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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.

Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.

Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.

Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.

A. The runner may lose consciousness due to heat stroke. B. It is not necessary to call 911. C. It is normal to vomit and not sweat during a marathon. D. Getting the patient to a cooler, air-conditioned place will reverse the heat exhaustion.

Correct Answer is A

Explanation

Heat stroke is a serious condition caused by overheating of the body, usually as a result of prolonged exposure to or physical exertion in high temperatures. It can damage the brain and other internal organs, and can be fatal if not treated promptly.

Some of the symptoms of heat stroke are:

• High body temperature of 104 F (40 C) or higher

• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma

• Lack of sweating despite the heat

• Red, hot and dry skin

• Rapid and strong pulse

• Throbbing headach

• Nausea and vomiting

Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.

Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.

Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.

Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.

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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?

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Correct Answer is C

Explanation

A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

Correct Answer is A

Explanation

A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?

Signs of hemolytic anaemias include:

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

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?