Nokea
How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?
- A. 1
- B. 4
- C. 3
- D. 2
Correct Answer: B
Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.
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Which is the proper hand position for performing chest percussion?
- A. Use the side of the hands
- B. Flatten the hands
- C. Spread the fingers of both hands
- D. Cup the hands
Correct Answer: D
Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.
Which of these should not be included when calculating a client's fluid intake?
- A. ice chips
- B. Jell-Oâ„¢
- C. pudding
- D. IV fluid from an antibiotic piggyback
Correct Answer: C
Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature. Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-Oâ„¢, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-Oâ„¢ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.
Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.
The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct Answer: B
Rationale: The correct answer is that the disorder is uncommon in adults. Erythema infectiosum, also known as Fifth's disease, commonly affects children and is characterized by a 'slapped face' appearance. It is associated with a rash and sometimes a low-grade fever. Therefore, the statement 'The disorder is uncommon in adults' is not correct, making it the correct answer. The other statements about the presence of a rash, 'slapped face' appearance, and the possibility of a fever are accurate in the context of erythema infectiosum.
Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct Answer: C
Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.