The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Bowel incontinence.

Impaired bed mobility.

Fluid volume deficit.

Caregiver role strain.

Answer and Explanation

The Correct Answer is C

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

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Correct Answer is A

Explanation

Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.

Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.

Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.

Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.

A. Provide at least 20 minutes of back massage and gentle efleurage. B. Instruct the client to use guided imagery and slow rhythmic breathing. C. Place a hot water circulation device, such as an aquathermia pad, on the operative site. D. Tune to a television show or easy listening music to provide distraction.

Correct Answer is B

Explanation

This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.

Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.

Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.

Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.

Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.

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The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is A

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is B

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?