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A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
- A. Administer prescribed gabapentin.
- B. Apply a cold pack to the stump.
- C. Distract the client with music.
- D. Explain the nature of phantom pain.
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.
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A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.
The nurse is assessing a client with acute diverticulitis. Which symptom requires immediate reporting to the physician?
- A. Mild left lower quadrant pain.
- B. Temperature of 101°F (38.3°C).
- C. Soft, formed stools.
- D. Nausea without vomiting.
Correct Answer: B
Rationale: A temperature of 101°F (38.3°C) in acute diverticulitis may indicate worsening infection or abscess, requiring immediate reporting. Mild pain, formed stools, and nausea are less urgent unless escalating. CN: Physiological adaptation; CL: Analyze
A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the nurse that he has not smoked a cigarette for 3 weeks, but is afraid he is going to 'slip up' and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?
- A. Don't worry about it. Everybody has difficulty quitting smoking, and you should expect to as well.'
- B. If you increase your self-control, I am sure you will be able to avoid smoking.'
- C. Try taking a couple of days of vacation to relieve the stress of your job.'
- D. It is good that you can talk about your concerns. Try calling a friend when you want to smoke.'
Correct Answer: D
Rationale: This response acknowledges the client's concerns and offers a practical coping strategy (calling a friend) to manage cravings, supporting the client's efforts in smoking cessation. The other options are dismissive, overly simplistic, or impractical.
An awake postoperative client received an intravenous regional nerve block (Bier block) in the arm that is now casted and elevated on a pillow. What action should the nurse encourage the client to avoid until sensation returns?
- A. Holding the operated arm close to the face.
- B. Holding the operated arm with the unoperated arm.
- C. Using the unoperated arm.
- D. Using pain medication.
Correct Answer: A
Rationale: Without sensation, holding the arm close to the face risks injury, as the client may not feel pressure or positioning issues. The other actions are safe or unrelated.
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
- A. Nephritis.
- B. Referred pain.
- C. Urine retention.
- D. Additional stone formation.
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.