The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?

Inﬂammation of the lips

Hypoxia

Beginning of a liver blister

Lack of dental care

Answer and Explanation

The Correct Answer is B

Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.

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Correct Answer is D

Explanation

This response demonstrates respect for the client's religious beliefs and a willingness to work with the client to meet their needs. It also opens up a dialogue between the nurse and the client to develop a plan of care that is consistent with the client's beliefs and values.

Option a, "Fasting is harmful to your body," is not an appropriate response as it does not respect the client's religious beliefs and may be perceived as insensitive or disrespectful.

Option b, "You must have food during times of illness," may be accurate in some situations, but it is not relevant to the client's request to fast during Ramadan.

Option c, "I will let your healthcare provider know that you need to be discharged," is not an appropriate response as it does not address the client's request to fast during Ramadan and may be perceived as dismissive or unhelpful.

A. Pain is an unpleasant sensation, typically experienced upon movement. B. Pain is validated by the nurse determining the cause of pain. C. Pain is whatever the person experiencing it says it is. D. Pain is very subjective, so observations must be used to determine the levels and intensity.

Correct Answer is C

Explanation

"Pain is whatever the person experiencing it says it is," to include in the orientation. This definition reﬂects the concept of pain as a subjective experience that cannot be directly observed or measured, but only reported by the individual experiencing it. It emphasizes the importance of believing and acknowledging the patient's report of pain, and not relying solely on objective indicators or assumptions about the cause or intensity of pain. This definition also aligns with current standards of pain assessment and management, which prioritize patient-centered care and the use of self-report measures to guide treatment decisions.

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The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?

Correct Answer is D

Explanation

The nurse is working at a pain clinic and is preparing orientation for new staﬀ nurses. Which of the following definitions of pain would the nurse correctly choose to include in the orientation?

Correct Answer is C

Explanation

Some of the factors that negatively aﬀect nutrition in the older adult include which of the following? (Select all that apply)

When assessing the heart, the nurse inspects and palpitates which of the following?

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