A nurse is assessing a client who is experiencing stress. The nurse recognizes which of the following is not a predisposing factor for stress?

Existing conditions.

Heredity.

Learned responses.

History of hypotension.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Existing conditions can indeed be a predisposing factor for stress. Chronic medical conditions, financial difficulties, or interpersonal conflicts can contribute to increased stress levels. These existing conditions create a foundation for stress to manifest.

Choice B rationale:

Heredity can also play a role in predisposing individuals to stress. Genetic factors can influence how a person responds to stressors and copes with challenging situations. A family history of anxiety disorders, for example, might increase an individual's susceptibility to stress.

Choice C rationale:

Learned responses are another predisposing factor for stress. If an individual has experienced traumatic events or has learned maladaptive coping mechanisms in response to stressors, they may be more prone to feeling stressed when faced with similar situations in the future.

Choice D rationale:

History of hypotension is the correct answer. Hypotension refers to abnormally low blood pressure. While it can have its own effects on the body, it is not typically considered a predisposing factor for stress. Stress is more closely associated with psychological and environmental factors rather than a person's blood pressure history.

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Correct Answer is A

Explanation

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

A. The client took an overdose of the medication. B. The client experienced a common side effect of the medication. C. The client demonstrated an allergic response to the medication. D. The client consumed alcohol while taking the medication.

Correct Answer is D

Explanation

Choice A rationale:

The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.

Choice B rationale:

Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.

Choice C rationale:

Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.

Choice D rationale:

The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.

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A nurse is assessing a client who is experiencing stress. The nurse recognizes which of the following is not a predisposing factor for stress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication the client is in the denial phase of the grief process?

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. The nurse recognizes that which of the following is an expected history associated with Wernicke-Korsakoff syndrome?

A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take while caring for the child? (Select all that apply.).

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following is an appropriate statement by the nurse?

A psychiatric nurse is caring for clients on a mental health unit during a group session. What should the nurse do to establish trust in a therapeutic relationship with the clients?