The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

Increased muscle tension

Altered sleep patterns

Increased peristalsis

Impaired immunity

Answer and Explanation

The Correct Answer is D

D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.

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Correct Answer is ["A","D"]

Explanation

A. The renal arteries are not typically located in the right upper quadrant. This area primarily contains the liver, gallbladder, and portions of the small intestine and large intestine. Therefore, RUQ is not associated with the location of the renal arteries.
D. LUQ (Left Upper Quadrant): The renal arteries are not typically located in the left upper quadrant. This area primarily contains the spleen, stomach, pancreas, and portions of the small intestine and large intestine. Therefore, LUQ is not associated with the location of the renal arteries.
B. Hypogastric: The hypogastric region, also known as the pubic region or lower abdominal region, is located below the umbilical region (lower middle abdomen). The renal arteries are not typically located in the hypogastric region. This area primarily contains structures such as the bladder, uterus (in females), and reproductive organs. Therefore, hypogastric is not associated with the location of the renal arteries.
C. LLQ (Left Lower Quadrant): The renal arteries are not typically located in the left lower quadrant. This area primarily contains the descending colon, sigmoid colon, and portions of the small intestine. Therefore, LLQ is not associated with the location of the renal arteries.
E. RLQ (Right Lower Quadrant): The renal arteries are not typically located in the right lower quadrant. This area primarily contains the appendix, cecum, ascending colon, and portions of the small intestine. Therefore, RLQ is not associated with the location of the renal arteries.

A. transferring a client to ICU without giving report. B. completing the admission assessment. C. documenting vital signs taken by another nurse. D. calling the physician to request an order for pain medication for the client. E. using an IV pump with a frayed cord.

Correct Answer is ["A","C","E"]

Explanation

A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.

C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs

D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.

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The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing abdominal vascular sounds (bruits) on a client. Which abbreviation(s) describe(s) the quadrants where the renal arteries are located? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D"]

Explanation

The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

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