A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Recurring urinary tract infections

A recent move to a new city

Lack of nutritional knowledge

Report of feeling depressed

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Recurring urinary tract infections are related to health and hygiene and are not typically considered external stressors.
B.   Correct. A recent move to a new city is an external stressor because it is an environmental change that can lead to feelings of stress and adjustment.
C.   Incorrect. Lack of nutritional knowledge is an internal stressor related to the client's knowledge and awareness, not an external factor.
D.   Incorrect. Feeling depressed is an internal emotional state and is not an external stressor.

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Correct Answer is B

Explanation

A. Incorrect. Offering to watch television may not address the client's agitation and anxiety effectively.
B. Correct. The client's behaviors suggest anxiety or agitation. Using short, simple sentences when speaking with the client can help reduce their stress and facilitate communication.
C. Incorrect. While some clients may benefit from alone time, it's important to assess the client's preferences and needs. Isolating the client in their room might not be the best approach if they are seeking engagement.
D. Incorrect. Moving the client to a group setting may increase their discomfort or agitation. It's important to consider the client's current emotional state and tailor interventions accordingly.

A. Administer aspirin if the client develops a fever. B. Initiate contact precautions for the client. C. Assign the client to a negative-pressure airflow room. D. Have visitors remain at least 0.91 m (3 feet. away from the client.

Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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