Two days after surgery, a client experiences incisional pain while dangling at the bedside and refuses to ambulate as prescribed. The nurse establishes a problem of "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care?

Avoid pain-causing activity.

Ambulate without discomfort.

Show evidence of incision healing.

Take analgesics as prescribed.

Answer and Explanation

The Correct Answer is B

A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.

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Correct Answer is B

Explanation

A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.
B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.
C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.
D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.

A. Discuss with the client that there may be a need for additional sleep if the feeling of fatigue is present the next day. B. Encourage the client to obtain a prescription for a benzodiazepine antagonist. C. Instruct the client that it is important to reduce the dose of the medication gradually. D. Advise the client to stop taking the medication immediately.

Correct Answer is C

Explanation

A. While additional sleep may be helpful, it does not address the root cause of the hangover effect from temazepam.
B. A benzodiazepine antagonist is typically used in cases of overdose, not for managing next-day drowsiness.
C. Temazepam is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The nurse should advise the client to taper off the medication gradually under medical supervision to prevent withdrawal symptoms and minimize the "hangover" effect.
D. Stopping the medication abruptly can lead to withdrawal symptoms and is not recommended.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Correct Answer is B

Explanation

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Correct Answer is C

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

A client who is 12 weeks pregnant has type 1 diabetes mellitus. Which instruction should the nurse provide related to insulin dosages?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]