A 75-year-old female patient presented to the office for an annual wellness visit. During the nurse's assessment, the patient explains she has been experiencing bilateral knee pain for the past eleven months. Based on the duration of the patient's symptoms, how would the nurse categorize the patient's pain?

Acute Pain

Intermittent Pain

Chronic Pain

Idiopathic Pain

Answer and Explanation

The Correct Answer is C

Choice A reason:
Acute pain is typically sudden in onset and is usually the result of a specific injury or illness. It is characterized by its sharp quality and tends to last for a short duration, generally not longer than six months. Since the patient's knee pain has persisted for eleven months, it does not fall under the category of acute pain.
Choice B reason:
Intermittent pain is pain that comes and goes at intervals. Although the patient's pain could be intermittent, the classification based on duration would not be described as intermittent. This term refers more to the pattern of the pain rather than its chronicity or cause.
Choice C reason:
Chronic pain is defined as pain that persists for longer than six months, often continuing even after the injury or illness that caused it has healed. The patient's bilateral knee pain has been present for eleven months, which exceeds the six-month threshold, thus categorizing it as chronic pain.
Choice D reason:
Idiopathic pain refers to pain that arises without a clear cause. It is not categorized based on the duration of the pain but rather on the absence of an identifiable underlying reason. Since the patient's pain has a specific duration, it is not appropriate to classify it as idiopathic without further information regarding its cause.

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Correct Answer is A

Explanation

Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.

Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.

Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.

Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.

A. Draping body areas that are not being assessed. B. Limit position changes as much as possible. C. Hand-washing throughout the exam. D. Using alcohol swabs to clean the stethoscope.

Correct Answer is B

Explanation

Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.

Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.

Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.

Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Correct Answer is A

Explanation

When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

Correct Answer is B

Explanation

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

During an assessment of the ear structures, the nurse would expect to identify which structure as part of the middle ear?

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

The nurse working in an ophthalmology clinic is preparing to assess a patient's near vision. Which piece of equipment would the nurse use for this assessment?

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?