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 of feeling depressed
Lack of nutritional knowledge
Recurring urinary tract infections
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.
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.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
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