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A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs.
Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe.
In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
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A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
- A. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
- B. Gently raise Mr. Gabatan to a sitting position to see if the pain either
- C. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available
- D. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
Correct Answer: C
Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy.
Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.
An adult had a total thyroidectomy. Which statement by the client demonstrates to the nurse an adequate understanding of long term care?
- A. “I will need to take replacement hormones for the rest of my life.”
- B. “ I should try to avoud stress and be alert for signs of recurrent hyperthyroidism.”
- C. “Thank goodness, this is over! I will never have to worry about throid problems again.”
- D. “ I should increase my caloric intake to replace what I lost during the surgery.”
Correct Answer: A
Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.
The nurse is aware that in communicating with an elderly client, the nurse will
- A. Lean and shout at the ear of the client
- B. Use a low-pitched voice
- C. Open mouth wide while talking to the client
- D. Use a medium-pitched voice
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly.
A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful.
C: Opening the mouth wide while talking is not necessary and may be seen as patronizing.
D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.