A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

Peer pressure.

Death of a family member.

Fear of medical test results.

Job transfer to another city.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Peer pressure (Choice A) is an external stressor, as it involves the influence of others on an individual's thoughts or actions. It originates from outside the individual and is not directly related to an internal psychological response.

Choice B rationale:

Death of a family member (Choice B) is an external stressor, as it is an event that occurs externally to the individual. While it can cause significant emotional distress, it is not considered an internal stressor.

Choice C rationale:

Fear of medical test results (Choice C) is the correct answer as an internal stressor. Internal stressors are psychological or emotional factors that originate within the individual and contribute to stress. Fear of medical test results is a personal worry that can lead to anxiety and emotional turmoil.

Choice D rationale:

Job transfer to another city (Choice D) is an external stressor, as it involves a change in the individual's external environment. It is not an internal psychological factor causing stress.

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Correct Answer is B

Explanation

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

A. Unclamp the client's gastrostomy tube before connecting the syringe to it. B. Verify that the client's gastric pH is at least 7 prior to feeding. C. Pour the client's formula into the syringe, raising or lowering it to control the rate of flow. D. Apply sterile gloves before accessing the client's gastrostomy tube.

Correct Answer is A

Explanation

Choice A rationale:

Unclamping the client's gastrostomy tube before connecting the syringe is the correct action. This allows the feeding to flow freely into the stomach. Clamping the tube while administering the feeding would prevent the formula from entering the stomach properly.

Choice B rationale:

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Choice C rationale:

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Choice D rationale:

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

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A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving intermittent enteral feedings via a gastrostomy tube. Which of the following actions should the nurse take when administering the feeding?

Correct Answer is A

Explanation

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