Nokea
The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply.
- A. music
- B. therapeutic massage
- C. stretching exercises
- D. relaxation
Correct Answer: A, B, C, D
Rationale: Music, therapeutic massage, stretching exercises, and relaxation are all evidence-based nonpharmacological methods to manage chronic pain.
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The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- A. Right breech presentation
- B. Right occipital anterior presentation
- C. Left sacral anterior presentation
- D. Left occipital transverse presentation
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a:
- A. Plastic zip-lock bag
- B. Rubber tote
- C. Paper bag
- D. Padded manila envelope
Correct Answer: C
Rationale: A paper bag allows air circulation, preventing moisture that could degrade biological evidence.