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 D

Explanation

A. Presence of WBCs in urine : This suggests a possible infection, not necessarily a blockage.

B. Cloudy urine : This may indicate an infection but is not specific for occlusion.

C. Urinary urgency: A client with a catheter should not experience urgency since urine continuously drains.

D. Bladder distention: If the catheter is occluded, urine will accumulate in the bladder, leading to distention.

A. The client reports taking the medication 30 min before the prescribed time. B. The client received an influenza vaccine 1 month ago. C. The client reports taking the medication with room temperature water. D. The client has a history of recurring bowel inflammation.

Correct Answer is D

Explanation

A. The client reports taking the medication 30 min before the prescribed time. Taking a medication slightly earlier is unlikely to significantly affect its therapeutic efficacy.

B. The client received an influenza vaccine 1 month ago. Vaccination does not interfere with arthritis medications unless it triggers an immune response leading to disease flare-up, which is rare.

C. The client reports taking the medication with room temperature water. The temperature of the water does not impact the drug’s effectiveness.

D. The client has a history of recurring bowel inflammation. Chronic bowel inflammation (e.g., Crohn’s disease) can affect drug absorption, reducing medication effectiveness.

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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

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