A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?

Dry skin

Increased urinary output

Dilated pupils

Hyperactive bowel sounds

Answer and Explanation

The Correct Answer is C

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

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Correct Answer is D

Explanation

A. “I'm sure your situation will get better with time." This response is dismissive and does not acknowledge the client’s feelings. It provides false reassurance rather than support.

B. "It must be terrible to be in this situation." While this statement attempts empathy, it may sound judgmental or patronizing rather than encouraging meaningful discussion.

C. "If I were you, I would talk with the hospital chaplain." This response assumes what the client should do rather than exploring their current coping mechanisms. It does not encourage self-reflection.

D. “Tell me what you have done in the past to cope with your problems.” This response uses therapeutic communication by allowing the client to reflect on past coping strategies and explore potential solutions.

A. Carotid bruit B. Heart murmur C. Pulse deficit D. Bounding radial pulse

Correct Answer is C

Explanation

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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A nurse is caring for a client who has been recently hospitalized. The nurse should identify that which of the following findings indicates that the client is experiencing stress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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