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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Lateral heels offloaded with pillows: Positioning the patient laterally with heels offloaded helps reduce pressure on the heels and prevent pressure sores.

B. Supine heels offloaded with pillows: Although offloading the heels is important, the supine position may still exert pressure on the heels and does not provide as effective offloading as the lateral position.

C. Fowler's heels offloaded with pillows: Fowler’s position may still place some pressure on the heels, even with pillows for offloading.

D. Prone ankles offloaded with pillows: The prone position is generally not recommended for patients with spinal injuries, and it does not effectively address heel pressure.

A. "How would you describe your sleep problem?" B. "What types of sleep treatments have you tried?" C. "What do you think is the cause of the sleep problem?" D. "How does the sleep problem affect your everyday living?" E. "Don't you think when you get tired enough, you'll sleep well?"

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

Explanation

A. "How would you describe your sleep problem?" Understanding how the patient describes their sleep problem provides insight into the nature of the disturbance and its potential causes.

B. "What types of sleep treatments have you tried?" Knowing what treatments have been tried helps identify what has or hasn’t worked and can guide further management.

C. "What do you think is the cause of the sleep problem?" Understanding the patient’s perspective on the cause can help in assessing their awareness and any possible underlying issues.

D. "How does the sleep problem affect your everyday living?" This question assesses the impact of sleep disturbances on daily life and overall well-being, providing context for the severity of the problem.

E. "Don't you think when you get tired enough, you'll sleep well?" This statement does not address the underlying problem and might dismiss the patient’s concerns. It is not useful in assessing or managing sleep disturbances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is reviewing sleep habits with a patient who reports difficulty sleeping. When evaluating sleep disturbances, the nurse should ask which of the following? Select all that apply.

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

Explanation

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 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 caring for a client who recently experienced the death of a partner. Which of the following statements would indicate to the nurse that the client is demonstrating appropriate coping strategies?

The home health nurse is visiting with a client with terminal cancer whose partner has become the primary caregiver. The partner states, "Maybe I will lose weight since I rarely have time to eat." Which of the following responses should the nurse make?

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 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 caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

The nurse is assessing a group of clients for somatic pain. Which of the following client's would be experiencing this type of pain?