Nokea
A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?
- A. Is your pain sharp or dull?
- B. Is your pain constant or intermittent?
- C. On a scale from 1 to 10, how severe is your pain?
- D. Where exactly is your pain located?
Correct Answer: A
Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.
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When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?
- A. Bend at the waist
- B. Keep feet close together
- C. Use back muscles for lifting
- D. Stand close to the cabinet when lifting it
Correct Answer: D
Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.
When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, what should be the next action by the nurse?
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contact with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: The correct action for the nurse in this situation is to discuss the feeling of reluctance with an objective peer or supervisor. By doing so, the nurse can address their emotions professionally and seek guidance on how to manage the situation effectively. This approach allows the nurse to receive support and potentially gain insights on how to navigate interactions with the manipulative client. Option B is incorrect because avoiding the client may not address the underlying issues causing the reluctance and can impact the quality of care provided. Option C is inappropriate as confronting the client directly about negative behaviors may escalate the situation and harm the therapeutic relationship. Option D is not the immediate action needed in this scenario; it is essential to address the nurse's feelings first before considering behavior modification plans.
Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?
- A. Determine the reason why the client is refusing to use the incentive spirometer.
- B. Insist that the client use the incentive spirometer.
- C. Administer pain medication to help the client use the spirometer.
- D. Document the refusal in the client's medical record.
Correct Answer: A
Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.
The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: C
Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.
A client newly diagnosed with type 1 diabetes mellitus is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statement?
- A. Insulin injections are not difficult to learn.
- B. Tell me what I can do to help you overcome your fear of giving yourself injections.
- C. It's important to learn self-care for future independence.
- D. You need to learn this for your health.
Correct Answer: B
Rationale: Choice B is the correct answer because it addresses the client's fear and offers support to help them overcome the resistance to self-care. By expressing willingness to assist and asking for ways to help the client, the nurse encourages open communication and collaboration in finding solutions to the client's concerns. Choices A, C, and D, while valid statements, do not directly address the client's fear or resistance, which is crucial in promoting self-care adherence in this situation.