Two clients have been in a similar motor vehicle accident, and have similar injuries. The nurse observes each client's different responses to this stressor. The nurse understands that the degree of stress each client experiences from the crash may be influenced by their: (SELECT ALL THAT APPLY)

health status prior to the accident.

different ages.

external resources.

individual problem-solving skills.

personalities.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. The health status prior to the accident can influence how individuals respond to stress. Clients with pre-existing medical conditions, chronic pain, or disabilities may experience increased stress due to concerns about exacerbation of their conditions, recovery, or long-term consequences. Therefore, health status prior to the accident can impact the degree of stress experienced.
B. Age can influence individuals' coping mechanisms and resilience in response to stress. Younger individuals may have less life experience and coping skills, while older individuals may have accumulated more experience and developed better coping strategies over time. Additionally, age-related factors such as physical resilience and social support networks can affect how individuals respond to stressors. Therefore, different ages can influence the degree of stress experienced.
C. External resources such as social support networks, access to healthcare, financial stability, and community resources can significantly impact individuals' ability to cope with stress. Clients with strong support systems, adequate access to medical care, and financial security may experience lower levels of stress compared to those lacking these resources. Therefore, external resources can influence the degree of stress experienced.
D. Individual problem-solving skills play a crucial role in how individuals perceive and manage stressful situations. Clients with strong problem-solving skills may feel more confident in their ability to address challenges and may experience lower levels of stress. Conversely, clients with limited problem-solving skills may feel overwhelmed and experience higher levels of stress. Therefore, individual problem- solving skills can influence the degree of stress experienced.
E. Personality traits such as resilience, optimism, neuroticism, and coping styles can impact how individuals respond to stressors. For example, individuals with resilient personalities and positive coping styles may adapt more effectively to stressors and experience lower levels of stress. Conversely, individuals with neurotic personalities or maladaptive coping styles may be more prone to experiencing heightened stress levels. Therefore, personalities can influence the degree of stress experienced.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B. A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C. The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D. A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E. Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

A. Stop the infusion immediately B. Document the findings in a nurse's note C. Flush the catheter with 3ml normal saline D. Remove the catheter and apply pressure to the site

Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

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Two clients have been in a similar motor vehicle accident, and have similar injuries. The nurse observes each client's different responses to this stressor. The nurse understands that the degree of stress each client experiences from the crash may be influenced by their: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Correct Answer is A

Explanation

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