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The nurse is assessing a client with chronic pain. Which of the following is an expected response?
- A. Elevated vital signs, physical inactivity, facial grimacing, and periods of anxiety.
- B. Normal vital signs, physical inactivity, and unusual physical sensitivity.
- C. Normal vital signs, normal facial expressions, and moaning.
- D. Elevated vital signs, grimacing, and depression.
Correct Answer: B
Rationale: Chronic pain often results in normal vital signs (due to adaptation), physical inactivity (to avoid pain), and unusual physical sensitivity, as patients may guard or protect painful areas.
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The nurse is caring for a client with a hyphema. The nurse should plan to take which action?
- A. Shield the affected eye.
- B. Place the client supine.
- C. Apply a cold compress to the eye.
- D. Request a prescription for aspirin.
Correct Answer: A
Rationale: Shielding the affected eye protects it from further injury in hyphema (blood in the anterior chamber). Supine positioning may worsen bleeding, cold compresses are not standard, and aspirin increases bleeding risk.
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
- A. Encourage the client to drink at least 1,000 mL per day.
- B. Provide parenteral rehydration therapy ordered by the physician.
- C. Turn and reposition every 2 hours.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
- A. Improve the nurse-client relationship.
- B. Enlist the help of the client's family.
- C. Allow the client additional time to work through his or her own responses to pain.
- D. Arrange to have the client share a room with a client who has little pain.
Correct Answer: A
Rationale: Improving the nurse-client relationship fosters trust, enhancing pain management through better communication and tailored interventions. Family help, time, or room sharing are less direct solutions.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:
- A. Similarities from one side to the other.
- B. Changes from the normal expected findings.
- C. Appearance of age-related wrinkles.
- D. Skin turgor.
Correct Answer: B
Rationale: Noting changes from normal findings is critical, as it helps identify abnormalities like lesions or discoloration that may indicate pathology, beyond expected age-related changes.