A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?

Dry skin

Increased urinary output

Dilated pupils

Hyperactive bowel sounds

Answer and Explanation

The Correct Answer is C

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. “The body produces antibodies in response to an antigen with active immunity." B. "There is lifelong immunity with passive immunity." C. "The body is able to recognize previous exposure to antigens with passive immunity." D. "There is a short duration of immunity with active immunity."

Correct Answer is A

Explanation

A. "The body produces antibodies in response to an antigen with active immunity." Active immunity develops after exposure to an antigen, leading to antibody production.

B. "There is lifelong immunity with passive immunity." Passive immunity is temporary (e.g., maternal antibodies).

C. "The body is able to recognize previous exposure to antigens with passive immunity." Passive immunity does not create immune memory.

D. "There is a short duration of immunity with active immunity." Active immunity is long-lasting and sometimes lifelong.

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A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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