NCLEX missed question

The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer. The most important information to gather in this initial assessment is the:

The most important component of pain assessment is the client's self-report of the pain. The nurse should have the client describe the quality, location, and intensity of the pain; the client's response to the pain; and any alleviating or aggravating factors affecting the pain.The physical assessment should follow the pain assessment and should be delayed if the client is uncomfortable.The amount of pain medication the client is currently taking is an important component of the pain assessment, but it is meaningless without the client's self-report of the pain and the effectiveness of the pain therapy.The family's response to the client's illness may indicate the amount of support the client has and alerts the nurse to potential problems. With care, however, these concerns are secondary to the issue of pain control.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool." Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions?

"I should hold one nostril closed while I insert the spray into the other nostril." When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the other nostril to ensure the best inhalation of the spray. Use of the inhaler is not limited to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation of the medication.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

"I will heat my infant's formula in the microwave." Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client:

"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears.The time required for a radioactive substance to be half-dissipated is called its half-life, but this does not determine discharge time. The client receiving sealed internal radiotherapy is not discharged until the radioactive source is removed.While the radiation is necessary for treatment, telling the client this does not provide information to address her concerns.With cervical implants, there is no way to shield the area above the waist from radiation.

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. What should the nurse do first?

Assess the client for signs of peritonitis. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client. The nurse's primary duty is to honor the client's request for a meeting with a spiritual adviser.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior. The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

Three victims with gunshot wounds are brought to the emergency department. The nurse should take which action to preserve forensic evidence on the clients' clothing?

Place each item of clothing in a separate paper bag.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement?

Tell the client to march in place. When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.

When the nurse is teaching a group of parents about common childhood problems, a parent asks, "Why are children more likely to develop ear infections than adults are?" The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which structure?

eustachian tubes. In infants and young children, the eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.Although bacteria may be present in the nasopharynx, this does not affect middle ear function.The size of the ear canal has no impact on the increased number of ear infections in children. An intact tympanic membrane prevents bacteria from entering the middle ear from the external ear canal. The tympanic membrane changes appearance with an ear infection, but its structure does not predispose infants and young children to ear infection.

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which finding should lead the nurse to believe the child is experiencing anxiety?

frequent requests for someone to stay in the room

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

making a copy of the incident report for the client. A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact?

The left kidney usually is slightly higher than the right one. The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4??) long, 5 to 5.8 cm (2? to 2¼?) wide, and 2.5 cm (1?) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.

A nurse is developing a plan to teach a parent how to reduce an infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan?

Place the infant in an upright position when giving a bottle. Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.

A nurse is caring for a client following transsphenoidal hypophysectomy and notes a watery discharge from the client's nose. Which action is appropriate for the nurse to take?

Test the drainage for a yellow "halo." Following transsphenoidal adenohypophysectomy, the client should avoid blowing the nose. The meninges require time to heal without the pressure of blowing the nose. If a cerebral spinal fluid leak develops, the client will experience persistent watery nasal drainage. Bruising, incisional pain, and swelling are all common events following surgery.

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance. The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the spouse what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the spouse to leave would probably be ineffective in the agitated and irrational state. Exploring the spouse's anger doesn't take precedence over safeguarding the client and staff.