The new nurse asks the educator, "What is the most important part of a pain assessment?" Which response should the nurse educator provide?
A. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment."
B. "The response to pain is unique and based on numerous factors, which need to be assessed."
C. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important."
D. "Vital signs are not reliable indicators of acute pain because only some clients are able to elicit a change in blood pressure or pulse rate."
Answer: B
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When taking a history of a child with cellulitis, which information would be most pertinent for the nurse to assess?
a. Any medication the child is taking b. Enlarged, mobile, and nontender lymph nodes c. Child's urinalysis results d. Recent infections or signs of infection
A patient with portal hypertension and hepatic encephalopathy asks why meat is being restricted in the diet. The nurse explains that a reduced protein diet will:
1. Help to restore his liver function 2. Help decrease the amount of ammonia in his blood 3. Give the liver a chance to rest 4. Prevent fluid from leaking into the abdomen
The nurse is intubating a client whose respiratory status is inadequate owing to status asthmaticus. What would the nurse do to verify proper placement?
A) Palpate the neck. B) Slightly pull on the tubing. C) Obtain a chest x-ray. D) Obtain a MRI.
Which of the following statements by a client reporting constipation reflects the most informed understanding of interventions that will aid in assuming proper bowel mobility?
1. "Could it be that I need to get more exercise, even here in the hospital?" 2. "Is it true that drinking coffee often helps stimulate the bowels to work?" 3. "I guess a little high-fiber cereal might help. Can you get me some from the cafe-teria?" 4. "May I have a cup of decaffeinated tea in addition to my breakfast juice? That usually helps."