Nokea
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
- A. A client who has peritonitis reports generalized abdominal pain.
- B. A client who has angina reports substernal chest pain.
- C. A client who is postoperative reports incisional pain.
- D. A client who has pancreatitis reports pain in the left shoulder.
Correct Answer: D
Rationale: Referred pain is pain perceived at a site different from its point of origin. In the case of pancreatitis, pain is often referred to the left shoulder due to shared nerve pathways. The other choices involve pain directly related to the affected area (peritonitis, angina, postoperative incision), making them incorrect.
You may also like to solve these questions
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
- A. Obtain an ECG.
- B. Administer an opioid pain medication.
- C. Infuse IV fluids to maintain urine output at 75 mL/hr.
- D. Change dressings over the entrance and exit wounds.
Correct Answer: A
Rationale: The correct answer is A: Obtain an ECG. The first step in managing a client with an electrical shock injury is to assess for any cardiac complications, as electrical shock can cause arrhythmias. Obtaining an ECG will help the nurse identify any abnormal heart rhythms and determine the need for immediate intervention. Administering opioid pain medication (B) is not a priority as assessing the cardiac status takes precedence. Infusing IV fluids (C) is important but not the first priority. Changing dressings (D) can wait until the client's immediate medical needs are addressed.
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to excessive loss of proteins in the urine, specifically albumin. This results in proteinuria. Choice A, hyperalbuminemia, is incorrect as nephrotic syndrome actually causes hypoalbuminemia due to protein loss. Choice C, decreased serum lipid levels, is incorrect because nephrotic syndrome causes hyperlipidemia due to increased hepatic synthesis of lipoproteins. Choice D, decreased coagulation, is incorrect as nephrotic syndrome is associated with hypercoagulability due to loss of anticoagulant proteins in the urine.
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
- A. Pad the upper two side rails of the client's bed.
- B. Keep a padded tongue blade at the client's bedside.
- C. Maintain peripheral IV access.
- D. Teach assistive personnel how to apply restraints.
Correct Answer: C
Rationale: The correct answer is C: Maintain peripheral IV access. This is important for clients with seizure disorders as they may require immediate administration of medications during or after a seizure. IV access allows for quick drug delivery.
Choice A is incorrect because padding the bed rails is not a standard intervention for seizure disorder.
Choice B is incorrect because a padded tongue blade is not necessary for managing seizures.
Choice D is incorrect because teaching assistive personnel to apply restraints is not a recommended intervention for clients with seizure disorders.
In summary, maintaining peripheral IV access is crucial for prompt medication administration during seizures, while the other choices are not directly related to managing seizures in this context.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.'
- B. I should take an antacid with each dose of this medication.'
- C. This medication may cause my blood pressure to increase.'
- D. I will have my liver function tested while I am taking this medication.'
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This answer demonstrates understanding because isoniazid (INH) is known to potentially cause liver toxicity. Regular monitoring of liver function is essential to detect any adverse effects early. Option A is incorrect as INH treatment typically lasts for several months, not just 1 week. Option B is incorrect as antacids can decrease the absorption of INH. Option C is incorrect as INH does not typically cause an increase in blood pressure.
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
- A. Encourage frequent visits from friends.
- B. Apply restraints to the upper extremities.
- C. Play soft, soothing music.
- D. Keep the over-the-bed light on.
Correct Answer: C
Rationale: The correct answer is C: Play soft, soothing music. This is beneficial for the older adult with dementia post-surgery as music has been shown to reduce anxiety, improve mood, and promote relaxation. It can also help in reducing agitation and promoting better sleep. Encouraging frequent visits from friends (A) may overwhelm the client. Applying restraints to the upper extremities (B) can lead to increased agitation and discomfort. Keeping the over-the-bed light on (D) may disrupt sleep patterns and worsen confusion.