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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. The client who is recovering from a motor vehicle collision. This situation involves an acute stressor related to trauma, which is significant but not a developmental stressor.

B. The client that is recently divorced. Divorce is a significant life event that can contribute to developmental stress, especially if it involves major life changes and adjustment issues.

C. The client experiencing the symptoms of menopause. Menopause is a normal developmental phase, though it can be stressful. However, it is less likely to be classified as a significant risk factor compared to other life events.

D. The client newly diagnosed with lung cancer. A new cancer diagnosis is a major stressor and can contribute to significant emotional and psychological stress, but it is more of an acute stressor than a developmental one.

A. Immunization record B. Daily activity level C. Patient's response after the activity or exercise D. Problems with mobility or exercise E. External factors affecting mobility

Correct Answer is ["B","C","D","E"]

Explanation

A. Immunization record: While important for overall health, the immunization record is less directly related to current activity levels and exercise.

B. Daily activity level: This provides important information about the patient's current physical activity, which is relevant for assessing overall health and mobility.

C. Patient's response after the activity or exercise: Understanding how the patient responds after activity helps assess the impact of exercise on their health and mobility.

D. Problems with mobility or exercise: Identifying any problems with mobility or exercise helps in tailoring the patient’s activity plan and addressing any issues related to physical function.

E. External factors affecting mobility: External factors, such as environmental barriers or equipment, can significantly impact the patient’s mobility and should be considered in the assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is obtaining a history from a patient reference activity. Which of the following should be included? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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?

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 home health nurse is visiting with an older retired adult who states, "My children do not want me to drive anymore, they say I am a dangerous driver." Which of the following responses would be most appropriate?

The nurse is preparing to apply a patient's knee-high graduated compression stockings. Which of the following should the nurse do first?

The nurse is caring for a seriously ill patient with a terminal disease who states, "I do not want to eat anymore, I cannot prolong this agony." Which of the following interventions should the nurse do first?

A home health nurse is teaching a sedentary elderly female about the importance of joint mobility. Which of the following lifestyle interventions would prevent injury to the affected joints?

The nurse is caring for a patient with a new mobility deficit due to a recent stroke (CVA). The patient states, "I hate not being able to do simple things like walking by myself anymore." Which of the following responses provides the best support for the patient?

The nurse is preparing to administer prescribed modified (cloudy) and nonmodified (clear) insulin to a client with type 1 diabetes. Place the following steps in the correct order, that the nurse should take to prepare the medication. All options must be used.