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Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?
- A. To ambulate without discomfort.
- B. To take analgesics as prescribed.
- C. To show evidence of incision healing.
- D. To avoid pain-causing activity.
Correct Answer: A
Rationale: The goal of the care plan should be to help the client overcome his activity intolerance related to pain. This can be achieved by helping him to ambulate without discomfort.
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A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.