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

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.

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.

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Correct Answer is B

Explanation

Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.

The other options listed are incorrect:

Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed in clients with DVT.
Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.

A. Decreased BUN level B. Decreased hemoglobin level C. Increased weight of 0.91 kg (2 lb) D. Increased urinary output

Correct Answer is D

Explanation

Furosemide works by promoting diuresis, which helps to reduce fluid volume overload in heart failure. Increased urinary output indicates that the medication is effectively removing excess fluid from the body. This can help alleviate symptoms such as edema and fluid retention commonly associated with heart failure. Therefore, an increased urinary output is a positive response to furosemide therapy in this context.

Decreased BUN (blood urea nitrogen) levels and weight loss are also expected outcomes of diuretic therapy, further indicating the effectiveness of the medication. However, a decreased hemoglobin level is not directly related to the efficacy of furosemide and might be indicative of other factors such as anemia or bleeding, requiring further assessment and intervention.

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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

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is D

Explanation

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