Nokea
A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the nurse use?
- A. Numeric rating scale
- B. Behavioral indicators)
- C. Visual analog scale
- D. Faces pain scale
Correct Answer: B
Rationale: For clients with dementia who have difficulty communicating, behavioral indicators such as increased agitation and restlessness are effective methods for assessing pain.
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A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Perform palpation before auscultation
- B. Perform percussion before auscultation
- C. Perform palpation after auscultation
- D. Perform inspection after auscultation
Correct Answer: C
Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and then palpation.
A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct Answer: D
Rationale: Eye contact, personal space, and touch are cultural variables that can affect communication.
A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?
- A. I should wear my slippers whenever I am out of bed
- B. I can walk barefoot at home
- C. I should apply lotion between my toes
- D. I can soak my feet in warm water
Correct Answer: A
Rationale: Wearing slippers or shoes when out of bed protects the feet from injury, which is crucial for clients with diabetes.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.