The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?

Individual with a small laceration on the left forearm.

Individual with hypoactive bowel sounds and last bowel movement 6 days ago

Newly diagnosed patient with diabetes who needs diabetic teaching

Patient with 5/10 postoperative pain

Answer and Explanation

The Correct Answer is B

A.   A small laceration is typically a second-level priority, as it requires wound care but is not lifethreatening.
B.   This suggests a risk for bowel obstruction or other serious gastrointestinal issues that require immediate attention, making it a first-level priority.
C.   While important, this is not an urgent, life-threatening situation and is not considered a first-level priority.
D.   This is a second-level priority, as it requires pain management but is not as urgent as more critical issues.

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Correct Answer is A

Explanation

A. Cranial nerve 11, the accessory nerve, controls the sternocleidomastoid and trapezius muscles, which contribute to the movement of the neck and shoulders. However, while facial symmetry is related to other cranial nerves, this is the correct action for cranial nerve 11's motor function testing.
B. Visual acuity is related to cranial nerve II (optic nerve), not cranial nerve XI.
C. The gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve XI.
D. Checking the pupillary response to light. The pupillary light reflex is controlled by cranial nerve II (optic) and cranial nerve III (oculomotor), not cranial nerve XI.

A. A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain. B. All patients will behave in the same way when in pain. C. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. D. Cultural norms have very little to do with pain tolerance because pain tolerance is always biologically determined.

Correct Answer is C

Explanation

A. This is incorrect, as a patient’s expression of pain can vary significantly based on cultural, emotional, and psychological factors, not just the severity of the injury.
B. This is false. Pain expression is highly individualized and influenced by cultural and personal factors.
C. This is correct. Different cultures and individuals have varied ways of expressing pain, which can affect their pain management.
D. This is not accurate. Cultural norms play a significant role in how individuals tolerate and express pain.

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The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve 11?

Correct Answer is A

Explanation

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

Correct Answer is C

Explanation

An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?

When performing a physical assessment of a client's maxillary the nurse should.

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

Which of the following statements is true regarding the function of the brain?

The movement of the leg laterally then medially, with knee straight is referred to as:

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?