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A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
- A. A client who has a broken femur and reports hip pain.
- B. A client who has incisional pain 72 hours following pacemaker insertion.
- C. A client who has food poisoning and reports abdominal cramping.
- D. A client who has episodic back pain following a fall 2 years ago.
Correct Answer: D
Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.
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A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.
- A. "We will apply oxygen through a tube in your nose."
- B. "We will perform resuscitation efforts regardless of your wishes."
- C. "You will receive only palliative care."
- D. "We will ensure your comfort measures are met as per your advance directives."
Correct Answer: A
Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.
A mother tells the nurse that her 2-year-old toddler has temper tantrums and says 'no' every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?
- A. Trying to increase independence.
- B. Developing a sense of trust.
- C. Establishing a new identity.
- D. Attempting to master a skill.
Correct Answer: A
Rationale: The correct answer is A: Trying to increase independence. Toddlers around the age of 2 often exhibit behaviors like temper tantrums and saying 'no' as they are asserting their independence and autonomy. This behavior is a normal part of their developmental stage where they are starting to explore and assert their own preferences and desires. Choice B, developing a sense of trust, is more relevant to infants during the trust vs. mistrust stage. Choice C, establishing a new identity, is typically associated with adolescence and identity formation. Choice D, attempting to master a skill, is more indicative of a child trying to learn and develop new abilities rather than the behavior described in the scenario.
The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?
- A. Encourage the patient to engage in self-care.
- B. Promote mobility in the patient.
- C. Encourage the patient to perform range of motion exercises.
- D. Assist the patient with comfort measures.
Correct Answer: D
Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.
A nurse on a med-surg unit is teaching a newly licensed nurse about tasks to delegate to APs. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. An AP may take orthostatic blood pressure measurements from a client who reports dizziness.
- B. An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids.
- C. An AP may perform a central line dressing change for a client who is ready for discharge.
- D. An AP may ambulate a client who had a stroke 2 days ago.
Correct Answer: D
Rationale: The correct answer is D. Delegating the task of ambulating a client who had a stroke 2 days ago to an AP is appropriate. This task falls within the scope of practice for an AP and can help promote mobility and prevent complications. Choices A, B, and C involve more complex nursing assessments or procedures that require a higher level of training and expertise. Taking orthostatic blood pressure measurements, monitoring a peripheral IV insertion site, and performing a central line dressing change should be tasks performed by licensed nurses to ensure proper assessment and management of the client's condition.
A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?
- A. Temporal
- B. Oral
- C. Rectal
- D. Axillary
Correct Answer: C
Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.