Nokea
The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
- A. Observe the client for grimaces, flinching, and other signs of pain.
- B. Monitor the client's blood pressure.
- C. Ask the client to rate his pain on a scale of 1 to 10.
- D. Monitor the client's pulse and respirations.
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.
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A client is diagnosed with lung cancer and undergoes a pneumonectomy.
In the immediate postoperative period, which of the following nursing assessments is MOST important?
- A. Presence of breath sounds bilaterally.
- B. Position of the trachea in the sternal notch.
- C. Amount and consistency of sputum.
- D. Increase in the pulse pressure.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation
The nurse is caring for clients in the diabetic clinic.
Which of the following clients should the nurse see FIRST?
- A. A client with sunken eyeballs and a fruity breath odor.
- B. A client who complains of pain in his calves when he exercises.
- C. A client who states that she drinking liquids frequently and is always hungry.
- D. A client says that she is having difficulty sleeping and cries frequently.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-indicates diabetic ketoacidosis; treat with normal saline and regular insulin (2) suggestive of intermittent claudication, not an emergency situation (3) suggestive of hyperglycemia, should assess blood sugar (4) psychosocial issues, physical takes priority
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
- A. Accept the letter and place it in the patient's medical record.
- B. Read the patient's letter and decide if it is appropriate to mail.
- C. Call the patient's psychiatrist and inform him of the letter.
- D. Discourage the patient from sending the letter, but mail it if patient insists.
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
- A. Eat large amounts of rice.
- B. Increase the amount of fruits and vegetables in your diet.
- C. Ask the doctor for a prescription for a drug such as diphenoxylate hydrochloride and atropine sulfate (Lomotil).
- D. Drink fluids only with meals.
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.