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An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain.To assess the intensity of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: B
Rationale: The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient's self-reporting is widely considered as the key to effective pain management. According to good practice guidelines, clinicians must accept a patient's statement, regardless of their own opinions.
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How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
- A. Acute pain.
- B. Neuropathic pain.
- C. Visceral pain.
- D. Nociceptive pain.
Correct Answer: B
Rationale: The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain. Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system.
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
- A. Solid with red streaks.
- B. Formed but solid.
- C. Brown liquid.
- D. Tarry appearance.
- E. Multiple hard pellets.
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
- A. Reinsert the peripheral IV catheter.
- B. Verify that the restraints can be quickly released.
- C. Assess capillary refill distal to the restraints.
- D. Replace the nasogastric tube.
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.