Nokea
A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain feel like burning or aching?
- C. Is the pain constant or intermittent?
- D. Does the pain feel like throbbing or stabbing?
Correct Answer: A
Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.
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A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct Answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?
- A. Morning stiffness
- B. Joint deformities
- C. Weight loss
- D. Fever
Correct Answer: D
Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.
A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?
- A. Capillary refill of 4 seconds
- B. 7.5 cm (3 in) diameter bruise on the ankle
- C. Warts on the affected ankle
- D. 2+ pitting edema
Correct Answer: A
Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.
Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?
- A. Risk for aspiration
- B. Impaired physical mobility
- C. Disturbed sensory perception
- D. Interrupted family processes
Correct Answer: A
Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?
- A. 'I can see that this is upsetting you.'
- B. 'It is necessary for your treatment.'
- C. 'It will be over quickly, and you will feel better.'
- D. 'Let me explain again why this procedure is important.'
Correct Answer: A
Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.