The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?
a. Frequently asking for ice chips
b. Facial grimacing
c. Changing positions in bed
d. Covering her face with her hands
ANS: B
Facial grimacing may be an indicator of unexpressed pain.
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A school-age child has been rehydrated following a bout of diarrhea. The nurse offers foods that are nonirritating to the bowel, including:
a. apricots and peaches. b. chocolate milk. c. applesauce and milk. d. bananas and rice.
Following a tracheostomy, the patient is exhibiting signs of a pneumothorax. The surgeon inserts a chest tube into the anterior of the chest wall. What would the nurse tell the family that the primary purpose of the chest tube is?
A) To remove air B) To drain sputum secretions C) To monitor bleeding D) To assist with mechanical ventilation
The nurse is caring for a client who has just received a diagnosis of advanced oral cancer that will require extensive surgery. Which statement by the client indicates that the diagnosis is accepted?
a. "The biopsy test results will be confirmed again next week." b. "Of all the bad things to happen to me, now I have cancer on top of it all." c. "If I can live long enough to see my son get married, everything will be alright." d. "I don't like it, but I have cancer and that's the way it is."
The nurse is caring for a client who has a history of alcohol abuse
When formulating a goal that "the client will be able to identify three physical effects of alcohol abuse," the nurse recognizes this goal as referring primarily to health teaching in which domain? a. Cognitive b. Affective c. Psychomotor d. Promoting acceptance