The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?
Increased muscle tension
Altered sleep patterns
Increased peristalsis
Impaired immunity
The Correct Answer is D
D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
Correct Answer is C
Explanation
C. Encourage the client to discuss his feelings about his health status: This option directly targets the affective domain by facilitating the expression and exploration of the client's emotions, attitudes, and beliefs related to their health status. Discussing feelings can help the client process emotions such as fear, anxiety, or frustration, and can promote emotional coping, self-awareness, and acceptance, all of which are important aspects of affective learning.
A. This option primarily involves the psychomotor domain, as it focuses on the client's ability to perform a physical skill (self-measurement of blood pressure). While this activity may indirectly influence the affective domain by building the client's confidence and sense of empowerment in managing their health, its primary focus is on the acquisition of motor skills.
B. This option engages the cognitive domain by encouraging the client to identify and express their informational needs about their diagnosis. While this approach can help address cognitive aspects of learning, such as knowledge acquisition and understanding, it may not directly target the affective domain unless the client's emotional responses and concerns are explicitly addressed.
D. Providing educational materials on exercise and nutrition guidelines can contribute to cognitive learning by imparting information about health behaviors but it may not directly address the affective domain unless the content specifically addresses emotional or motivational aspects of behavior change. However, if the brochures include content that inspires or motivates the client to adopt healthy lifestyle changes by appealing to their values, beliefs, or emotions, then it could indirectly influence the affective domain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.