Nursing Exam
When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:
actively solicit information about the client's pain level.
A nurse works with an older adult client who has two broken femurs. The client does not report pain. Which action will the nurse take?
Assess the client for nonverbal cues of pain.
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?
Endorphins
A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?
It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression.
The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.
Language assessment
Which guideline regarding pain should be included in the nurse's education plan for a group of parents with infants and toddlers?
Pain can be a source of fear and threat to the toddler's security.
Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?
Respiratory
A pediatric nurse provides education to numerous clients. Which group of children benefits most from being involved in the teaching-learning process?
School-aged children
The nurse is caring for a client whose language skills are very limited in the dominant language, and an interpreter has been obtained. The interpreter appears to be telling the client more than the nurse is saying and possibly providing an opinion or medical advice. Which action is appropriate for the nurse to take?
Speak privately with the interpreter and instruct them to only provide language interpretation.
The younger nurses on a unit, who seem to adapt easily to the new technology presented, are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond?
The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.
A new nurse observes a priest visiting the clients every Saturday afternoon and praying with them. This activity supports which of the nursing outcomes?
The client uses a type of spiritual experience that provides comfort.
Which response from the client enables the nurse to determine the effectiveness of a recent medication teaching session for an older adult client who is diagnosed with tuberculosis (TB)?
"I will be taking the TB medication for at least 6 months, because it takes a long time to kill the TB germs."
A nurse is admitting a client to the unit. Which cultural question is most appropriate?
"What are your dietary needs and preferences?"
The nurse working on a medical unit always performs hand hygiene between contact with each client. In addition to being understood as an infection control measure, this practice can be understood as:
A ritual
An adolescent client is experiencing menstrual pain. Which action(s) will the nurse take to assist the client with decreasing pain? Select all that apply.
Administer analgesic medication Apply heat to the pelvic area Recommend avoidance of sugar Provide chamomile tea Encourage exercise
A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?
Administer the pain medication.
A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?
Autonomy
When asking an older adult client about abdominal pain, the client reports, "I don't want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action?
Gently mention that the client appears to be experiencing pain that can be treated.
The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?
Wong-Baker FACES® scale
Persistent gaps between the health status of minorities and non-minorities are defined as:
health disparities.
A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:
require an individualized approach by the nurse.
