A client is grimacing and with fists clenched states, "I'm in excruciating pain." Which of these entries indicates correct documentation of the client's affect?
a. "Client is angry."
b. "Client is in a hostile mood."
c. "Client states, ‘I'm in excruciating pain.' Grimacing, clenched fists noted."
d. "Client is uncooperative during the assessment process."
C
The pain assessment is to include pain intensity and quality. Pain is subjective and therefore is whatever the client states it is. Documentation require the use of quotations when describing the client's pain level if no scale is being used.
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A nurse wishing to be an advocate for access to health care would most likely choose to participate in which of the following activities?
A. Lobby for improved insurance access for all individuals, whether or not they are employed. B. Help establish fast-track or minor illness areas in local emergency rooms. C. Partner with medical centers to provide free services for low-income patients. D. Work with visiting nurses associations to create on-site clinics at day-care centers.
Which of the following information related to medications should the nurse include in the teaching plan for a client who is positive for the human immunodeficiency virus (HIV)?
a. Do not skip a dose. If a dose is missed, double the next dose. b. Take this medication at any time after eating. c. Tell the prescriber if you decide to stop treatment. d. Wait until the next visit before reporting significant side effects.
A client makes the following statement: "I must be paying for all the wrongs I did in my life, to have such a diagnosis as this." The nurse suspects that this client views health from which type of belief?
1. Magico-religious belief 2. Holistic health belief 3. Biomedical health belief 4. Folk medicine
A nurse asks her mentor, "What can I do to develop better critical thinking skills?" The best re-sponse for the mentor would be:
1. "Critical thinking includes judgment, intuition, and expertise. It takes years to develop expertise, so be patient and the skill will develop." 2. "Critical thinking uses an explicit linear process, depending primarily on keeping data organized, so focus on organization." 3. "Critical thinking is entirely dependent on making a rapid nursing diagnosis. Concentrate on speeding up your diagnosis making." 4. "Critical thinking requires observing, distinguishing, validating, organizing, and categorizing data. Being aware of the components can help you use the process."