A nurse is teaching a class about the general adaptive syndrome. The nurse should include that which of the following manifestations occurs during the exhaustion stage?
Blood glucose levels return to the expected reference range.
Blood pressure increases.
Depression
Dilation of pupils
The Correct Answer is C
A. Blood glucose levels return to the expected reference range. Blood glucose levels are more likely to be elevated due to prolonged stress during the exhaustion stage, not normalized.
B. Blood pressure increases. During the exhaustion stage, the body's resources are depleted, and blood pressure may drop rather than increase.
C. Depression: The exhaustion stage is characterized by physical and psychological symptoms such as depression, fatigue, and reduced immune function.
D. Dilation of pupils: Pupil dilation occurs during the alarm stage of the general adaptation syndrome, not during the exhaustion stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.
B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.
C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.
D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.
Correct Answer is D
Explanation
A. "Your colostomy will not produce formed stool." A sigmoid colostomy is located in the lower part of the large intestine where stool is typically more formed. Therefore, this statement is incorrect and should not be included in the teaching.
B. "You should expect your stoma to be a purple color." A healthy stoma should be pink or red and moist. A purple, dusky, or dark color may indicate compromised blood flow to the stoma and is a sign of a medical emergency. This statement is incorrect.
C. "The end of the stoma will be painful after this procedure." The stoma itself does not have nerve endings, so it should not be painful. Pain around the incision site may occur, but the stoma itself should not be painful. This statement is incorrect.
D. "You will have a stoma in your left lower abdomen." The sigmoid colon is located on the lower left side of the abdomen, so the stoma for a sigmoid colostomy is typically placed in this area. This statement is correct.
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