The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the re-sulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.)
1. Rectal temperature of 102.2° F
2. Pulse Ox of 97% on room air
3. Respirations of 30 breaths per minute
4. Heart rate greater than 100 beats per minute
5. Fasting glucose level of 118 mg/dL
6. Systolic blood pressure 26 mm Hg above baseline
ANS: 3, 4, 5, 6
This reaction prepares a person for action by increasing heart rate; diverting blood from the intes-tines to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar levels. Body temperature and oxygen saturation are not typically affected by fight or flight.
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A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
a. Rubella b. Leukoplakia c. Rheumatic fever d. Scarlet fever
For a client who has aplastic anemia and has not responded to medical treatment, the client's BEST hope for recovery would be:
a. administration of antithymocyte globulin for 7 to 10 days b. bone marrow transplant c. transfusions of packed cells and platelets d. treatment with antibiotics
A client who prefers complementary treatments reports drinking cranberry juice to prevent UTIs. What should the nurse respond to this client?
a. "There is no proof that cranberry juice can help to prevent UTIs." b. "Dried cranberries are more effective in preventing UTIs than cranberry juice." c. "Cranberry juice has high amounts of added sugar and is more likely to cause than prevent UTIs." d. "Cranberry juice may help to prevent UTIs when combined with adequate fluid intake and good personal hygiene."
A nurse is assessing a worker who has had a health reaction to a "safe" low-level exposure. Which of the following most likely describes what has happened?
a. An allergic reaction b. A compromised immune system c. Hypersusceptibility d. Malnutrition