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A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Alternate IV and IM analgesic medications.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Educate client on signs and symptoms of narcotic dependency.
Correct Answer: B
Rationale: Administering opioid and non-opioid medication simultaneously addresses severe pain from multiple pathways, providing effective relief for stage IV bone cancer.
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The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
- A. Teach importance of medication regimen and follow-up protocol.
- B. Discuss that partners without similar symptoms may not be infected.
- C. Emphasize that using safe sex practices removes the risk of STIs.
- D. Clarify that all STIs are transmitted through sexual intercourse.
Correct Answer: A
Rationale: Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Increasing anxiety.
- B. Inappropriate laughter.
- C. Asymmetrical weakness.
- D. Weakened cough effort.
Correct Answer: D
Rationale: Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Assess the pin sites for signs of infection.
- B. Administer pain medication at designated intervals around the clock.
- C. Assess the pulses proximal to the fracture site.
- D. Remove traction every shift and provide skin care.
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.