Nokea
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
- A. Some clients exaggerate their level of pain
- B. Pain must have an identifiable source to justify the use of opioids.
- C. Objective data are essential in assessing pain
- D. Pain is whatever the client says it is.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the
You may also like to solve these questions
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client is experiencing noticeable symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes. This indicates that the infection has progressed to the point where the body is actively fighting off the pathogen, resulting in the manifestation of symptoms. The other choices are incorrect because: A: Prodromal stage is characterized by mild, nonspecific symptoms. B: Incubation stage is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence stage is the recovery period after the illness when symptoms start to improve.
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
- A. "Assault"
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: "Assault." Assault is the intentional act that creates fear of imminent harmful or offensive contact. In this scenario, the AP's threat of putting a diaper on the client if he does not use the urinal properly next time constitutes assault as it instills fear in the client. Choice B, Battery, involves actual harmful or offensive contact, which is not present here. Choice C, False Imprisonment, involves restricting someone's freedom of movement, which is not happening in this scenario. Choice D, Invasion of Privacy, is not applicable as the situation does not involve a violation of the client's privacy.
A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water.'
- B. Once my baby can sit up, he should be safe in the bathtub.'
- C. I will test the temp of the water before placing my baby in the bath.'
- D. Once my infant starts to push up, I will remove the mobile from over the bed.'
Correct Answer: B
Rationale: The correct answer is B: "Once my baby can sit up, he should be safe in the bathtub." This statement indicates a need for further clarification because infants are not safe to be left unattended in the bathtub even if they can sit up. They are still at risk of drowning. It is essential for the caregiver to always supervise the baby closely during bath time to ensure their safety. Testing the water temperature (Choice C) and removing the mobile from over the bed (Choice D) are appropriate safety measures. Beginning swimming lessons when the baby can close her mouth under water (Choice A) may be premature but not necessarily dangerous.
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
- A. Encourage isometric exercises
- B. Suction Q8 hr
- C. Give low-dose heparin
- D. Promote incentive spirometer use
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice A) does not specifically target airway patency. Suctioning every 8 hours (choice B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice C) is used to prevent blood clots, not to maintain airway patency.