When assessing a client's pain, the nurse understands that pain:
a. Rarely results in physiologic or psychologic changes.
b. Is an intense sensory experience related to the amount of tissue damage.
c. Is measurable by objective means.
d. Is determined by the client's perception.
ANS: D
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The nurse is assigned to a 79-year-old patient who has decreased mobility resulting from a stroke
The nurse understands the interventions to prevent skin breakdown for this bedfast patient is to include repositioning of the patient at least every _____ hour(s). a. 1 b. 2 c. 3 d. 4
A nurse who provides care on a reconstructive orthopedic unit has walked past the room of a patient who is receiving balanced suspension traction for the treatment of a femoral head fracture
The nurse observes a nursing assistant lifting the suspended weights to facilitate positioning a bedpan under the patient. How should the nurse best follow-up this observation? A) Ensure the nursing assistant knows that such transfers must be performed quickly and efficiently. B) Assess the patient for the ability to transfer to a commode rather than using a bedpan. C) Teach the nursing assistant that weights should not be removed from traction, except in an emergency. D) Teach the nursing assistant to apply temporary weights to compensate for positional changes.
The nurse is monitoring an ice bag being used on a client's ankle. What color of the client's skin indicates immediate removal of the ice bag?
A) Mottled B) Ashen C) Jaundice D) Greenish
The intervention mode in which the consultant
acts as a facilitator to help the client clarify understanding of problems by increasing information, breaking down barriers to communication, and raising awareness of the problem is the: a. Acceptant mode b. Catalytic mode c. Prescriptive mode d. Theory-principles mode