An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Introduce non-pharmacologic strategies for pain reduction.

Allow adequate privacy and time for the client's phone call.

Document the concern of incongruent pain rating and behavior.

Administer pain medication per the healthcare provider's orders.

Answer and Explanation

The Correct Answer is B

Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.

Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.

Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.

Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

A. Maintain protein intake and increase intake of fruits and vegetables. B. Decrease protein intake and eat more whole grains and vegetables. C. Increase protein intake with the additional intake of dairy products. D. Maintain protein intake but substitute fish and nuts for meat and eggs.

Correct Answer is D

Explanation

Choice A: Maintaining protein intake and increasing intake of fruits and vegetables is generally a balanced and healthy approach to nutrition.

Choice B: Decreasing protein intake and eating more whole grains and vegetables may not be necessary unless there are specific dietary restrictions or medical indications.

Choice C: Increasing protein intake with additional dairy products may not be needed and depends on individual dietary preferences and nutritional goals.

Choice D: Maintaining protein intake but substituting fish and nuts for meat and eggs can be a balanced and healthy dietary choice. Fish and nuts can provide protein and healthy fats while reducing saturated fat intake from red meat and eggs.

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An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

A 30-year-old male client tells the nurse that about half of his diet comes from eating meat and eggs. What instruction should the nurse provide?

Correct Answer is D

Explanation

When conducting diet teaching for a client diagnosed with hypokalemia, which foods should the nurse encourage the client to eat?

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