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

A recent move to a new city

Report feeling depressed

Lack of nutritional knowledge

Recurring urinary tract infections

Answer and Explanation

The Correct Answer is A

Stressors can be categorized as external or internal. External stressors are factors or events in the environment that can cause stress.
In this case, the recent move to a new city is an external stressor because it is an event that has occurred outside of the client and is influencing their current state of stress. Moving to a new city can bring about significant changes and challenges, such as adjusting to a new environment, finding new social connections, and adapting to unfamiliar surroundings.
B. Feeling depressed is an internal stressor because it relates to the client's emotional state or mental health condition. Depression can be caused by various factors, such as biochemical imbalances, life circumstances, or genetic predispositions.

C. Lack of nutritional knowledge: This is an internal stressor because it refers to the client's lack of knowledge or awareness regarding nutrition. While the lack of nutritional knowledge can contribute to stress, it is an internal factor that can be addressed through education and learning.
D. While recurring urinary tract infections can be stressful for the client, they are considered an internal stressor because they involve a physical condition or health issue within the client's body. Addressing and managing the infections would involve medical interventions and possibly lifestyle modifications.

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Correct Answer is ["A","C","E"]

Explanation

Since the client's respiratory rate is labored and there are abnormal breath sounds (crackles and wheezes), it is important to assess their oxygen saturation level. This finding can help determine the adequacy of their oxygenation and whether intervention is needed.

The client's labored respirations, along with the presence of abnormal breath sounds, indicate potential respiratory distress. Assessing their respiratory rate is crucial to determine the severity of the respiratory compromise and the need for immediate intervention.

The nurse's note mentions that the client is restless and not following commands. This change in the level of consciousness may indicate a decline in neurological status and should be promptly evaluated.

The other options listed (tremors in hands, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.

A. Ask other group members to limit the number of times they speak. B. Allow the client extra time to think of a response. C. Appoint the client to lead the discussion. D. Tell the client to leave the group if they cannot contribute.

Correct Answer is ["A","B"]

Explanation

Silence can be a natural part of the group therapy process, and individuals may need additional time to process their thoughts and feelings before contributing. By allowing the client extra time, the nurse creates a non-threatening space for the client to participate when they are ready.

In some group settings, certain members might dominate the conversation, making it challenging for others to contribute. By requesting that other group members be mindful of their speaking time, the nurse helps create space for the silent client to share their thoughts and experiences.

The nurse can privately communicate with the silent client outside the group session to offer support and explore any concerns or barriers they may be experiencing. This individualized attention can help the client feel valued and encourage their participation in future sessions. Appointing the client to lead the discussion or telling them to leave the group if they cannot contribute are not appropriate actions. These approaches can increase the client's discomfort and create a negative atmosphere, which goes against the principles of group therapy. It is important to foster an inclusive and supportive environment that encourages participation at each person's pace.

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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

Correct Answer is ["A","C","E"]

Explanation

A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?

Correct Answer is ["A","B"]

Explanation

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