The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.


Which term will the nurse use to describe this area?

Choice A rationale:

Employee Assistance Programs (EAPs): These programs focus on providing confidential counseling and support services to employees for personal and work-related issues, such as mental health, substance abuse, stress management, and family concerns. They do not play a role in determining nursing training requirements for intravenous line initiation.

Choice C rationale:

The MedWatch program: This is a voluntary reporting system for healthcare professionals and consumers to report adverse events and medication errors to the FDA. It's crucial for monitoring drug safety but does not establish training standards for nurses.

Choice D rationale:

The US Food and Drug Administration (FDA): This federal agency regulates food, drugs, medical devices, and cosmetics to ensure their safety and efficacy. While it sets standards for drug approval and labeling, it does not directly determine specific nursing training requirements.

Choice B rationale:

State Nurse Practice Acts: These laws, enacted by each state's legislature, define the scope of nursing practice, including the skills and tasks that nurses are legally authorized to perform. Intravenous line initiation is a skill that falls within the scope of nursing practice, and the specific training requirements for this skill are typically outlined in each state's Nurse Practice Act.

Key points:

State Nurse Practice Acts are the primary legal authority governing nursing practice within each state, including the necessary training for nurses to perform specific skills.

EAPs, MedWatch, and the FDA play important roles in healthcare but do not determine nursing training requirements

Nurses must be aware of the Nurse Practice Act in their state to ensure they are practicing within the legal scope of their profession and have received the required training for the skills they perform.

Choice B rationale:

Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.

Choice C rationale:

Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.

Choice E rationale:

Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.

Rationale for incorrect choices:

Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.

Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.