An indicator that an individual is experiencing acute stress is:
Decreased respirations
Tachycardia
Hair loss
Pupil constriction
The Correct Answer is B
Choice A: Decreased Respirations
Decreased respirations, or a slower breathing rate, are not typically associated with acute stress. In fact, acute stress often leads to an increase in respiratory rate as part of the body’s “fight or flight” response. This response is mediated by the autonomic nervous system, which prepares the body to respond to a perceived threat by increasing heart rate, respiratory rate, and blood pressure.
Choice B: Tachycardia
Tachycardia, or an increased heart rate, is a common indicator of acute stress. When an individual experiences acute stress, the body releases stress hormones such as adrenaline and cortisol. These hormones stimulate the heart to beat faster, providing more oxygen and nutrients to the muscles and brain to prepare for a rapid response to the stressor. Tachycardia is a hallmark of the acute stress response and can be easily measured by checking the pulse.
Choice C: Hair Loss
Hair loss is generally associated with chronic stress rather than acute stress. Chronic stress can lead to conditions such as telogen effluvium, where hair follicles enter a resting phase and hair falls out more easily. However, this process takes time and is not an immediate response to acute stress. Therefore, hair loss is not a reliable indicator of acute stress.
Choice D: Pupil Constriction
Pupil constriction, or miosis, is not typically associated with acute stress. In fact, acute stress usually causes pupil dilation (mydriasis) as part of the “fight or flight” response. Dilated pupils allow more light to enter the eyes, improving vision and awareness of the surroundings. Pupil constriction is more commonly associated with relaxation or the body’s “rest and digest” state, mediated by the parasympathetic nervous system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Discontinuing the drug at the first signs of toxicity might seem like a straightforward solution, but it is not always the best approach. Some drugs are essential for treating serious conditions, and stopping them abruptly can cause more harm than good. Instead, the nurse should monitor the patient closely and consult with the healthcare provider to adjust the dosage or switch to a safer alternative if necessary.
Choice B Reason:
Teaching the patient how to treat symptoms if they develop is important, but it is not sufficient on its own. While patient education is a crucial aspect of managing drug side effects, it should be part of a broader strategy that includes regular monitoring and medical supervision.
Choice C Reason:
Ensuring that complete blood counts are ordered periodically is a good practice, especially for drugs that can affect blood cells. However, this approach is too narrow. Toxic side effects can impact various organs and systems, so a comprehensive monitoring plan is necessary.
Choice D Reason:
This is the correct answer. Monitoring the function of all organs potentially affected by the drug is the most comprehensive and effective approach. This includes regular blood tests, liver function tests, kidney function tests, and other relevant assessments. By closely monitoring the patient’s organ functions, the healthcare team can detect early signs of toxicity and take appropriate action to prevent serious complications.
Correct Answer is D
Explanation
Choice A: Minimal Effect on Vessels
A reduction in blood pH, which indicates acidosis, does not have a minimal effect on blood vessels. Acidosis can significantly impact vascular tone and function. Therefore, this choice is incorrect as it underestimates the physiological changes that occur in response to a decrease in pH.
Choice B: No Effect on Vessels
Similarly, stating that a reduction in blood pH has no effect on vessels is inaccurate. Blood pH is tightly regulated, and deviations from the normal range (7.35-7.45) can lead to significant physiological responses. Acidosis can alter vascular tone, making this choice incorrect.
Choice C: Vasodilation
While vasodilation can occur in response to certain conditions, a reduction in blood pH typically leads to vasoconstriction rather than vasodilation. Vasodilation is more commonly associated with an increase in blood pH (alkalosis) or other factors such as increased levels of nitric oxide or prostaglandins.
Choice D: Vasoconstriction
When the pH of blood reduces, indicating acidosis, it often leads to vasoconstriction. This response is mediated by chemoreceptors that detect changes in pH and stimulate the vasomotor center to increase vascular tone. Vasoconstriction helps to maintain blood pressure and ensure adequate perfusion of vital organs during acidosis. Therefore, this is the correct answer.
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