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A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)

Muscular tension, blood pressure, and triglycerides increase.

Epinephrine is released, increasing heart and respiratory rates.

Corticosteroid release increases stamina and impedes digestion.

Cortisol is released, increasing gluconeogenesis and reducing fluid loss.

Immune system functioning decreases, and risk of cancer increases.

Risk of depression, autoimmune disorders, and heart disease increases.

Answer and Explanation

Correct Answer : A,D,E,F

The correct answer is: A, D, E, and F.

Choice A reason:

Muscular tension, blood pressure, and triglycerides increase. Long-term stress can lead to chronic muscle tension, elevated blood pressure, and increased triglyceride levels. Chronic muscle tension is a common response to prolonged stress, often resulting in pain and discomfort. Elevated blood pressure is a well-documented effect of chronic stress, which can increase the risk of cardiovascular diseases. Increased triglycerides are also associated with prolonged stress, contributing to metabolic syndrome and cardiovascular risk.

Choice B reason:

Epinephrine is released, increasing heart and respiratory rates. This response is more characteristic of acute stress rather than long-term stress. Epinephrine (adrenaline) is released during the “fight-or-flight” response, causing immediate increases in heart rate and respiratory rate. However, this is a short-term physiological response and not typically sustained over long periods.

Choice C reason:

Corticosteroid release increases stamina and impedes digestion. While corticosteroids like cortisol are released during stress, their primary long-term effect is not to increase stamina but to manage energy by increasing blood glucose levels through gluconeogenesis. Chronic cortisol release can indeed impede digestion by diverting energy away from non-essential functions like the digestive system.

Choice D reason:

Cortisol is released, increasing gluconeogenesis and reducing fluid loss. Cortisol, a key stress hormone, is released during long-term stress and increases gluconeogenesis, which is the production of glucose from non-carbohydrate sources. This helps maintain energy levels during prolonged stress. Cortisol also helps in reducing fluid loss by promoting sodium retention in the kidneys.

Choice E reason:

Immune system functioning decreases, and risk of cancer increases. Chronic stress can suppress the immune system, making the body more susceptible to infections and diseases. Prolonged immune suppression can also increase the risk of cancer as the body’s ability to detect and destroy abnormal cells is compromised.

Choice F reason:

Risk of depression, autoimmune disorders, and heart disease increases. Long-term stress is linked to an increased risk of depression and other mental health disorders due to the continuous release of stress hormones affecting brain function. It can also trigger autoimmune disorders by causing chronic inflammation and dysregulation of the immune system. Additionally, the persistent high levels of stress hormonees can lead to heart disease by promoting hypertension and other cardiovascular issues.

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Correct Answer is D

Explanation

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.

A. Associative looseness B. Tangentiality C. Neologism D. Circumstantiality E. Choice C reason:

Correct Answer is C

Explanation

Choice A reason:

Associative looseness refers to a disorganized thought process where connections between ideas are unclear or illogical. The use of the word "flakala" does not demonstrate a loose association between ideas but rather the creation of a new word.

Choice B reason:

Tangentiality occurs when a person goes off on a tangent and does not return to the original topic. In this case, the client is not going off on a tangent but is repeatedly using a made-up word, which is indicative of neologism.

Choice C reason:

Neologism is the creation of new words that others may not understand. The client's use of "flakala" fits this definition, as it appears to be a word created by the client that is not part of standard language¹. This can be a sign of disorganized thinking, where the client's internal thoughts do not align with conventional language patterns.

Choice D reason:

Circumstantiality involves providing unnecessary detail that makes communication less efficient but eventually returns to the original point. The client's statement does not include unnecessary details; it is the repetition of a newly created word, suggesting neologism.

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A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?

Correct Answer is C

Explanation

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