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Experiencing poverty can indeed be a source of chronic stress due to the ongoing hardships and struggles associated with financial instability. However, it is not typically classified as an example of acute stress, which is usually associated with a specific event or situation that causes a sudden and intense reaction.

Being part of a dysfunctional family can lead to chronic stress due to ongoing family conflicts, communication problems, or other issues. While specific incidents within the family context (like a heated argument) could potentially trigger acute stress responses, the overall experience of living in a dysfunctional family is more commonly associated with chronic stress.

Experiencing racism can lead to both acute and chronic stress. Acute stress might occur in response to a specific incident of racial discrimination, while chronic stress could result from living in a society where racism is pervasive. However, without a specific incident mentioned, it is less likely to be considered an example of acute stress compared to being a victim of a crime.

Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.

Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.

The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.

While palliative care can indeed help improve a patient’s quality of life, it is not typically aimed at curing the disease or significantly prolonging life. Instead, the focus is on managing symptoms and improving comfort. Therefore, the statement “This treatment should help me live a little longer and give me hope for a cure” does not accurately reflect the goals of palliative care.

The statement “I will continue my strict dietary plan” does not necessarily indicate an understanding of palliative care. While maintaining good nutrition can be an important part of managing some conditions, palliative care is more focused on symptom management and improving quality of life. Strict dietary restrictions may not be necessary or beneficial in a palliative care context.

The statement “This is not working and I plan to stop treatment” does not necessarily reflect an understanding of palliative care. While a patient has the right to stop treatment at any time, this decision should be based on a thorough understanding of their condition and the potential benefits and drawbacks of continuing or discontinuing treatment.

While the thickness of the tympanic membranes can indeed change with age, it typically increases rather than decreases. Thickening of the tympanic membranes can contribute to hearing loss by reducing the ability of the ear to transmit sound vibrations.

Tinnitus, or ringing in the ears, is not typically decreased in older adults. In fact, tinnitus is often more common in older individuals and can be a sign of age-related hearing loss.

Decreased ear wax is not typically associated with aging. In fact, some older adults may produce more ear wax, which can contribute to hearing problems if it becomes impacted.

A motor vehicle accident is typically an acute stress event. While it can cause significant stress at the moment, it is usually not a long-term stressor unless it results in severe injury or trauma that significantly impacts a person’s daily life.

Being a victim of a crime can indeed cause stress, but it is typically considered an acute stress event. However, if the crime results in long-term effects such as physical harm or psychological trauma, it could potentially lead to chronic stress.

The loss of a loved one can cause both acute and chronic stress. The initial loss can cause acute stress, and the subsequent grieving process can lead to chronic stress, especially if the individual has difficulty moving through the stages of grief. However, not everyone who loses a loved one will experience chronic stress.

The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.

Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.

An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.

Increased muscle mass is not typically an age-related change. In fact, older adults often experience a decrease in muscle mass, a condition known as sarcopenia.

Increased calcification of bones is not a typical age-related change. Older adults are more likely to experience osteoporosis, a condition characterized by a decrease in bone density.

Decreased balance is a common age-related change, but it is not the correct answer for this question.

Restlessness is an observable behavior, making it an objective finding.

Pacing is also an observable behavior, so it is considered an objective finding.

Alertness is an objective finding because it can be directly observed and measured.

Episodic acute stress is a type of stress that occurs in response to specific situations or events. It does not typically involve flashbacks of a traumatic event.

Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. While stress can exacerbate symptoms of IBS, it is not a stress-related disorder in the sense of being a psychological response to stress.

Acute stress disorder (ASD) is a stress-related disorder that can occur in response to a traumatic event. However, ASD symptoms occur immediately after the traumatic event and typically resolve within a month. Since the patient reports experiencing flashbacks of a traumatic event that occurred a year ago, ASD is not the correct answer.

Hypoglycemia, or low blood sugar, is not typically a manifestation of the fight-or-flight response. In fact, the opposite is true. During the fight-or-flight response, the body’s glucose levels often increase to provide extra energy for the perceived threat.

Bronchial airway constriction is not typically associated with the fight-or-flight response. In fact, the bronchial airways often dilate during this response to allow for increased oxygen flow, which is necessary for physical exertion.

Decreased blood pressure is not a typical response to stress. During the fight-or-flight response, blood pressure usually increases to enhance blood flow to the muscles and brain.

Regression is a defense mechanism where an individual reverts to an earlier stage of development or a less mature behavior when faced with stress or anxiety. This does not fit the scenario provided.

Projection involves attributing one’s own unacceptable feelings or thoughts to others. This is not the case in the scenario provided.

Repression involves unconsciously blocking out painful or uncomfortable thoughts or feelings. This does not fit the scenario provided.

Using a standard height toilet seat is not necessarily a recommended strategy for reducing the risk of falls. A toilet seat at an appropriate height for the individual would be more beneficial.

Wearing backless shoes is not a recommended strategy for reducing the risk of falls. Shoes with good support and non-slip soles are typically recommended.

Covering extension cords with a throw rug is not a recommended strategy for reducing the risk of falls. This could potentially create a tripping hazard.

Fairness refers to treating all people equally and making decisions without favoritism or prejudice. This is not the most fitting answer because the scenario does not provide information about the nurse treating all patients equally.

Confidence in nursing involves trust in one’s abilities and clinical judgment. Although confidence is important in all nursing actions, this scenario does not specifically highlight the nurse’s confidence. Choice C rationale
Advocacy in nursing refers to the nurse’s role in standing up for the rights and needs of their patient. While notifying the provider could be seen as a form of advocacy, the nurse’s actions in this scenario are more closely aligned with accountability.

Neurogenic bladder is a condition where a person lacks bladder control due to a brain, spinal cord or nerve condition. This is not the most fitting answer because the scenario does not provide information about any neurological conditions.

Bladder outlet obstruction is a condition where the bladder is not able to empty properly. While urinary retention could be a symptom of this condition, the scenario does not provide enough information to suggest this diagnosis.

Genitourinary System Effects is a broad term that refers to any effects on the genital and urinary systems. This is not the most fitting answer because it is less specific than Choice B2.

A wrist fracture is a physical stressor, not a psychological one. It involves damage to the body’s structures.

A burn injury, like a wrist fracture, is a physical stressor. It involves physical harm to the body.

Hypothermia is a physical stressor. It involves a dangerously low body temperature and is a medical emergency.

Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case, the patient is able to stand up from a seated position using a cane for support, which suggests that they do not need assistance.

Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane.

Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.

A low-fiber diet can actually contribute to constipation. Fiber adds bulk to the stool and helps it move more quickly through the intestines.

While mineral oil can sometimes be used to relieve constipation, it is not typically the first intervention chosen. It can interfere with the absorption of certain nutrients and medications.

Cold fluids do not have a significant effect on constipation. While staying hydrated is important, the temperature of the fluids is not typically a factor in constipation.

Reporting the APs to the charge nurse may seem like an appropriate action, but it does not directly address the conflict. It’s important for the nurse to take an active role in conflict resolution, rather than passing the responsibility to someone else.

Allowing the APs to resolve their issues might be a good idea in some situations, but it’s not the best choice here. As a nurse, it’s part of your role to ensure that conflicts are resolved in a way that promotes a positive and productive work environment. By simply allowing the APs to resolve their issues, you’re not taking an active role in conflict resolution.

Telling the APs they are acting immaturely is not an effective way to resolve conflict. This approach is likely to escalate the conflict rather than resolve it. It’s important to approach conflicts with a goal of understanding and resolution, rather than placing blame or making judgments.

Adventitious stressors are unexpected and often traumatic events that occur outside of the normal course of life. These could include natural disasters, accidents, or violent crimes. While homelessness can be traumatic, it is not considered an adventitious stressor because it is related to the individual’s social and economic circumstances.

Developmental stressors are those that occur as a result of going through the normal stages of life, such as starting school, getting a job, getting married, having children, and retiring. Homelessness is not a developmental stressor because it is not a normal or expected part of life.

Cultural stressors are related to a person’s cultural background and experiences. While culture can influence a person’s socioeconomic status, homelessness itself is not a cultural stressor.

Academic pressure is a psychological stressor, not a physiological one. It involves mental or emotional strain or tension resulting from adverse or demanding circumstances, in this case, related to academic performance.

Financial difficulties are a type of environmental stressor, not a physiological one. They involve external factors in a person’s environment that cause stress, such as financial problems or jobrelated stress.

A change in marital status is a type of psychosocial stressor, not a physiological one. It involves both psychological factors (such as emotions and behavior) and social factors (such as relationships and social interactions).

Finishing sentences for the patient can be seen as disrespectful and may lead to frustration. It’s important to allow the patient to communicate at their own pace.

While open-ended questions can be useful in some situations, they may be challenging for a patient with impaired speech. It might be more effective to ask yes/no questions or use other communication aids.

Visual aids can be very helpful for patients with speech impairments. They can supplement verbal communication and make it easier for the patient to understand and be understood.