The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Ask the client to describe the pain.

Observe body language and movement.

Identify effective pain relief measures.

Provide a numeric pain scale.

Answer and Explanation

The Correct Answer is A

Choice A reason: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.

Choice B reason: Observing body language and movement can offer insights into the pain's impact on function, but it does not replace the client's verbal description of the pain experience.

Choice C reason: Identifying effective pain relief measures is part of managing osteoarthritis but does not directly assess the quality of the client's knee pain.

Choice D reason: Providing a numeric pain scale is a method to quantify pain intensity but may not fully capture the quality or characteristics of the pain.

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Correct Answer is C

Explanation

The correct answer is: c. Inspiratory and expiratory bilateral crackles.

Choice A: Average urine output of 28 mL/hour

Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.

Choice B: Vesicular bibasilar breath sounds

Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.

Choice C: Inspiratory and expiratory bilateral crackles

Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.

Choice D: Central venous pressure of 12 mm Hg

Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.

A. Mild sedation. B. Dizziness reported after the initial dose. C. Somnambulism. D. A change in the sleep-wake cycle.

Correct Answer is C

Explanation

Choice A reason: Mild sedation is a common and expected side effect of ramelteon, which is a sedative used to treat insomnia. It is generally not a cause for concern unless it persists or worsens.

Choice B reason: Dizziness reported after the initial dose is also a common side effect of ramelteon. It usually diminishes as the body adjusts to the medication. However, if dizziness persists or is severe, it should be reported to the healthcare provider.

Choice C reason: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.

Choice D reason: A change in the sleep-wake cycle is an expected effect of ramelteon, as it is used to manage the sleep-wake cycle in people with insomnia. It is not typically a side effect that needs to be reported unless the changes are extreme or cause significant distress.

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The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Nursing Test Bank

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