A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?

Cheyne-Stokes respirations

Mottled skin

Constricted pupils

Grimacing

Answer and Explanation

The Correct Answer is D

Choice A reason: Cheyne-Stokes respirations, alternating hyperventilation and apnea, indicate neurological dysfunction or end-of-life changes in brain tumor patients, not pain. This reflects brainstem involvement, requiring respiratory management rather than analgesics, as it is a physiological response to disease progression in palliative care.
Choice B reason: Mottled skin signals poor perfusion or impending death, common in palliative care as circulation declines. It is not a pain indicator but a sign of systemic shutdown, requiring comfort measures like warmth, not analgesics, which are irrelevant to this physiological change in terminal illness.
Choice C reason: Constricted pupils may reflect opioid effects or neurological changes in brain tumor patients but do not directly indicate pain. They suggest autonomic or brainstem dysfunction, necessitating neurological assessment, not immediate pain medication, in palliative care where comfort is prioritized based on clear pain cues.
Choice D reason: Grimacing indicates pain in palliative care patients with brain tumors, reflecting physical discomfort. As a facial expression of distress, it signals the need for analgesics to improve comfort and quality of life, aligning with palliative goals to manage pain effectively in end-stage disease.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Guiding the client by walking parallel is less effective than offering an arm for support, which provides stability and orientation. Parallel walking does not ensure safe navigation for someone with visual impairment, as it lacks physical guidance, making it less appropriate for preventing falls or ensuring safety.
Choice B reason: Using a loud tone of voice assumes hearing impairment, which is not indicated in visual sensory loss. Normal volume with clear enunciation is sufficient, and loud tones may be perceived as disrespectful or startling. This intervention is unnecessary and inappropriate for addressing visual impairment, focusing on an irrelevant sensory issue.
Choice C reason: Rearranging bedside table items frequently disorients a visually impaired client, increasing confusion and fall risk. Consistent placement of items supports independence and safety by allowing the client to rely on memory and touch, making this intervention counterproductive and unsafe for the care plan.
Choice D reason: Removing objects from the path to the bathroom prevents tripping hazards, enhancing safety for a client with reduced visual perception. This intervention reduces fall risk, promotes independent mobility, and aligns with evidence-based practices for visually impaired individuals, making it the most effective and appropriate action.

A. Dry cough B. Increased urinary frequency C. Excessive sweating D. Metallic taste in mouth

Correct Answer is C

Explanation

Choice A reason: Dry cough is not associated with sertraline, an SSRI affecting serotonin pathways. Cough is linked to ACE inhibitors via bradykinin accumulation, not SSRIs, which cause neurological or gastrointestinal side effects. Including this misinforms the client about sertraline’s actual adverse effect profile.
Choice B reason: Increased urinary frequency is not a common sertraline side effect. SSRIs may cause urinary retention due to anticholinergic effects, but frequent urination is linked to diuretics or diabetes. Sertraline’s effects focus on serotonin-mediated mood changes, not bladder function alterations.
Choice C reason: Excessive sweating is a recognized sertraline adverse effect, driven by serotonin’s influence on autonomic sweat gland regulation. This hyperhidrosis, common in SSRI therapy, affects patient comfort and adherence, requiring education to prepare clients for this side effect during depression treatment.
Choice D reason: Metallic taste is not linked to sertraline. It occurs with antibiotics or chemotherapy agents due to oral mucosa irritation. Sertraline’s side effects include nausea or insomnia, driven by serotonin modulation, not gustatory changes, making this an incorrect inclusion in teaching.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply)

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the preceptor?

A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?