A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress

Question

What did the nurse assess to make this determination?
Standard Text: Select all that apply.
1. Dilated pupils
2. Diaphoretic
3. Tachycardia
4. Flaccid muscle tone
5. Excessive oral secretions

Answer 1

Correct Answer: 1, 2, 3
Rationale 1: Pupils dilate to increase visual perception when serious threats to the body arise.
Rationale 2: Sweat production or diaphoresis increases to control elevated body heat due to increased metabolism.
Rationale 3: The heart rate increases to transport nutrients and by-products of metabolism more efficiently.
Rationale 4: Muscle tension increases to prepare for rapid motor activity or defense.
Rationale 5: The mouth might be dry, and would not have an increase in oral secretions.