoms and prevent the condition from worsening.
Choice C rationale
Assisting a person with a serious mental illness to fill a pill-reminder is an example of tertiary prevention. Tertiary prevention focuses on rehabilitation and preventing further deterioration in individuals with an existing disease. By ensuring medication adherence, this intervention helps to manage the chronic illness, reduce symptoms, and prevent relapses, thereby improving the client's quality of life and functioning.
Choice D rationale
Medicating an acutely ill client who has assaulted a staff person is an example of tertiary prevention. This intervention is a reactive response to a dangerous behavior that has already occurred, aiming to manage acute symptoms and prevent further harm. Tertiary prevention is implemented after a disease or crisis has manifested to mitigate its consequences and restore stability.
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