The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

"I am so depressed living with this pain that I don't know if I can go on anymore."

"At home I take something for pain before it gets too bad."

"I try to pretend that the pain isn't part of me, but it's hard to do."

"I live with pain every day, and it sometimes prevents me from doing the things I love to do."

Answer and Explanation

The Correct Answer is A

This statement raises concern because it suggests that the client is experiencing thoughts of hopelessness and suicidal ideation. Expressions of feeling overwhelmed by pain to the extent of questioning the desire to continue living indicate a need for immediate attention and intervention to address the client's emotional distress and ensure their safety.

B. This statement indicates the client's proactive approach to pain management by taking medication preemptively before pain becomes severe. It reflects an understanding of pain management strategies and a willingness to address pain effectively.

C. Although this statement acknowledges the challenge of coping with pain, it also suggests the client's attempts to cope by mentally dissociating from the pain. While coping mechanisms vary among individuals, this response does not raise immediate concern unless accompanied by more severe signs of distress.

D. This statement acknowledges the chronic nature of the client's pain and its impact on daily activities but does not indicate thoughts of self-harm or severe emotional distress. It reflects the client's adaptation to living with pain and a willingness to engage in activities despite its presence.

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Correct Answer is D

Explanation

A. Diarrhea: Diarrhea typically involves the passage of loose or watery stools, often occurring frequently throughout the day. It is characterized by increased frequency, urgency, and volume of stool output. While diarrhea can cause bloating, it is not usually associated with continuous oozing of small amounts of liquid stool.

B. Flatus: Flatus refers to the passage of gas through the rectum, commonly known as "passing gas" or "flatulence." While flatus can contribute to feelings of bloating or discomfort, it does not involve the continuous oozing of liquid stool.

C. Overflow: Overflow typically occurs in the context of fecal impaction, where liquid stool leaks around a fecal mass that is blocking the rectum. However, overflow is characterized by the intermittent leakage of liquid stool, often preceded by constipation and fecal impaction. Continuous oozing of small amounts of liquid stool is not typically associated with overflow alone.

D. Impaction: Fecal impaction occurs when a large, hardened mass of stool accumulates in the rectum, making it difficult or impossible to pass stool. Continuous oozing of small amounts of liquid stool can occur around the impacted fecal mass, leading to symptoms such as bloating, discomfort, and leakage of liquid stool. Therefore, fecal impaction is the most likely condition associated with the client's symptoms.

In summary, option D (Impaction) is the correct answer as it best aligns with the client's symptoms of feeling bloated and experiencing continuous oozing of small amounts of liquid stool in the context of being on bedrest after surgery

A. White blood cells B. Platelets C. Red blood cells D. Hematocrit

Correct Answer is A

Explanation

A. White blood cells (WBCs): The nurse should monitor the client's white blood cell count to assess their ability to withstand exposure to pathogens. WBCs are integral to the body's immune response, as they play a crucial role in defending against infections. An elevated or decreased WBC count can indicate an underlying infection or immune dysfunction, helping the nurse identify potential risks to the client's health. Regular monitoring of WBC levels allows for timely intervention and assessment of the client's immune status.

B. Platelets: Platelets are primarily responsible for blood clotting and are not directly involved in the body's immune response to pathogens. While they are important for hemostasis and preventing excessive bleeding, monitoring platelet count is not directly indicative of a client's ability to withstand exposure to pathogens.

C. Red blood cells: Red blood cells (RBCs) are responsible for transporting oxygen throughout the body and are not directly involved in the immune response to pathogens. Monitoring red blood cell count, hemoglobin, and hematocrit levels is important for assessing oxygen-carrying capacity and detecting conditions such as anemia, but it does not provide specific information about the client's ability to combat infections.

D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is used to assess blood volume and oxygen-carrying capacity. While changes in hematocrit levels may indirectly indicate certain health conditions, such as dehydration or polycythemia, it does not directly reflect the client's immune status or ability to withstand exposure to pathogens.

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The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?

Correct Answer is D

Explanation

The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

Correct Answer is A

Explanation

A nurse verbally contracts with a client to reassess their pain level after repositioning and an analgesic is given. The nurse returns within 60 minutes to evaluate effectiveness of the interventions. What ethical principle does this represent?

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