The nurse is caring for a patient from another culture who recently had surgery on their right arm. The patient grimaces every time the nurse tries to assess the right arm, however when asked about their pain level the patient reports, "The pain is not so bad, I can take it. Which of the following should the nurse do next?

Assess the patient for physiological indicators of pain.

Observe the patient for behavior that is indicative of pain.

Involve the patient in the pain assessment by asking more direct questions.

Compare the patient's facial expression to a FACES pain scale.

Answer and Explanation

The Correct Answer is C

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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Correct Answer is C

Explanation

A. "I will try to make myself useful while I am in their home." This statement reflects a positive attitude and willingness to contribute, which does not require immediate follow-up.

B. "My adult child has been preparing my grandchildren for my arrival." This statement indicates that preparations are being made, which is generally a good sign and does not require immediate follow-up.

C. "I will miss my home that I lived in for so long." This statement requires immediate follow-up because it may indicate emotional distress or difficulty adjusting to the new living situation. The nurse should assess the client’s feelings and provide support to help them cope with the transition.

D. "My other adult child is willing to help me too." This statement is positive and indicates additional support, which is generally reassuring and does not require immediate follow-up.

A. Small muscle twitching. B. An increase in temperature. C. Difficult to arouse. D. An increase in pulse rate.

Correct Answer is C

Explanation

A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.

B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.

C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.

D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

Correct Answer is C

Explanation

The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

Correct Answer is C

Explanation

The nurse is assessing clients for risk factors of experiencing developmental stress. Which of the following clients should the nurse identify has having a risk factor?

The nurse is assisting a client, who is postoperative abdominal surgery, to the chair. The nurse notes the client is guarding the abdomen and grimacing when ambulating. Which of the following would be the most appropriate question or statement by the nurse?

The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

The nurse is discussing the difference between a Do Not Resuscitate (DNR) order and a Allow Natural Death (AND) order to a patient with a terminal illness. Which of the following correctly explains the difference of these two orders?

The nurse is caring for a client who reports daytime drowsiness. The client states, "My partner says my snoring is getting louder and it sometimes wakes me up." The nurse should further assess the client for which of the following?

The nurse is teaching a group of young adult clients about preventive measures to help avoid the major health problems-of middle adult years. Which of the following should the nurse include in the teaching?

The nurse is caring for a patient diagnosed with a terminal illness who is interested in signing a healthcare Advanced Directive. Which of the following are included in this type of end-of-life planning? Select all that apply.

The nurse is preparing to transfer a patient from the bed to a chair next to the bed. The patient has full weight bearing on the right leg and partial weight bearing on the left leg. They use a walker when ambulating. Which of the following assistive devices would be appropriate for the transfer?