Pain
Who is the authority on the presence and extent of pain experienced by a client?
The physician
The nurse
The surgeon
The patient
The patient
A nurse is assessing a patient’s pain. She asks the patient, “Does the pain your experiencing come and go, or is it constant?” Which letter of the COLDSPA pneumonic is she using in her question?
C- Character
L- Location
S - severity
P- pattern
P- pattern
The nurse observes that a client requires frequent rest breaks during ambulation and has an increased pulse after minimal activity. Which nursing diagnosis is most appropriate?
A. Activity intolerance
B. Impaired physical mobility
C. Risk for disuse syndrome
D. Fatigue
Activity intolerance
Which statement by a patient demonstrates understanding of protein function in the body?
A. “Protein gives me quick energy when I’m tired.”
B. “Protein helps repair tissue and build muscle.”
C. “Protein helps prevent constipation.”
D. “Protein provides most of the body’s heat.”
“Protein helps repair tissue and build muscle.”
The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?
fracture pan
Regular bathroom
Bedside commode
Bed pan
Bedside commode
The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client?
Use massage and heat application to the lower back
Administer opioid analgesics
Have the client perform active exercises to stretch the back muscles
Encourage the client to have an epidural steroid injection
Use massage and heat application to the lower back
A nurse is assessing a client with limited mobility. Which finding requires immediate follow-up?
A. Mild muscle atrophy
B. Warm, reddened area over the heel
C. Decreased appetite
D. Slightly decreased joint flexibility
Warm, reddened area over the heel
A nurse is planning care for a client on bed rest. Which intervention best prevents respiratory complications of immobility?
A. Encourage frequent turning, coughing, and deep breathing
B. Limit fluids to reduce congestion
C. Maintain the head of bed flat
D. Provide rest periods to conserve energy
Encourage frequent turning, coughing, and deep breathing
A nurse is caring for an older adult who reports decreased appetite and weight loss. Which intervention is the priority?
A. Encourage the client to eat three large meals daily
B. Offer nutrient-dense snacks between meals
C. Encourage high-fat foods to increase calorie intake
D. Provide low-protein foods to prevent renal strain
Offer nutrient-dense snacks between meals
The nurse is caring for an older adult who reports constipation. Which finding most likely contributes to this issue?
A. High-fiber diet
B. Increased mobility
C. Decreased fluid intake
D. Regular exercise
Decreased fluid intake
Which example(s) of the pain response is a physiologic response? Select all that apply.
A. protecting the painful area
B. increased blood pressure
C. muscle tension and rigidity
D. nausea and vomiting
B. increased blood pressure
C. muscle tension and rigidity
D. nausea and vomiting
The nurse is assessing for signs of dehydration. Which finding is most concerning?
A. Dry mouth
B. Sunken eyes
C. Amber-colored urine
D. Confusion
Confusion
A nurse assists a client with ambulation. Which intervention best promotes balance and stability?
A. Keeping the feet close together
B. Standing upright with locked knees
C. Widening the base of support and flexing knees slightly
D. Leaning forward at the waist
Widening the base of support and flexing knees slightly
A nurse is caring for four patients. Which patient should the nurse assess first according to Maslow’s Hierarchy of Needs?
A. Patient anxious about a new diagnosis of diabetes
B. Patient who needs assistance with toileting
C. Patient expressing loneliness after surgery
D. Patient asking questions about discharge teaching
Patient who needs assistance with toileting
Which nursing action best promotes normal urination?
A. Encouraging fluid intake of 1,000 mL/day
B. Allowing privacy and positioning the client upright
C. Limiting caffeine and fluids after 4 PM
D. Performing perineal care only when incontinent
Allowing privacy and positioning the client upright
A nurse works with an older adult client who has a broken ankle. The client does not report pain. Which action will the nurse take?
Document that the client has no pain.
Report finding to the health care provider
Assess the client for nonverbal cues of pain.
Have a discussion with the client’s family.
Assess the client for nonverbal cues of pain.
During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:
A. Percussion
B. Deep palpation
C. Auscultation
D. Light palpation
Auscultation
The nurse is assessing muscle tone in a client’s extremities. Which finding should the nurse document as spasticity?
A. Lack of muscle tone and limp extremities
B. Firm resistance to passive movement
C. Rhythmic muscle contractions
D. Normal tone and flexibility
Firm resistance to passive movement
A nurse is teaching a client about Maslow’s hierarchy of needs. Which statement shows correct understanding?
A. “Nutrition is part of emotional well-being.”
B. “Meeting safety needs comes before physical needs.”
C. “Nutrition and hydration are basic physiological needs.”
D. “Self-actualization is required before homeostasis.”
“Nutrition and hydration are basic physiological needs.”
A patient with urinary incontinence expresses embarrassment and anxiety about accidents. Which nursing intervention is most therapeutic?
A. Limit fluids to reduce urination
B. Offer a bedpan every 8 hours
C. Encourage scheduled toileting and positive reinforcement
D. Insert an indwelling catheter
Encourage scheduled toileting and positive reinforcement
A nurse is caring for a client who reports an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:
Visceral pain
Neuropathic pain
Somatic pain
Cutaneous pain
Visceral pain
A client has received teaching about proper skin care at a stoma site. The nurse’s teaching has been effective when the client identifies which practice?
A.ensuring the peristomal area is kept moist
B.having health care providers perform ostomy care and skin care
C.disinfecting the skin around the site with alcohol-based sanitizer
D.cleansing the site with water and mild soap
cleansing the site with water and mild soap
A nurse identifies the diagnosis “Risk for Constipation related to immobility.” Which is the most appropriate goal for this patient?
A. Patient will report no pain during defecation.
B. Patient will have a soft, formed stool every 1–3 days.
C. Patient will increase fluid intake by 200 mL per day.
D. Patient will verbalize understanding of constipation causes.
Patient will have a soft, formed stool every 1–3 days.
A patient at risk for dehydration is on a fluid restriction due to heart failure. Which intervention best promotes homeostasis?
A. Encourage the patient to drink unlimited water
B. Offer frequent oral care and ice chips as allowed
C. Restrict all oral fluids completely
D. Increase sodium intake to maintain thirst
Offer frequent oral care and ice chips as allowed
An older adult reports having hard stools and straining despite taking a daily laxative. Which nursing action should the nurse take first?
A. Assess the client’s daily fluid and fiber intake.
B. Administer a stronger laxative as prescribed.
C. Encourage the client to ambulate frequently.
D. Suggest switching to a low-fiber diet temporarily.
Assess the client’s daily fluid and fiber intake.