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 B
Explanation
A. The nurse coats the indwelling urinary catheter with lubricant. This is correct procedure and requires no intervention. Lubricating the catheter reduces friction and discomfort during insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter. This is correct procedure and requires no intervention. The sterile drape maintains a sterile field.
C. The nurse separates the client's labia with her dominant hand. The nurse should separate the client's labia with her non-dominant hand, which then remains in place as a "dirty" hand. The dominant hand, which remains sterile, is used to insert the catheter.
D. The nurse provides perineal care prior to inserting the urinary catheter. This is correct procedure and requires no intervention. Perineal care reduces the risk of introducing bacteria into the urinary tract.
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