During the physical assessment, the hospitalized client states, "I've been under an incredible amount of stress since my healthcare provider diagnosed me with colon cancer 2 days ago."
Which assessment data collected by the nurse are associated with increased stress?
Select all that apply.
1. Apical heart rate is 104 beats per minute.
2. Respiratory rate is 16 breaths per minute.
3. Pupils were equal, dilated, and round.
4. Client is hypoglycemic.
5. Blood pressure is 158/94.
Correct Answer: 1, 3, 5
When the client is experiencing increased levels of stress, the apical heart rate increases. The client with increased levels of stress will have an increased respiratory rate. The client who is experiencing increased levels of stress may exhibit dilated pupils. The client with increased levels of stress will have an increased serum glucose level. The client who is experiencing increased levels of stress may have an increased blood pressure.
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