Nokea
A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
- A. Vital sign measurement
- B. Client's self-report of pain
- C. Visual observation for nonverbal signs of pain
- D. Nature of invasiveness of the surgical procedure
Correct Answer: B
Rationale: The correct answer is B: Client's self-report of pain. This is the most reliable source for determining the intensity of the client's pain because pain is a subjective experience and can vary greatly among individuals. The client is the best source to accurately describe their pain level, location, and quality. Vital sign measurements (A) may provide some indication of pain, but they are not as accurate as the client's self-report. Visual observation (C) may be helpful, but it can be subjective and may not always correlate with the client's actual pain level. The nature of invasiveness of the surgical procedure (D) may give some indication of potential pain level, but it does not directly measure the client's current pain intensity.
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A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.
A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.
A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse-client relationship?
- A. Telephones the client at his home prior to admission to make an introduction.
- B. Dominate the conversation to reduce the client's anxiety.
- C. Share stories about personal experiences with the client.
- D. Use active listening when with the client.
Correct Answer: D
Rationale: Using active listening helps establish presence by showing genuine interest and attention to the client.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C: Listen attentively when the client talks about the past. Active listening is crucial in helping the client cope with feelings of grief. By providing a supportive environment and allowing the client to express his emotions, the nurse can validate his feelings and provide emotional support. This helps the client feel understood and accepted, facilitating the grieving process.
Choice A is incorrect because simply stating that it is a common problem does not address the individual client's feelings. Choice B is incorrect as it dismisses the client's emotions and distracts rather than addressing the root of the issue. Choice D is inappropriate as it is not empathetic and may invalidate the client's experience by comparing it to others.