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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Placenta previa is a condition where the placenta covers part or all of the cervix.
Bright red vaginal bleeding, especially painless bleeding, is a hallmark sign of placenta previa.
B. Incorrect. Persistent uterine contractions are not a typical finding in placenta previa and could indicate preterm labor or other issues.
C. Incorrect. Increased fetal movement is not a characteristic sign of placenta previa.
D. Incorrect. A rigid abdomen is not associated with placenta previa; it could be a sign of other conditions such as placental abruption.
Correct Answer is B
Explanation
Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
Taping the tube to the child's cheek is not typically done as it can cause discomfort and skin irritation. The tube should be secured with a stabilization device or a specialized dressing designed for gastrostomy tube care.
Applying a skin barrier protectant around the gastrostomy site is a good practice. It helps protect the skin from irritation, breakdown, and leakage of gastric contents, which can cause skin excoriation. This helps maintain the integrity of the skin around the site.
Applying water-soluble lubricant to the site is not necessary for routine site care. Lubrication is typically used when inserting or removing the tube, but it is not part of routine site care.
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