Stress
Which of the following are common physiological effects observed during the resistance stage of General Adaptation Syndrome? Select all that apply.
A. Increased cortisol secretion
B. Stabilization of blood pressure
C. Decreased immune function
D. Return to parasympathetic dominance
E. Continued high alertness
Correct: A, B, C, E
A. Increased cortisol secretion: Cortisol continues to be secreted to help the body cope.
B. Stabilization of blood pressure: The body attempts to return to normal, despite continued stress.
C. Decreased immune function: Persistent stress hormone release suppresses the immune response.
E. Continued high alertness: The body remains physiologically aroused to resist the stressor.
D is incorrect because the body remains under sympathetic (not parasympathetic) influence during stress.
A client experiencing chronic stress has a decrease in heart rate variability (HRV). What does this finding most likely indicate?
A. Improved parasympathetic nervous system function
B. A healthy adaptation to stress
C. Poor autonomic nervous system flexibility
D. Increased emotional resilience
Correct: C. Poor autonomic nervous system flexibility
Decreased HRV reflects dysregulation of the autonomic nervous system, particularly a dominance of the sympathetic (fight-or-flight) response and suppression of parasympathetic (rest-and-digest) activity. It’s linked to chronic stress and a reduced ability to adapt to physiological challenges.
A client reports no bowel movement in 5 days, along with abdominal distension and discomfort. The nurse auscultates hypoactive bowel sounds. Which intervention does the nurse anticipate?
A. Administering an antidiarrheal medication
B. Preparing the client for an enema
C. Encouraging bed rest and low-residue diet
D. Placing the client on NPO status immediately
Correct: B. Preparing the client for an enema
A prolonged absence of bowel movements, distension, and decreased peristalsis suggest constipation. An enema may be ordered to stimulate evacuation.
Antidiarrheals and NPO status are inappropriate, and bed rest would worsen motility.
A nurse is assessing a female client who reports urine leakage when laughing, coughing, or lifting heavy objects. The nurse recognizes this as which type of incontinence?
A. Urge incontinence
B. Functional incontinence
C. Overflow incontinence
D. Stress incontinence
Correct: D. Stress incontinence is caused by increased intra-abdominal pressure (from laughing, coughing, sneezing) that overcomes weakened pelvic floor muscles, leading to urine leakage. It is common in women, especially postpartum or postmenopause.
A. Urge incontinence involves involuntary bladder contractions that cause a sudden, intense urge to void, often resulting in leakage. It is common in clients with overactive bladder, neurologic disorders, or bladder irritation.
Functional incontinence occurs when a client is unable to reach the toilet or recognize the need to void due to cognitive impairment or immobility.
C. Overflow incontinence occurs when the bladder is overdistended and cannot empty properly, leading to constant dribbling. Common causes include prostate enlargement, diabetes-related neuropathy, or spinal cord injury.
A client with hypovolemic shock is admitted to the emergency department. Which type of fluid does the nurse anticipate administering first?
A. 0.45% Normal Saline (½ NS)
B. 5% Dextrose in Water (D5W)
C. 0.9% Normal Saline (NS)
D. 3% Normal Saline
Correct: C. 0.9% Normal Saline (NS)
Isotonic fluids, like 0.9% NS, expand intravascular volume without shifting fluid between compartments, making them ideal for immediate fluid resuscitation in hypovolemic shock.
Hypotonic and hypertonic solutions are not appropriate first-line in this setting.
A college student reports difficulty sleeping and loss of appetite after failing an important exam. The nurse identifies this as:
A. Physiological stress
B. Psychological stress
C. Developmental stress
D. Situational stress
Correct: B. Psychological stress
Psychological stress arises from perceived threats to emotional or mental well-being, such as academic failure, conflict, or grief. The symptoms may manifest physically (e.g., insomnia or appetite changes).
A. Physiological stress is the body’s direct response to a physical stressor, such as infection, trauma, blood loss, or pain. Sepsis causes a systemic inflammatory response that activates the sympathetic nervous system
C. Developmental stress is associated with life stage transitions, such as becoming a parent, entering middle age, or retiring. The “sandwich generation” often experiences stress from multiple caregiving roles.
D. Situational stress occurs in response to sudden or unpredictable life events, such as illness, job loss, or a car accident. It’s not related to age or developmental stage.
A client recently diagnosed with diabetes begins meal prepping, exercising regularly, and attending a diabetes education class. Which type of coping strategy is the client using?
A. Accepting the stressor
B. Adapting to the stressor
C. Altering the stressor
D. Aggravating the stressor
Correct: C. Altering the stressor
Altering the stressor involves taking direct action to change the situation (e.g., managing diet and lifestyle). It’s problem-focused coping, aimed at removing or changing the source of stress.
A. Accepting the stressor is used when the situation cannot be changed, so the focus shifts to emotional regulation and mindset.
B. Adapting means changing one’s thoughts, behaviors, or environment to tolerate the stressor more effectively.
D. Aggravating the stressor leads to worsening of the stressor via poor coping with using substances, lashing out, and avoiding the situation
Which type of ostomy output is most likely to contain digestive enzymes and be highly irritating to the surrounding skin?
A. Descending colostomy
B. Sigmoid colostomy
C. Ileostomy
D. Urostomy
Correct: C. Ileostomy
An ileostomy involves bringing the ileum (end of the small intestine) to the surface of the abdomen. The output is liquid to semi-liquid and contains active digestive enzymes (e.g., bile, pancreatic enzymes) that can irritate or damage peristomal skin. This requires careful skin protection and frequent pouch changes.
A nurse is caring for a postoperative client who just had abdominal surgery. The nurse notes the client’s urine output is 15 mL/hr for the first hour. What is the most appropriate nursing action?
A. Document the output and continue routine monitoring
B. Encourage oral fluids and reassess in 2 hours
C. Notify the healthcare provider immediately
D. Administer a diuretic as ordered
Correct: C. Notify the healthcare provider immediately
Urine output less than 30 mL/hr is a sign of oliguria, which may indicate hypovolemia, renal impairment, or obstruction postoperatively. Prompt notification is required for early intervention.
A nurse is assessing a client for signs of hypovolemia following a gastrointestinal illness with vomiting and diarrhea. Which of the following findings are most indicative of hypovolemia? Select all that apply.
A. Tachycardia
B. Bounding pulse
C. Hypotension
D. Dry mucous membranes
E. Increased skin turgor
F. Decreased urine output
G. Warm, flushed skin
Correct: A, C, D, F
A. Tachycardia – The body compensates for low blood volume by increasing heart rate.
C. Hypotension – Decreased volume leads to low blood pressure, especially orthostatic hypotension.
D. Dry mucous membranes – Common finding in dehydration or fluid volume deficit.
F. Decreased urine output – Kidneys conserve fluid in response to volume loss, leading to oliguria.
B (Incorrect). Bounding pulse – Seen in fluid overload, not deficit. Hypovolemia produces weak, thready pulses.
E (Incorrect). Increased skin turgor – In hypovolemia, skin turgor is decreased (skin “tents” when pinched).
G (Incorrect). Warm, flushed skin – More typical of vasodilation (e.g., fever or sepsis); hypovolemia causes cool, pale skin.
A hospitalized client expresses anxiety about an upcoming procedure. Which nonpharmacological intervention should the nurse implement first?
A. Offer the client a PRN anti-anxiety medication
B. Teach the client deep breathing and relaxation techniques
C. Tell the client not to worry because the procedure is routine
D. Suggest the client try to sleep to avoid thinking about it
Correct: B. Teach the client deep breathing and r
The nurse should begin with nonpharmacological techniques to promote relaxation and reduce stress. Deep breathing and relaxation can help the client regain a sense of control.
Medications (option A) may be appropriate later but are not the first-line intervention.
Option C invalidates the client’s feelings
Option D avoids the issue rather than addressing it.
Which of the following vital sign changes might indicate that a client is experiencing poor coping and stress overload? Select all that apply.
A. Increased heart rate
B. Decreased respiratory rate
C. Elevated blood pressure
D. Elevated body temperature
E. Decreased oxygen saturation
Correct: A, C, D
A. Increased HR – sympathetic activation
C. Elevated BP – common in stress-induced sympathetic stimulation
D. Elevated temp – stress may raise body temperature mildly due to catecholamine release
B. Decreased RR – opposite of typical stress response
E. Decreased SpO₂ – not typically related to psychological stress unless respiratory compromise exists
The nurse is assessing a client who reports not having a bowel movement in several days. Which of the following assessment questions are appropriate for evaluating constipation? Select all that apply.
A. “How often do you normally have a bowel movement?”
B. “Do you feel the urge to defecate but are unable to pass stool?”
C. “Are you experiencing any abdominal pain or bloating?”
D. “Do you take any medications such as opioids or iron supplements?”
E. “Would you like to try a high-protein diet to help your bowels move?”
F. “Have you had any changes in your diet, fluid intake, or physical activity?”
G. “Is your stool hard, dry, or difficult to pass?”
Correct: A, B, C, D, F, G
A. "How often do you normally have a bowel movement?"
Establishing the client’s baseline pattern is crucial for identifying changes.
B. "Do you feel the urge to defecate but are unable to pass stool?"
Helps determine functional vs. mechanical constipation or signs of obstruction.
C. "Are you experiencing any abdominal pain or bloating?"
These are common symptoms of constipation or bowel dysfunction.
D. "Do you take any medications such as opioids or iron supplements?"
Certain medications are well-known causes of constipation.
F. "Have you had any changes in your diet, fluid intake, or physical activity?"
Lifestyle factors are key contributors to bowel health.
G. "Is your stool hard, dry, or difficult to pass?"
This identifies classic signs of constipation, based on stool consistency.
E (Incorrect). "Would you like to try a high-protein diet to help your bowels move?"
High-protein diets are not indicated for constipation; high-fiber and fluid intake are more appropriate.
A nurse is reviewing orders for clients requiring urinary catheterization. Which of the following are appropriate clinical indications for inserting an indwelling urinary catheter? Select all that apply.
A. A client in the ICU who is hemodynamically unstable and needs accurate urine output monitoring
B. A client with urinary incontinence who is not cooperative with toileting
C. A client undergoing a prolonged surgical procedure under general anesthesia
D. A client with a stage 4 pressure ulcer who is incontinent of urine
E. A client in acute urinary retention who is unable to void
F. A client requesting a catheter to avoid using the bedpan
G. A client receiving epidural anesthesia for labor pain control and has limited mobility
Correct: A, C, D, E, G
A. ICU monitoring – In critical care, accurate hourly output is essential for managing unstable clients.
C. Long surgical procedures – Catheterization is needed to monitor urine output and prevent bladder overdistension during surgery.
D. Stage 4 pressure ulcer – Incontinence can delay healing; catheterization is acceptable when needed to protect wounds.
E. Acute urinary retention – Catheter insertion is the standard treatment to relieve retention.
G. Limited mobility due to epidural anesthesia – Catheter use is appropriate until the client can void safely.
B (Incorrect). Incontinence alone is not a justification for a catheter unless it interferes with wound healing (e.g., sacral ulcers). Behavioral or toileting interventions should be tried first.
F (Incorrect). Patient convenience is never an appropriate reason for catheterization.
A nurse is reviewing lab values and client symptoms. Which of the following findings indicate abnormal electrolyte levels? Select all that apply.
A. Potassium 6.2 mEq/L in a client with muscle weakness and ECG changes
B. Sodium 132 mEq/L in a client reporting confusion and headache
C. Calcium 10.5 mg/dL in a client with constipation and lethargy
D. Magnesium 1.0 mg/dL in a client with tremors and positive Chvostek’s sign
E. Sodium 148 mEq/L in a client with dry mucous membranes and thirst
F. Potassium 3.8 mEq/L in a client with no cardiac symptoms
G. Calcium 8.6 mg/dL in a client post-parathyroidectomy with muscle cramps
Correct: A, B, C, D, E, G
A. Potassium 6.2 mEq/L
Indicates hyperkalemia. Symptoms include muscle weakness, bradycardia, peaked T waves—can be life-threatening.
B. Sodium 132 mEq/L
Hyponatremia, especially when symptomatic (confusion, headache), is abnormal and requires intervention.
C. Calcium 10.5 mg/dL
Upper limit of normal; paired with constipation and lethargy, this suggests hypercalcemia.
D. Magnesium 1.0 mg/dL
Hypomagnesemia often presents with tremors, seizures, and positive Chvostek’s or Trousseau’s sign (also seen in hypocalcemia).
E. Sodium 148 mEq/L
Hypernatremia, indicated by thirst, dry mucous membranes, confusion, often caused by dehydration.
G. Calcium 8.6 mg/dL
Borderline hypocalcemia. Post-parathyroidectomy clients are at high risk for hypocalcemia, with symptoms like muscle cramps, tetany, numbness/tingling.
F (Incorrect). Potassium 3.8 mEq/L
Normal range is 3.5–5.0 mEq/L; no symptoms = no concern.
A nurse is preparing a client for surgery when the client’s family repeatedly interrupts with questions and concerns. What is the best nursing action?
A. Ask the family to leave the room immediately
B. Ignore the interruptions to focus on surgical prep
C. Involve the family by giving brief, appropriate updates and setting boundaries
D. Let the family take over the preparation to comfort the client
Correct: C. Involve the family by giving brief, appropriate updates and setting boundaries
Including family members in a structured and respectful way supports client-centered care, while setting boundaries helps maintain focus.
A is abrupt and may escalate stress.
B ignores client needs.
D is inappropriate and unprofessional delegation of care.
Which of the following are appropriate nursing actions when providing crisis intervention? Select all that apply.
A. Promote a sense of control
B. Encourage decision-making
C. Avoid discussing the stressful event
D. Inquire about support system
E. Focus on long-term therapy goals
Correct: A, B, and D
A. Promote a sense of control – helps reduce helplessness.
B. Encourage decision-making – restores autonomy.
D. Inquire about support system– a support system provides emotional comfort and potential help when a client begins to cope after a crisis.
C (Incorrect). Avoid discussing the event – not appropriate; clients may need to express and process their feelings.
E (Incorrect). Focus on long-term therapy – crisis care is short-term, not for long-term therapy planning.
The nurse is performing a focused GI assessment. Which of the following questions are appropriate when a client reports infrequent bowel movements? Select all that apply.
A. “When was your last bowel movement?”
B. “What does your usual stool look like?”
C. “Have you experienced any unintentional weight loss?”
D. “Do you avoid dairy products?”
E. “Have you recently changed any medications?”
F. “How often do you normally have a bowel movement?”
Correct: A, B, C, E, F
A. Last BM – Establishes baseline and potential severity of delay
B. Usual stool appearance – Assesses for abnormalities (color, consistency)
C. Weight loss – Could indicate malabsorption or GI pathology
E. Medications – Many (e.g., opioids, iron, anticholinergics) can cause constipation
F. Normal pattern – Helps determine deviation from baseline
D. Dairy – Not directly related unless lactose intolerance or IBS is suspected
Which of the following are appropriate steps when providing catheter care for a male client? Select all that apply.
A. Perform hand hygiene and wear clean gloves
B. Retract the foreskin if the client is uncircumcised and replace it after cleansing
C. Use a sterile technique to clean the catheter
D. Clean the catheter tubing from insertion site toward the drainage bag at least for 4 inches
E. Use a clean washcloth and warm water to cleanse the perineal area
F. Perform catheter care at least once per shift or per facility policy
Correct: A, B, D, E, F
A. Hand hygiene and gloves are essential for preventing infection.
B. Retracting and replacing the foreskin prevents paraphimosis and ensures proper cleaning.
D. Always clean the catheter from insertion site down the tubing to prevent introducing bacteria.
E. Using a clean washcloth with warm water is part of standard perineal hygiene.
F. Catheter care should be done at least once per shift or more often if needed (e.g., incontinence or soiling).
C (Incorrect). Sterile technique is not required for routine catheter care — clean technique is appropriate.
Which of the following are appropriate nursing considerations when administering a hypertonic sodium phosphate enema? Select all that apply.
A. Position the client in the left lateral Sims’ position
B. Warm the solution to body temperature before administration
C. Instruct the client to retain the enema for 5–15 minutes
D. Monitor for signs of fluid volume overload in elderly clients
E. Use caution in clients with chronic kidney disease
F. Flush the enema tubing with 30 mL of sterile water before use
Correct: A, C, D, E
A. Left Sims’ position promotes flow into the sigmoid colon.
C. Retention for 5–15 minutes helps maximize effect.
D. Older adults are at risk for fluid shifts and electrolyte imbalance.
E. Sodium phosphate enemas can cause hyperphosphatemia and hypocalcemia in clients with renal impairment.
B (Incorrect). Warming is not necessary and may alter solution composition. Room temperature is appropriate.
F (Incorrect). No need to flush; it comes pre-lubricated and pre-filled.
Which of the following clinical findings in a client suggest they are in the alarm stage of stress response? Select all that apply.
A. Restlessness
B. Cool, clammy skin
C. Hypertension
D. Fatigue and immune suppression
E. Tachypnea
F. Slow digestion
Correct: A, B, C, E, F
A. Restlessness – Increased alertness and anxiety are common during acute stress.
B. Cool, clammy skin – Peripheral vasoconstriction shunts blood to vital organs.
C. Hypertension – Blood pressure rises due to SNS stimulation.
E. Tachypnea – Increased respiratory rate helps oxygenate tissues.
F. Slow digestion – GI activity slows during stress to conserve energy for vital functions.
D (Incorrect). Fatigue and immune suppression – These are more associated with the resistance or exhaustion stages.
The nurse is caring for a hospitalized client experiencing high levels of stress related to a new diagnosis. Which of the following nonpharmacological interventions can the nurse implement to support the client’s coping? Select all that apply.
A. Deep breathing exercises
B. Progressive muscle relaxation
C. Administering PRN anxiolytics
D. Guided imagery
E. Music therapy
F. Encouraging verbal expression of feelings
Correct: A, B, D, E, F
A. Deep breathing exercises – Activates the parasympathetic nervous system and reduces tension.
B. Progressive muscle relaxation – Decreases physical symptoms of anxiety and stress.
D. Guided imagery – Helps clients mentally escape stress through visualization techniques.
E. Music therapy – Proven to lower heart rate, reduce anxiety, and promote calm.
F. Encouraging verbal expression of feelings – Part of therapeutic communication that facilitates emotional processing.
C (Incorrect). Administering PRN anxiolytics – This is a pharmacologic, not nonpharmacologic, intervention.
Which nursing interventions would help support a client who is having difficulty coping with a new colostomy? Select all that apply.
A. Offer to involve the client's support system (family, spouse)
B. Encourage expression of feelings about body image changes
C. Avoid discussing the colostomy unless the client brings it up
D. Refer to a wound ostomy continence (WOC) nurse
E. Provide step-by-step teaching for pouch emptying and skin care
F. Reassure the client that the colostomy can be reversed at any time
Correct: A, B, D, E
A. Involving support systems promotes emotional adjustment and prevents isolation.
B. Encouraging open discussion helps clients process changes and validate emotions.
D. Referral to a WOC nurse provides expert support and can improve confidence and outcomes.
E. Step-by-step teaching builds self-care skills, promotes independence, and reduces fear.
C (Incorrect). Avoidance may worsen anxiety and hinder adaptation. Nurses should create open dialogue.
F (Incorrect). Not all colostomies are reversible. Offering false reassurance undermines trust.
A client with an indwelling urinary catheter reports discomfort and inability to urinate properly. Which of the following assessments should the nurse perform? Select all that apply.
A. Check the catheter tubing for kinks or obstruction
B. Assess the color, clarity, and amount of urine in the drainage bag
C. Palpate the bladder for distension
D. Ask the client about the sensation of bladder fullness
E. Flush the catheter with sterile water immediately
F. Inspect the catheter insertion site for redness or swelling
Correct: A, B, C, D, F
A. Check tubing for kinks or obstruction
Kinks or clots can block urine flow, causing retention and discomfort.
B. Assess urine characteristics
Cloudy, bloody, or foul-smelling urine may indicate infection; low urine volume may signal obstruction or dehydration.
C. Palpate the bladder
Distension suggests urine retention despite catheter presence, indicating possible blockage or malfunction.
D. Ask about bladder sensation
Understanding the client’s perception helps evaluate if catheter is draining properly.
F. Inspect insertion site
Redness, swelling, or discharge may indicate infection or irritation contributing to symptoms.
E (Incorrect). Flush catheter immediately
Flushing should only be done per protocol or provider order to avoid infection or trauma.
The nurse is assessing a client suspected of having fluid volume excess. Which of the following findings support this diagnosis? Select all that apply.
A. Bounding peripheral pulses
B. Increased hematocrit level
C. Neck vein distention (JVD)
D. Crackles in the lungs
E. Dry mucous membranes
F. Weight gain in a short period
G. Edema in the lower extremities
H. Hypotension
Correct: A, C, D, F, G
A. Bounding peripheral pulses
Excess fluid increases vascular volume and pressure, resulting in strong, bounding pulses.
C. Neck vein distention (JVD)
A classic sign of fluid overload, especially with right-sided heart failure.
D. Crackles in the lungs
Fluid may accumulate in the alveoli, causing crackles/rales, especially with pulmonary edema.
F. Weight gain in a short period
A key indicator of FVE. Rapid gain of even 2–3 lbs in 24 hours can reflect fluid retention.
G. Edema in the lower extremities
Increased hydrostatic pressure leads to interstitial fluid accumulation, especially in dependent areas.
B (Incorrect). Increased hematocrit level
Hematocrit is diluted in fluid volume excess, so it typically decreases, not increases.
E (Incorrect). Dry mucous membranes
Seen in fluid volume deficit, not excess.
H (Incorrect). Hypotension
FVE typically causes hypertension due to increased intravascular volume.