The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, "Nothing helps the pain." What best describes the pain being experienced by the client?
1. The client is experiencing referred pain.
2. The client is experiencing intractable pain.
3. The client is experiencing retractable pain.
4. The client is experiencing radiating pain.
2
Rationale 1: Referred pain refers to pain that is felt in an area that is physically distant to the affected area.
Rationale 2: Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy.
Rationale 3: Retractable pain does not exist.
Rationale 4: Radiating pain refers to pain that extends to surrounding areas of the body.
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The nurse is discussing alignment and posture with a group of teens. Many of the female students have adopted a curved posture. The nurse explains to the teens that
1. When the body is properly aligned, the organs are properly supported 2. Equilibrium depends on the proper body alignment 3. Muscular strength decreases with physical activity 4. Orthostatic hypotension is common with improper alignment
A woman complains of irregular menstrual periods and wonders if she is in perimenopause or menopause. Her laboratory work shows high levels of follicle-stimulating hormone (FSH) and low levels of estradiol. What response by the nurse is best?
A. "No, in menopause the FSH is low and the estradiol is high." B. "No, those two laboratory findings are not related to the climacteric phase." C. "These laboratory findings usually indicate menopause or perimenopause." D. "Yes you are definitely in menopause right now."
The client finds fault in every success she has. She is afraid to try anything new because she "just knows" that she will fail because she is mentally ill. Her behaviors demonstrate:
a. Low self-esteem b. Suicidal ideation c. Low abstraction abilities d. Altered thought processes
When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do?
a. Notify the provider immediately. b. Do nothing; this is normal. c. Give the baby sterile water until the mother's milk comes in. d. Apply a skin barrier cream to the buttocks to prevent irritation.