A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Client is asleep and resting

Client had 150 mL of emesis in last hour

Ondansetron 4 mg IV bolus for nausea and vomiting

Client reports nausea and vomiting 30 minutes following surgery

Answer and Explanation

The Correct Answer is C

A.   This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B.   This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C.   It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D.   This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.

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Correct Answer is B

Explanation

A. Peripheral neuropathy typically results in a decreased ability to detect temperature changes due to nerve damage. Clients often experience reduced sensation or may not feel temperature variations accurately.
B. This is a common symptom of peripheral neuropathy. Many clients report a burning, tingling, or "pins and needles" sensation in their feet. This phenomenon is often associated with nerve damage, especially in conditions like diabetes.
C. Peripheral neuropathy can lead to diminished or altered sensation, including the inability to sense pressure accurately. Clients may not feel pressure on their feet, which increases the risk of injuries and ulcers.
D. Hyperreflexia refers to increased reflex responses, which may occur with upper motor neuron lesions or central nervous system issues, not peripheral nerve damage. Peripheral neuropathy usually results in diminished reflexes or areflexia.

A. The client rates their pain as an 8 on a scale of 0 to 10. B. The client reports a burning sensation. C. The client grimaces when they move. D. The client states the pain is located on their abdomen.

Correct Answer is C

Explanation

A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.

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A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

Correct Answer is C

Explanation

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics?

A nurse is assisting with teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

A nurse is assisting with the care of a client. Exhibits A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Which of the following is an essential component of patient safety in healthcare settings?

What is the purpose of evidence-based practice (EBP) in nursing?

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A nurse is reinforcing teaching with a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following statements by the client indicates an understanding of the teaching?