Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

The patient’s blood glucose level is 36 mg/dL.

The patient’s heart rate is 132 beats per minute.

The patient’s pupils are dilated.

The patient’s blood pressure is 104/56 mmHg.

The patient is having difficulty sleeping at night.

Answer and Explanation

Correct Answer : B,C,E

Choice B rationale:

Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.

Choice C rationale:

Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.

Choice E rationale:

Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.

Rationale for incorrect choices:

Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.

Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.

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Correct Answer is A

Explanation

The correct answer is E(None of the Above)

Rationale for E:

The options A, B, C, and D all describe actions or physiological measurements that do not directly indicate an allergic reaction.

Allergic reactions involve the immune system's response to a specific substance, whereas side effects are unintended reactions to a medication that are not caused by an immune response.

Key differences between allergic reactions and side effects:

Allergic reactions:

Typically occur rapidly after exposure to the allergen.

Can involve various body systems, including the skin (hives, itching, rash), respiratory system (wheezing, difficulty breathing, throat tightness), gastrointestinal system (nausea, vomiting, diarrhea), and cardiovascular system (low blood pressure, shock).

May be life-threatening in severe cases, such as anaphylaxis. Side effects:

Can occur at any time during medication use.

Usually more predictable and less severe than allergic reactions.

Often subside as the body adjusts to the medication or with dose adjustments. Important considerations for nurses:

Carefully assess patients for potential allergies before administering medications.

Monitor patients closely for any signs of allergic reactions or side effects after medication administration.

Promptly intervene if an allergic reaction is suspected, following established protocols and administering emergency medications as needed.

Document all observations and actions related to medication administration and patient responses.

A. Standing order B. PRN order C. Single order D. Stat order

Correct Answer is A

Explanation

Choice A rationale:

Standing orders are pre-approved orders that nurses can implement for specific patient situations without requiring a new order from a provider each time. They are designed to streamline care, promote efficiency, and ensure consistency in treatment. In this case, the standing order for EKGs on all cardiac unit admissions serves several key purposes:

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Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

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Naxlex Comprehensive Predictor Exams

The nurse administers a medication to the patient. Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

Correct Answer is A

Explanation

A patient is admitted to the cardiac unit.Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?

Correct Answer is A

Explanation

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