Question

A nurse is conducting a class on stress. Which of the following would the nurse include as an example of acute stress?

Answer 1

Correct Answers:

Being a victim of a crime

Rationale :

✅Acute stress results from a sudden, short-term exposure to a traumatic or intense event.

✅Being a victim of a crime fits this definition because it introduces an immediate, threatening experience that activates the sympathetic nervous system, triggering symptoms like increased heart rate, alertness, and anxiety.

✅Nurses must recognize this as an acute psychological response that typically resolves once the threat is removed or managed.

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Answer 2

Correct Answers:

The nurse understands that these are impending signs of death and are normal

Rationale :

In hospice care, symptoms such as loss of appetite, peripheral edema, increased sleep, Cheyne-Stokes respirations, and hallucinations are hallmark signs of impending death.
These changes result from multisystem organ decline.
Cheyne-Stokes breathing reflects irregular respiratory patterns caused by neurological dysregulation, while hallucinations are often due to metabolic shifts or hypoxia.
These signs require comfort care, not emergency interventions.

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Answer 3

Correct Answers:

100 mL/hr

Rationale :

✍To calculate the correct IV rate:

Total volume ÷ total time = infusion rate
1,000 mL ÷ 10 hr = 100 mL/hr.

✍This ensures precise fluid replacement to restore hydration while avoiding complications such as fluid overload, especially in clients with cardiac or renal conditions.

✍Accurate programming of the IV pump is a core nursing responsibility.

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Answer 4

Correct Answers:

"l am hoping this will limit my discomfort and give me the best quality of life for me."

Rationale :

🎯Palliative care focuses on comfort, symptom relief, emotional support, and quality of life, rather than cure.

🎯The patient’s statement shows an accurate understanding of palliative intent, where care is holistic and tailored to physical, emotional, and spiritual needs.

🎯Nurses play a key role in ensuring that patients’ goals and values guide care.

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Answer 5

Correct Answers:

Decreased ability to hear high-frequency sounds

Rationale :

▶Presbycusis is the gradual loss of hearing associated with aging, especially for high-frequency sounds like consonants (e.g., “s” or “th” sounds).

▶It results from degeneration of hair cells in the cochlea and decreased elasticity of the tympanic membrane.

▶This auditory change impacts communication and can lead to social withdrawal or safety issues if not addressed.

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Answer 6

Correct Answers:

Living in poverty

Rationale :

🤞Chronic stress refers to ongoing, long-term exposure to stressors that persist over time without resolution.

🤞Living in poverty is a continuous social stressor that impacts mental health, coping ability, and physical well-being.

🤞It contributes to chronic cortisol elevation, increasing risks for hypertension, diabetes, and depression.

🤞Nurses should assess for socioeconomic stress and advocate for resources.

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Answer 7

Correct Answers:

A perceived stressor stimulates the central nervous system.

Rationale :

💎In the alarm stage of the General Adaptation Syndrome (GAS), the body perceives a stressor and activates the central nervous system (CNS).

💎This stimulation triggers the hypothalamic-pituitary-adrenal (HPA) axis, releasing adrenaline and cortisol, and preparing the body for fight-or-flight.

💎Recognizing this initial response helps nurses implement early interventions for stress management.

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Answer 8

Correct Answers:

Increased joint stiffness

Rationale :

🔹A normal aging change in the musculoskeletal system includes increased stiffness of joints, primarily due to decreased synovial fluid production, cartilage wear, and reduced flexibility.

🔹This can impair mobility and increase fall risk.

🔹Nurses should encourage gentle exercise, ROM activities, and fall-prevention strategies to support safe movement.

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Answer 9

Correct Answers:

Anxiety

Rationale :

🟣Subjective data is any information reported by the patient that cannot be observed or measured directly.

🟣Anxiety is a personal emotional experience, not visible like pacing or restlessness.

🟣Nurses document this based on patient self-report, which is essential in understanding psychological status and guiding care interventions.

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Answer 10

Correct Answers:

Post-traumatic stress disorder (PTSD)

Rationale :

📌PTSD is a long-term mental health disorder that occurs after exposure to a traumatic event, often presenting with flashbacks, intrusive thoughts, hypervigilance, and emotional detachment.

📌When symptoms persist for more than one month, the diagnosis shifts from acute stress disorder to PTSD.

📌This condition requires psychological support, counseling, and sometimes medication, making early identification by nurses vital.

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QLexNursing

1 : A nurse is conducting a class on stress. Which of the following would the nurse include as an example of acute stress?

3 : The provider orders fluid replacement for a dehydrated patient. The order entered is 1000 mL over 10 hours. If using an IV pump, what is the rate that the nurse should enter?

4 : A nurse is caring for a patient who has cancer and is receiving palliative care. Which of the following statements by the patient indicates an understanding of this type of treatment?

5 : A nurse is teaching a class about physiological changes to hearing in older adult patients. Which of the following should the nurse include?

6 : A nurse is teaching a class about stress. The nurse should include that which of the following is an example of chronic stress?

7 : A nurse is teaching a class about the stages of the general adaptive syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs during GAS?

8 : A nurse is assessing an older adult patient who is experiencing age-related changes. Which of the following findings should the nurse expect?

9 : A nurse is assessing a patient who reports feeling stress and anxiety. The patient appears restless and is pacing in the room. The patient is alert and oriented to person, place, and time. Which of the following findings is subjective?

10 : A nurse is providing care for a patient who reports experiencing flashbacks of a traumatic event that occurred a year ago. Which of the following stress-related disorders should the nurse identify that the patient is experiencing?