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 D

Explanation

Correct answer: D

veracity, in (option A) is incorrect because it refers to telling the truth and being honest with the client. While the nurse's action in obtaining a healthy meal for the client is a positive action, it is not directly related to veracity.

countertransference in (option B) is incorrect because it, refers to the nurse's emotional or personal reaction towards the client that may influence their behaviour or response. It is not applicable to the scenario described.

C. Boundary Crossing happens when a professional line is blurred. In this case, the nurse prioritizes the client's well-being, not a personal connection.

D. Promoting trust involves actions that build rapport, establish a therapeutic relationship, and demonstrate caring and empathy towards the client. By interrupting the bath to obtain a healthy meal for the client, the nurse shows responsiveness to the client's needs, which can enhance trust and confidence in the nurse's care

A. Locks the wheels on the client's bed B. Clears furniture from the path leading to the bathroom C. Assists the client to the bathroom every 2 hr D. Raises all four side-rails on the client's bed

Correct Answer is D

Explanation

The nurse should intervene when the AP raises all four side rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.

A. Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensure stability.

B. Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.

C. Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.

It's important to promote mobility and independence for the client while ensuring their safety.

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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 begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is D

Explanation

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is D

Explanation

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