In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of stress management in order to:

  • Recognize nonverbal cues to physical and/or psychological stressors
  • Assess stressors, including environmental, that affect client care (e.g., noise, fear, uncertainty, change, lack of knowledge)
  • Implement measures to reduce environmental stressors (e.g., noise, temperature, pollution)
  • Provide information to client on stress management techniques (e.g., relaxation techniques, exercise, meditation)
  • Evaluate the client's use of stress management techniques

Homeostasis is bodily balance. The body aims to maintain its balance despite changes in its internal environment and the external environment. For example, the body will compensate for internal changes such as hypothermia with physiological responses such as shivering to create heat, and the body will compensate for external changes and disruptions such as infectious pathogenic organisms with the defenses of the skin and other natural, protective mechanisms such as the immune response to regain its balance.

Homeostasis can be threatened by physical, psychological, social and spiritual forces and factors such as metabolic acidosis, a psychological trauma, a low economic status, and spiritual distress, respectively. All threats to homeostasis are responded to with responses by the body to regain its balance and its normal state.

These disruptive factors and forces are referred to as stressors and the responses of the body to these stressors include bio-psycho-spiritual stress and distress as well as maladaptive and adaptive methods of coping. A failure of the human body to effectively cope with stressors and to regain its balance and normal functioning will lead to death.

Although at first glance stressors may appear to be only destructive to homeostasis, that is not the case. Without stressors we would not be able to survive. For example, the human body would not breathe without a stressor; it is the presence of carbon dioxide in the body, which is a physiological stressor, that causes us to breathe. Breathing occurs as the result of the body's response to this stressor. When stressors become so great and intense and the body is no longer able to cope with them and adapt to them effectively that harm occurs to the client.

As mentioned earlier, Hans Selye's General Adaptation Syndrome theory and the Local Adaptation theory explain the body's local and systemic responses to stressors. The stages of stress, according to the General Adaptation Syndrome theory, in correct sequential order, include:

  • The stage of alarm
  • The stage of resistance
  • The stage of exhaustion

The signs and symptoms for each of these stages of the General Adaptation Syndrome theory will be discussed immediately below in the section entitled "Recognizing Nonverbal Cues to Physical and/or Psychological Stressors".

Recognizing Nonverbal Cues to Physical and/or Psychological Stressors

The nonverbal cues, signs and symptoms in terms of a response to psychological stressors include, during the alarm stage of stress and in terms of generality, those physiological and psychological responses that ready the body to take flight and flee from the stressor. These responses were totally necessary and appropriate during earlier times when the human cave man, for example, had to escape from life threatening stressors such as wild, predatory and carnivorous lions and tigers; however, at the current time these same responses create not only psychological damage but also physiological damage, such as hypertension, that can remain permanent and life threatening when these responses persist over a long period of time. These responses are a vivid and clear example of the close connection of the mind and the body.

Some of the specific physiological responses of the body during the alarm stage include dilation of the pupils, decreased gastrointestinal functioning so the person does not have to take the time to eliminate bodily wastes, altered immune responses and functioning which can lead to an increased susceptibility to infection, as well as increases in the person's metabolic rate, blood cortisol, adrenalin, glucose consumption and utilization, cardiac output, blood pressure, pulse, respiratory rate, increases in terms of the person's cardiac, respiratory, and blood pressure measurements, all of which prepare the client to fight or flee.

The physiological responses of the human body during the stage of resistance include a maintained high level of adrenalin, increased cardiac output, increased cortisol levels, increased blood pressure, an increased pulse and respiratory rate while some of the other physiological responses of the alarm phase, or stage, may return to normal levels.

The last stage, the stage of exhaustion, is marked with complete exhaustion and the depletion of all bodily reserves to cope with and adapt to the stressors and the resulting stress. Unless reversed, the stage of exhaustion can lead to death.

Some of the nonverbal cues to physical stressors, in addition to those above, in summary, include the objective signs and symptoms of the specific physical disease or disorder that the client is affected with. For example, a client with diabetes will have hyperglycemia and a client with disseminated intravascular disease will have abnormal clotting levels.

Assessing Stressors Including Environmental Stressors that Affect Client Care

As bio-psycho-social-spiritual beings with cultural influences within and in interaction with the environment, human beings can be impacted with a wide variety of stressors. Many of these stressors impact on the nurse's role and how client care is provided to their clients.

Physiological stressors will be discussed later in this NCLEX-RN review under the section entitled "Physiological Integrity"; psychological stressors were discussed throughout this section, social and cultural stressors were previously discussed in the section entitled "Cultural Awareness/Cultural Influences on Health", and spiritual stressors were also previously discussed under the section entitled "Religious and Spiritual Influences on Health".

In addition to the previously defined and described stressors and responses such as fear, uncertainty about the unknown, and a knowledge deficit, other stressors include those related to the physical environment of the client. Nurses must, to the greatest extent possible, eliminate sources of environmental stress because these types of stressors, in combination with the other bio-psycho-social-spiritual stressors that the client is experiencing, create an additive and cumulative effect and impact on the client.

Some of these stressors include noise, constant lighting that can affect the client's innate circadian rhythm or body clock, environmental, ambient temperatures, and environmental community stressors like air pollution, overcrowding and unsanitary water, that impact on the client, including the individual client, the family, the group, and the entire global community.

Implementing Measures to Reduce Environmental Stressors

In addition to the most obvious and basic measures and interventions to reduce some environmental stressors that are impacting on the client, other interventions include the elimination of all extraneous and unnecessary noise and conversations in the patient care area, adjusting the temperature of the client's area according to the clients' needs and not the needs of the staff, the establishment and maintenance of a safe environment, and adjusting the lighting to accommodate for the client's needs in addition to their biological clock's need for periods of both light and darkness.

In terms of community nursing, the nurse assesses for environmental stressors in the community and addresses them accordingly. Environmental hazards can be local, national and global including those related to overcrowding, second hand smoke and global warming. Environmental hazards can also be considered as biological, gaseous, and chemical hazards.

Some environmental stressors that are risk factors in the community vary in terms of their frequency and also in terms of the age and developmental status of the client. For example, infants, toddlers, and preschool children are more prone to and adversely affected with stressors such as environmental radiation including sunlight, lead and mercury poisoning. Although to a lesser extent, other age groups can be adversely affected with these same environment stressors, it is infants, toddlers, and preschool children who are the most adversely and most often subjected to these hazards. Young adults and middle years adults may be affected with occupational environmental safety stressors, including those associated with the use of dangerous heavy equipment, ergonomic hazards, and noise pollution, at their place of work.

Biological Environmental Stressors

Some of the biological environmental stressors that can be local, national and global include:

  • Contaminated water which contains toxic chemicals, lead, infectious pathogens and other hazardous materials
  • Air pollution with gaseous stressors
  • Infectious diseases
  • Biohazardous waste
  • Contaminated foods

All age groups are subject to some of these forces while other age groups may be more susceptible and vulnerable to some over others. For example, people of all ages who live in undeveloped countries and regions are more frequently exposed to contaminated water and foods, whereas those of all ages in developed and industrialized nations and regions are more frequently exposed to the dangerous and cumulative effects of air pollution and its harmful components.

Some age related differences include prenatal HIV/AIDS, childhood infectious diseases, gastrointestinal infections and respiratory infections among infants and young children, childhood diseases, gastrointestinal infections, respiratory infections, scabies and lice among school children, sexually transmitted diseases, meningococcal disease and Epstein-Barr virus among adolescents and young adults, and older adults are more vulnerable to these environmental biological stressors because they are more likely than other age groups along the lifespan to be impaired with decreased immunological functioning as one of the normal and expected changes of the aging process.

Chemical and Gaseous Environmental Stressors

Some examples of environmental chemical hazards include:

  • The noxious chemicals contained in polluted air, including those found in industrial pollution, like carbon monoxide, lead, nitrogen dioxide, sulfur dioxide, ozone, particulate matter, mercury from coal powered industrial plants, fossil fuel by products, second hand smoke, and waste burning by products.
  • Asbestos
  • Poisons, including ground water that is contaminated with harmful substances, toxic chemicals, and discarded medications such as codeine, acetaminophen, antibiotics and estrogen replacement hormones in our waterways

Some of the chemical and gaseous environmental stressors according to the most susceptible age groups along the life span are listed below.

Young children including infants, toddlers, and pre-school children are particularly prone to the chemicals and gases contained in:

  • Food additives
  • Poisonous plants
  • Home flooring products
  • Leaded paints
  • Drugs including illicit drugs
  • Cleaning agents
  • Pesticides
  • Herbicides

School age children are particularly prone to the chemicals and gases contained in alcohol, illicit drugs like inhalants, and cigarettes in addition to many of these listed above. Adolescents are at great risk for alcohol and illicit drugs; examples of risks among young and middle age adults are black lung disease, also referred to as pneumoconiosis, among coal workers, mesothelioma and asbestosis among those who work with asbestos and the components of industrial gaseous toxins in the air. Lastly, manganese, lead and organic solvents can have adverse effects among young female clients who are pregnant and to the developing fetus.

Some of the risk factors associated with community environmental health stressors along the life span include intrinsic risk factors such as age, as detailed above, and genetics. Some of these risk factors are correctable and modifiable and often preventable, and others, such as age, gender and genetics are not correctable, preventable or modifiable.

Nurses assess these risk factors and plan care for the community, accordingly. The "I PREPARE" mnemonic can be used to guide this assessment. The "I PREPARE" mnemonic stands for:

  • I – Investigate exposures, including potential ones
  • P – Present employment: Does the client's current employment have risks? If so, what are these risks and how can the client reduce or eliminate these risks?
  • – Residence: Does the client's current residence have risks including those associated with sick house syndrome like mold?
  • – Environmental concerns in the client's neighborhood and local area
  • – Past work and leisure activities including hazardous avocations and hobbies like rock climbing and car racing
  • – Referrals and resources: What resources and referrals are appropriate to the client's assessed needs?
  • – Education checklist

According to the CDC, some of the agencies that clients can be referred to in terms of environment stressors include the:

  • Agency for Toxic Substances & Disease Registry at
  • Association of Occupational & Environmental Clinics at
  • Environmental Protection Agency at
  • Material Safety Data Sheets at
  • Occupational Safety & Health Administration at
  • Local Health Department, Environmental Agency, Poison Control Center

In addition to assessing the presence of environmental stressors as part of community health nursing, registered nurses also:

  • Investigate and determine whether or not the present or potential risk factor is a treatable as based on epidemiological and toxicological data
  • Measure and quantify the potential risk in its source such as in the air or soil
  • Investigate and determine the stressor route of entry into the environment and the humans within it

Nursing interventions should reflect the primary, secondary and tertiary prevention strategies. For example, some primary prevention interventions can include advocacy, community education and informing communities about risks and hazards as mandated by such laws as the Clean Water Act, the Food Quality Protection Act, and the Insecticide, Fungicide and Rodenticide Act; some secondary prevention interventions can include things like reducing the amount of solid waste in the environment by adhering to the 3 Rs which are Reduce, Reuse and Recycle; and some of the tertiary prevention interventions can include things like the registered nurses' participation in setting public policies and legislation.

The Healthy People 2020 Environmental Health objectives focus on these elements of environmental health:

  • Outdoor air quality
  • Surface and ground water quality
  • Toxic substances and hazardous wastes
  • Homes and communities
  • Infrastructure and surveillance
  • Global environmental health

Providing Information to the Client on Stress Management Techniques

As previously detailed in the section entitled "Evaluating the Client on Alternative or Homeopathic Health Care Practices", nurses should instruct clients about stress management techniques such as:

  • Daily exercise
  • Massage
  • Meditation
  • Prayer
  • Deep Breathing
  • Progressive Muscular Relaxation
  • Distraction
  • Imagery
  • Biofeedback
  • Hypnosis and Self Hypnosis
  • Reiki
  • Music Therapy
  • Mind-Body Exercises

Evaluating the Client's Use of Stress Management Techniques

Nurses can monitor and evaluate the client's effective use of stress management techniques by determining and measuring the client's achievement of their pre-established goals and expected outcomes. Some of the appropriate expected outcomes for clients who are using stress management techniques can include:

  • The client will demonstrate stress management techniques in the correct manner and as taught
  • The client will have less anxiety as demonstrated with decreased feelings of being threatened
  • The client will verbally express a decrease in terms of their level of anxiety
  • The client will exhibit less fear
  • The client will have a restored level of energy
  • The client will demonstrate better coping, decision making and problem solving processes
  • The client will be without the physiological changes that occur with stress and the General Adaptation Syndrome


SEE – Psychosocial Integrity Practice Test Questions

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