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 A

Explanation

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

A. Request additional information about the caller's relationship to the client. B. Provide a general update about the client's condition over the telephone. C. Refer the family member to the client's provider for the update. D. Encourage the family member to contact the client directly for information.

Correct Answer is C

Explanation

Choice A rationale:

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Choice B rationale:

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Choice C rationale:

Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.

Choice D rationale:

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports having diarrhea for the past 72 hr. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Correct Answer is C

Explanation

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