The nurse recognizes that a client experiencing anxiety related ...

[mikaylakyoung]

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

Question 2

A client has developed pneumonia, and his temperature has increased to 37.7 C. The client is shivering and feels uncomfortable. The nurse should:
 
  1. Apply hot packs to the axilla and groin
  2. Wrap the client's four extremities
  3. Restrict oral fluid consumption
  4. Apply a hypothermia mattress

[fur]

Answer to Question 1

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.

Answer to Question 2

ANS: 3
Wrapping the client's extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the client's axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided.

[mikaylakyoung]

Thank you!

[fur]

Always glad to help...