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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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.

A. The client who is recovering from a motor vehicle collision. B. The client that is recently divorced. C. The client experiencing the symptoms of menopause. D. The client newly diagnosed with lung cancer.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 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 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?

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 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?

The nurse is assisting a client with performing range-of-motion of the shoulder and the client asks the nurse to identify each movement performed. Which of the following movements should the nurse include? Select all that apply.

The nurse is administering a subcutaneous injection to a client. Which of the following actions should the nurse take?

The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

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.