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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back may indicate supine hypotensive syndrome. This condition can occur during pregnancy when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and causing a drop in blood pressure.

Positioning the client on their left side helps relieve the pressure on the inferior vena cava and improves blood flow. This position allows for optimal circulation and helps alleviate the symptoms associated with supine hypotensive syndrome.

Checking the client's temperature is not necessary in this situation as the symptoms described are not typically associated with a fever. The priority is addressing the client's symptoms related to supine hypotensive syndrome.

Instructing the client to take a brisk walk is not recommended as it may exacerbate their symptoms. Walking increases physical exertion and could further decrease blood flow to the heart.

Providing the client with a glass of orange juice may be helpful if the symptoms were related to low blood sugar (hypoglycemia). However, in this case, the symptoms are more consistent with supine hypotensive syndrome. The priority is to reposition the client to improve blood flow and relieve symptoms. If the client continues to experience symptoms or if there are concerns about low blood sugar, further assessment and appropriate interventions should be implemented.

A. Initiate droplet precautions. B. Administer granulocyte colony-stimulating factor. C. Educate the infant's guardians about exchange transfusions. D. Monitor the infant's lymphocyte count.

Correct Answer is D

Explanation

A. Droplet precautions are not indicated for HIV; standard precautions should be followed.
B. Granulocyte colony-stimulating factor is typically used to increase white blood cell production and is not directly related to HIV care.
C. Exchange transfusions are not a routine intervention for infants with HIV.
D. Correct. Monitoring the infant's lymphocyte count is important to assess immune function and response to HIV treatment.

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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 collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

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