A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress.
Which of the following manifestations should the nurse include?
Decreased blood pressure.
Bronchial airway constriction.
Hypoglycemia.
Dilated pupils.
The Correct Answer is D
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
Giving food and fluids to a client with POI may worsen the condition and cause complications.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.
Correct Answer is C
Explanation
The role of the risk manager is to identify and analyze the factors that contributed to the adverse event and to implement strategies to prevent or reduce the likelihood of recurrence. The risk manager is not concerned with assigning blame or protecting the staff from litigation, but rather with improving the quality and safety of care.
Choice A is wrong because it implies a punitive approach that does not address the underlying system issues.
Choice B is wrong because it suggests a defensive attitude that does not foster a culture of learning and improvement.
Choice D is wrong because it assumes that the nurses were not aware of the patient’s fall risk, which may not be the case.
The risk manager should investigate all aspects of the situation, including the communication and documentation of the patient’s fall risk assessment and interventions.
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