At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?
Knowledge deficit.
Anxiety.
Pain intolerance.
Anticipatory grieving.
The Correct Answer is B
Choice B is correct because anxiety is the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anxiety is a feeling of fear, nervousness, or apprehension that can interfere with coping and decision making. The nurse should assess the level and source of anxiety and provide emotional support and reassurance to the client. The nurse should also review the pain management techniques and explain the benefits and risks of different analgesic options.
Choice A is incorrect because knowledge deficit is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Knowledge deficit is a lack of information or understanding about a topic or situation that can affect learning and behavior. The nurse should evaluate the client's learning needs and provide appropriate education and resources, but this is not as urgent as addressing the client's anxiety.
Choice C is incorrect because pain intolerance is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Pain intolerance is an inability or unwillingness to endure pain that can affect quality of life and recovery. The nurse should assess the client's pain level and response to analgesics and adjust the pain management plan accordingly, but this is not as urgent as addressing the client's anxiety.
Choice D is incorrect because anticipatory grieving is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anticipatory grieving is a process of mourning that occurs before an expected loss or death that can affect emotional and physical well-being. The nurse should acknowledge the client's feelings and provide empathy and support, but this is not as urgent as addressing the client's anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.
Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.
Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.
Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.
Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.
Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.
Correct Answer is B
Explanation
Choice A: Assigning the UAP to provide care for another client and assume full care of the client is not an action that the nurse should take, as this is unnecessary and inefficient. The UAP can safely assist the client with influenza if they follow proper infection control measures. This is an incorrect choice.
Choice B: Reviewing the need for the UAP to wear a face mask while in close contact with the client is an action that the nurse should take, as this can protect the UAP and others from droplet transmission of influenza. This is a standard precaution that should be reinforced by the nurse. Therefore, this is the correct choice.
Choice C: Instructing the UAP to apply a fitted respirator mask before entering the client's room is not an action that the nurse should take, as this is not indicated for a client with influenza. A respirator mask is required for airborne transmission, not droplet transmission. This is another incorrect choice.
Choice D: Directing the UAP to notify the nurse of any changes in the client's respiratory status is not an action that the nurse should take, as this is a general instruction that does not address the specific issue of infection control. This is another incorrect choice.
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