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The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss?
- A. The nurse must believe the client's report of pain.
- B. Clients in chronic pain may not show objective signs.
- C. Alternate pain-control therapies are used for chronic pain.
- D. Referral to a pain clinic may be necessary.
Correct Answer: A
Rationale: Believing the client’s pain report is critical, as pain is subjective, per pain management guidelines. Objective signs, therapies, or referrals are secondary.
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The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process?
- A. How angry are the family members about the death?
- B. Which family member will be making decisions?
- C. What previous coping skills have been used?
- D. What type of funeral service has been planned?
Correct Answer: C
Rationale: Previous coping skills inform tailored grief interventions, per nursing process. Anger, decision-makers, or funeral plans are less critical initially.
The nurse pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart?
- A. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank.
- B. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead.
- C. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate.
- D. Client found without pulse, body cold to touch. Pronounced deceased at 0900.
Correct Answer: C
Rationale: Documentation should include objective findings (absent vital signs), time, and physician’s role, per legal standards. Brain scan or CPR details are specific, and cold body is insufficient.
Which element is not necessary to prove nursing malpractice?
- A. Breach of duty.
- B. Identify the ethical issues.
- C. Injury to the client.
- D. Proximate cause.
Correct Answer: B
Rationale: Malpractice requires duty, breach, injury, and causation. Identifying ethical issues is not a legal element, though relevant to ethics.
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
The client is being discharged from the hospital for intractable pain secondary to cancer and is prescribed morphine, a narcotic. Which statement indicates the client understands the discharge instructions?
- A. I will be sure to have my prescriptions filled before any holiday.
- B. There should not be a problem having the prescriptions filled anytime.
- C. If I run out of medications, I can call the HCP to phone in a prescription.
- D. There are no side effects to morphine I should be concerned about.
Correct Answer: A
Rationale: Filling prescriptions before holidays ensures access to narcotics, reflecting understanding of controlled substance challenges. Other statements are inaccurate or unsafe.