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A nurse is teaching a patient about managing chronic pain. Which of the following strategies should the nurse emphasize?
- A. Increasing activity to improve function.
- B. Using medications only when absolutely necessary.
- C. Implementing physical therapy and exercises.
- D. Using complementary therapies such as meditation and relaxation.
Correct Answer: C
Rationale: The correct answer is C: Implementing physical therapy and exercises. This is crucial for managing chronic pain as it helps improve strength, flexibility, and overall function. Physical therapy can also address underlying issues contributing to pain. Choice A could worsen pain if not done appropriately. Choice B may be necessary but should not be the sole approach. Choice D can be beneficial but may not address the root cause of pain like physical therapy does.
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Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
- A. Store insulin at room temperature to prevent crystallization.
- B. Use insulin immediately after drawing it up into the syringe.
- C. Inject insulin into the same spot to avoid tissue damage.
- D. Rotate injection sites to prevent lipodystrophy.
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications.
A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration.
B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations.
C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which of the following would be the next appropriate action?
- A. Establishing priorities
- B. Identifying expected outcomes
- C. Evaluating the individual's condition and comparing actual outcomes with expected outcomes
- D. Interpreting data, identifying clusters of cues, and making inferences
Correct Answer: C
Rationale: The next appropriate action is to evaluate the individual's condition and compare actual outcomes with expected outcomes (Choice C). This step is crucial in determining the effectiveness of the implemented interventions in addressing the nursing diagnosis of acute pain. By evaluating the individual's condition, the nurse can assess whether the interventions have been successful in alleviating the pain. Comparing actual outcomes with expected outcomes helps in identifying any discrepancies and adjusting the plan of care accordingly to ensure optimal patient outcomes.
Establishing priorities (Choice A) is important but would come before implementing interventions. Identifying expected outcomes (Choice B) is necessary before implementing interventions but does not directly address the need for evaluation. Interpreting data and making inferences (Choice D) is part of the assessment phase and not the next appropriate action after implementing interventions.
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
- A. Encouraging regular foot inspections.
- B. Providing additional protein to the diet.
- C. Encouraging weight loss to reduce joint stress.
- D. Administering pain medication for relief.
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications.
Incorrect choices:
B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy.
C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy.
D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
A nurse is caring for a patient with acute pancreatitis. The nurse should monitor for which of the following signs of complications?
- A. Decreased urine output and increased thirst.
- B. Increased blood pressure and heart rate.
- C. Hypotension and tachycardia.
- D. Tachypnea and cyanosis.
Correct Answer: C
Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.