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 A

Explanation

A. Offer toileting reminders every 2 hours: This is the best nursing action because it helps prevent urinary incontinence by prompting the client to use the bathroom regularly. Clients with cognitive impairment may have difficulty recognizing the need to void or remembering when to do so. Providing frequent reminders helps maintain bladder continence and reduces the risk of accidents.

B. Provide clothing that is easy to manipulate: While providing clothing that is easy to manipulate can be helpful for clients with cognitive impairment to independently manage toileting, it does not directly address the issue of facilitating bladder continence. Easy-to-manipulate clothing may assist with toileting independence but does not address the need for regular voiding to prevent urinary incontinence.

C. Explain the need to call for the nurse to help with toileting: While educating the client about when to seek assistance for toileting needs is important, it may not be sufficient for facilitating bladder continence in a client with cognitive impairment. Clients may still have difficulty recognizing the need to void or remembering to call for assistance, making frequent reminders more effective in promoting continence.

D. Encourage avoidance of fluids between meals: Encouraging avoidance of fluids between meals is not an appropriate strategy for promoting bladder continence. Restricting fluids can lead to dehydration and other health complications. Maintaining adequate hydration is essential for overall health, and clients should be encouraged to drink fluids regularly throughout the day. Additionally, restricting fluids does not address the underlying issue of cognitive impairment affecting toileting behaviors.

A. lithotomy with a drape for privacy B. Supine with arms at their sides C. left decubitus D. a position that feels most comfortable for the client

Correct Answer is B

Explanation

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

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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

What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Correct Answer is A

Explanation

Which position would be appropriate for the nurse to perform an abdominal assessment?

Correct Answer is B

Explanation

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