After an assessment, the nurse realizes that a client demonstrates cognitive responses to stress. What behaviors did the client demonstrate for the nurse to make this clinical determination?
Irritable
Lethargic
Angry
Decreased attention to detail
The Correct Answer is D
A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.
B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.
C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.
D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continue to talk to the client as if they are awake: Even though the client is unresponsive, hearing can be the last sense to diminish as death approaches. Speaking to the client in a calm and reassuring manner can provide comfort and a sense of presence, even if the client cannot respond verbally.
B. Limit the client's visitors to one at a time: While it's important to manage visitors to prevent overwhelming the client, limiting them to one at a time may not be necessary if the client's condition allows for multiple visitors and the client's wishes or cultural preferences support it.
C. Avoid touching the client: Touch can be a powerful form of communication and comfort, even for an unresponsive client. Gentle touch can convey warmth and support to both the client and their family members.
D. Whisper when talking in the client's room: Whispering may create a sense of unease or anxiety for the client or their family members. Speaking in a calm and soothing voice at a normal volume is more appropriate and can help create a peaceful environment for the client's end-of-life care.
Correct Answer is D
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.
Analysis:
pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.
PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.
Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.
PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.
Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.
Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.
Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.
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