Nokea
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.
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After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
- A. Determine how the client feels.
- B. Support the client when rising.
- C. Offer a pair of non-skid socks.
- D. Place the chair by the bed.
Correct Answer: A
Rationale: After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels. This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.Which action should the nurse take to evaluate the client for urinary retention?
- A. Review the chart for number of voids over the last 24 hours.
- B. Evaluate the client for urinary incontinence.
- C. Scan the client's bladder after voiding.
- D. Palpate the suprapubic region for distention.
Correct Answer: C
Rationale: This will help determine if there is any residual urine left in the bladder after voiding.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
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 planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.