For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Severity of the condition

Vital signs

Nonverbal behavior

Self-report of pain

Answer and Explanation

The Correct Answer is D

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

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Correct Answer is A

Explanation

Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.

Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.

Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.

Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.

A. Systemic B. Health care-associated C. Endogenous D. Exogenous

Correct Answer is B

Explanation

Choice A reason: A systemic infection would affect the entire body or multiple systems, not just the urinary tract. While a urinary tract infection can become systemic if it leads to sepsis, the scenario provided does not specify such progression.

Choice B reason: A health care-associated infection (HAI) is an infection that a patient acquires while receiving treatment for another condition within a healthcare setting. Since the infection occurred after the insertion of a urinary catheter in a hospital, it is considered an HAI.

Choice C reason: An endogenous infection originates from the host's own microbial flora. The scenario does not provide enough information to determine if the infection was caused by the client's own flora or by external sources.

Choice D reason: An exogenous infection comes from outside the body. While the urinary tract infection could be exogenous, the scenario suggests it is more likely to be health care-associated due to the timing and context of the catheter insertion.

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For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Correct Answer is A

Explanation

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

Correct Answer is B

Explanation

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following should apply? (Select all that apply)

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

Prior to taking the health history, the nurse should first do which of the following?

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?