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. Heart rate: The heart rate of 98/min is within normal limits and does not indicate an immediate need for further evaluation based solely on this value.

b.The blood pressure of 112/88 mmHg is within normal limits and does not indicate an immediate need for further evaluation based solely on this value.

c.The client has a temperature of 38.1°C (100.5°F), which is indicative of a fever. Fever, especially when associated with other symptoms such as cough, fatigue, night sweats, and weight loss, suggests a systemic infection or inflammatory process requiring further investigation.

d.The client reports a cough that is often productive and blood-tinged sputum. Respiratory complaints with blood-tinged sputum can indicate potential serious conditions such as pneumonia, tuberculosis, or other respiratory infections that require prompt evaluation and treatment.

e.The pulse oximetry reading of 98% on room air is normal and does not indicate an immediate need for further evaluation based solely on this value.

f.The client reports a recent weight loss of 2.26 kg (5 lb) over the past week, along with decreased appetite. Unintentional weight loss, especially when associated with other symptoms like fever and cough, raises concerns about underlying systemic illness or malignancy that requires further investigation.

g.Blood in sputum can have various causes and needs investigation.

h.Recent travel can increase exposure to different illnesses, so it's relevant and needs further evaluation.

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.
A. "The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.
C. "What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.
D. "Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.