The nurse recognizes that a client experiencing anxiety related to a t

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

ANSWER

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.