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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Thick, creamy yellow discharge is a hallmark characteristic of purulent drainage. This type of drainage is commonly referred to as pus and is indicative of an infection within the wound. It is composed of white blood cells, dead bacteria, cellular debris, and inflammatory cells, giving it its characteristic opaque, thick, and yellowish appearance.
Purulent drainage is a significant clinical finding that requires prompt attention and intervention. Early identification and management of wound infections can prevent complications such as abscess formation, cellulitis, sepsis, and delayed wound healing.
Accurate documentation of purulent drainage is essential for communication among healthcare providers, monitoring wound progress, and guiding treatment decisions.
Choice B rationale:
Serosanguineous drainage is a mixture of serous fluid (clear, thin, and watery) and blood. It often appears pink or slightly red and is commonly observed in the early stages of wound healing or after dressing changes. While it may contain a small amount of blood, it lacks the thick, creamy consistency and yellow color that are characteristic of purulent drainage.
Choice C rationale:
Serous drainage is clear, thin, and watery, resembling plasma. It is a normal part of the wound healing process and is often seen in the early inflammatory stage. It does not contain the thick consistency or yellow coloration that are indicative of purulent drainage.
Choice D rationale:
Sanguineous drainage is composed primarily of fresh blood. It is bright red in color and typically indicates active bleeding within the wound. It does not exhibit the thick, creamy consistency or yellow hue that are characteristic of purulent drainage.
Correct Answer is B
Explanation
Choice A rationale:
Echinacea: It has anti-inflammatory properties and is not typically associated with exacerbating rheumatoid arthritis symptoms. Studies have shown potential benefits in reducing inflammation, including evidence of possible effectiveness for osteoarthritis and rheumatoid arthritis. However, more research is needed to confirm its efficacy and safety in rheumatoid arthritis.
Choice B rationale:
Turmeric:
Curcumin, the active component of turmeric, has both anti-inflammatory and pro-inflammatory effects.
While it has potential benefits for some inflammatory conditions, it can also stimulate the immune system, which could worsen rheumatoid arthritis symptoms in certain individuals.
Studies have shown mixed results, with some indicating potential benefits and others suggesting a possible worsening of symptoms.
Due to this uncertainty, caution is advised, and patients with rheumatoid arthritis should consult with their healthcare providers before using turmeric supplements.
Choice C rationale:
Ginger: It has well-documented anti-inflammatory properties and is not known to exacerbate rheumatoid arthritis symptoms.
Studies have shown ginger to be potentially effective in reducing pain and inflammation in individuals with rheumatoid arthritis.
It is generally considered safe for use in this population.
Choice D rationale:
Valerian: It is a herb primarily used for its sedative and sleep-promoting effects.
It has not been shown to have any significant impact on inflammation or rheumatoid arthritis symptoms. There is no evidence to suggest that it would worsen the condition.
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