A nurse is caring for a client who is experiencing stress. Which of the following actions should the nurse take first?
Develop a statement about the client’s health alteration.
Conduct a mental status exam for the client.
Establish short- and long-term goals for the client.
Teach the client stress-reduction techniques.
The Correct Answer is B
Choice A reason: Developing a statement about health alterations is part of documentation but not the first action. Stress impacts the hypothalamic-pituitary-adrenal axis, increasing cortisol, and requires assessment first to identify cognitive or emotional changes, ensuring targeted interventions rather than premature documentation of unassessed conditions.
Choice B reason: Conducting a mental status exam first assesses cognitive, emotional, and behavioral changes due to stress, which activates the amygdala and elevates cortisol, impairing prefrontal cortex function. This identifies severity (e.g., anxiety, impaired concentration), guiding appropriate interventions like counseling or relaxation techniques to address physiological and psychological stress effects.
Choice C reason: Establishing goals is important but secondary to assessment. Stress affects neuroendocrine pathways, increasing catecholamines and cortisol, which impair cognition. Without assessing mental status, goals may be misaligned, as understanding the client’s stress-related symptoms is critical to setting realistic, effective short- and long-term objectives.
Choice D reason: Teaching stress-reduction techniques is effective but not the first step. Stress elevates sympathetic activity, increasing heart rate and cortisol. Without assessing mental status, techniques may be inappropriate. A mental status exam identifies specific stress manifestations, ensuring tailored interventions to reduce physiological and psychological stress responses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Taking a 1-hour nap each day can disrupt nighttime sleep patterns, worsening insomnia by reducing sleep drive. Naps longer than 20-30 minutes or late in the day interfere with the body’s circadian rhythm, decreasing the need for sleep at night, making this an incorrect understanding of insomnia management.
Choice B reason: Going to bed at the same time each night, even if not tired, establishes a consistent sleep schedule, reinforcing the body’s circadian rhythm. This sleep hygiene practice conditions the brain to associate a specific time with sleep, improving sleep onset and quality, making it the correct statement for managing insomnia effectively.
Choice C reason: Watching television in the bedroom before sleep stimulates the brain with blue light and engaging content, delaying melatonin production and sleep onset. Good sleep hygiene recommends avoiding screens in the bedroom to create a restful environment, making this an incorrect statement for effective insomnia management.
Choice D reason: Stopping exercise 2 hours before bedtime is generally good advice, but it is not the most critical aspect of insomnia management compared to a consistent sleep schedule. Exercise close to bedtime may increase arousal, but a regular bedtime routine has a stronger impact on circadian rhythm regulation, making this less optimal.
Correct Answer is C
Explanation
Choice A reason: Anemia results from factors like iron deficiency or chronic disease, not directly from prolonged stress. Stress may elevate cortisol, affecting hematopoiesis indirectly, but anemia is not a primary manifestation. Chronic stress primarily impacts neuroendocrine and immune systems, not red blood cell production or hemoglobin levels.
Choice B reason: Prolonged stress typically increases blood pressure via sympathetic activation, releasing catecholamines (e.g., epinephrine), which cause vasoconstriction and elevated heart rate. Decreased blood pressure is not a common stress response, as the hypothalamic-pituitary-adrenal axis drives hypertension, not hypotension, in chronic stress scenarios.
Choice C reason: Prolonged stress elevates cortisol and catecholamines, suppressing immune function by inhibiting T-cell proliferation and cytokine production. This reduces the body’s ability to fight infections, increasing susceptibility to illness. Chronic activation of the hypothalamic-pituitary-adrenal axis downregulates immune responses, a well-documented effect of sustained stress.
Choice D reason: Hypoglycemia is not a typical manifestation of prolonged stress. Stress hormones (cortisol, glucagon) increase blood glucose by promoting glycogenolysis and gluconeogenesis to provide energy. While acute stress may cause transient glucose fluctuations, chronic stress typically leads to hyperglycemia, not low blood sugar, in most individuals.
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