A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective?
The client is laughing at a television show.
The client's skin on the lower back is intact without redness.
The client states that he is able to concentrate while reading.
The client's vital signs are within the expected reference range.
The Correct Answer is B
Choice A rationale:
Laughing at a television show is not a direct indicator of the effectiveness of the warm, moist compress in relieving lower back pain.
Choice B rationale:
Intact skin on the lower back without redness indicates that the compress has been effective in preventing skin damage or irritation.
Choice C rationale:
The ability to concentrate while reading may not be a specific indicator of the effectiveness of the warm compress in relieving lower back pain.
Choice D rationale:
Vital signs within the expected reference range are important but do not directly reflect the effectiveness of the warm compress in relieving pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Delirium can affect a client's sleep cycle, often causing disturbances in sleep-wake patterns.
Choice B rationale:
Delirium typically has a rapid onset, not a slow progression.
Choice C rationale:
The correct statement is that delirium has an abrupt onset. Understanding this characteristic helps nurses recognize and address delirium promptly.
Choice D rationale:
Delirium can significantly impact a client's perception of the environment, leading to confusion and disorientation.
Correct Answer is C,B,D,E,A
Explanation
Choice A rationale:
Checking for areas of tenderness helps to identify any inflammation, infection, or injury in the abdominal cavity.
Choice B rationale:
Listening to the abdominal arteries helps to detect any bruits or abnormal sounds that may indicate vascular problems.
Choice C rationale:
Providing adequate lighting allows the nurse to inspect the abdomen for any abnormalities, such as distension, scars, or lesions.
Choice D rationale:
Percussing the abdomen helps to assess the size and density of the organs, as well as to detect any fluid or gas accumulation.
Choice E rationale:
Locating the liver and spleen borders helps to determine if they are enlarged or displaced.
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