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 B

Explanation

A. Decreased blood urea nitrogen (BUN): BUN typically increases with dehydration.

B. Increased hematocrit: Hemoconcentration occurs in dehydration, increasing hematocrit levels.

C. Decreased urine specific gravity: Dehydration typically causes an increase in urine specific gravity.

D. Increased calcium level: Calcium levels do not directly indicate fluid volume status.

A. "Contacted the provider to report client findings." B. "Reports stomach pain as 3 on a pain scale of 0 to 10." C. "Vomited 120 mL of clear, yellow emesis." D. "Denies further nausea or vomiting since antiemetic administration.

Correct Answer is D

Explanation

A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.

B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.

C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).

D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).

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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?

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