Question

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite a clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is m important for the nurse to obtain?

Answer 1

Correct Answers:

Sensory pattern, area, intensity, and nature of the pain.

Rationale :

🔷 A comprehensive pain assessment is the foundation of effective pain management.

🔷 Identifying the location, quality, severity, onset, and relieving factors helps distinguish cancer pain patterns (somatic, visceral, neuropathic).

🔷 Trigger points and sympathetic responses are more relevant to acute or musculoskeletal pain, not chronic cancer pain.

🔷 Documentation of the current pain regimen is important but comes after determining the client’s pain characteristics.

🔷 A full pain assessment supports tailored interventions, including adjustments to pharmacologic and non-pharmacologic therapies.

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Answer 2

Correct Answers:

The nurse notes that there are numerous scatter rugs throughout the house.

Rationale :

💠 For a post-stroke client using a cane, fall risk is the top safety concern.

💠 Scatter rugs increase the likelihood of tripping and falling, which could cause serious injury.

💠 Appetite changes and minor pulse increases are less urgent than safety hazards.

💠 Caregiver stress is important but does not carry the same immediate risk of harm as fall hazards.

💠 Identifying and eliminating environmental risks supports safe mobility and independence

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Answer 3

Correct Answers:

A 10-year-old who was burned by a camp fire earlier today.

Rationale :

😉 Acute tissue injury like burns causes severe pain due to nerve ending exposure.

😉 Children often experience and express pain intensely, making management essential.

😉 Chronic pain (e.g., low back pain) may be significant but is often adapted to over time.

😉 Post-op infections and sprains cause pain but generally less than a fresh burn injury.

😉 Acute burns require immediate intervention to prevent pain trauma and shock.

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Answer 4

Correct Answers:

Foods and liquids consumed during the past 24 hours.

Rationale :

🥗 A 24-hour dietary recall provides the most accurate baseline for assessing current nutritional intake.

🥗 This method helps identify protein deficits and guides immediate dietary interventions.

🥗 Weekly or supplement intake data is less specific and may miss current deficiencies.

🥗 For older adults, detailed recall identifies cultural food patterns and barriers to protein intake.

🥗 This ensures care planning is individualized and culturally appropriate.

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Answer 5

Correct Answers:

Risk for aspiration.

Rationale :

🫁 Coughing during meals indicates potential impaired swallowing and high risk for aspiration.

🫁 Aspiration can lead to pneumonia, hypoxia, and airway obstruction, making it the priority nursing diagnosis.

🫁 Impaired gas exchange or ineffective breathing may occur later but aspiration prevention is the first focus.

🫁 Identifying aspiration risk guides interventions such as swallow studies, modified diets, and positioning.

🫁 Early prevention improves safety and quality of life.

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Answer 6

Correct Answers:

The drainage tubing is secured over the siderail.

Rationale :

🔷 Tubing draped over the siderail can cause backflow of urine, increasing the risk of catheter-associated urinary tract infection (CAUTI).

🔷 The drainage bag should be below bladder level and attached to the bed frame, not the siderail.

🔷 An open clamp is correct, as urine must flow freely.

🔷 No dependent loops in tubing is desirable to prevent urinary stasis.

🔷 The most urgent intervention is to reposition the tubing to restore gravity drainage and prevent infection.

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Answer 7

Correct Answers:

Use reflective listening techniques when the client expresses spiritual doubts.

Rationale :

💠 Reflective listening demonstrates empathy and support while allowing the client to explore their feelings.

💠 Reassuring or promising outcomes may invalidate the client’s distress.

💠 Distraction ignores the problem rather than addressing it.

💠 Referral to a chaplain can be appropriate later, but first the nurse must provide direct therapeutic communication.

💠 This builds trust and helps address spiritual distress in a meaningful way.

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Answer 8

Correct Answers:

Turn the client every 2 hours.

Rationale :

✅Findings: immobile, hypothermic, wet lung sounds, concentrated urine → risk for fluid stasis and pneumonia.

✅ Turning promotes lung expansion, mobilizes secretions, and prevents hypostatic pneumonia.

✅ Giving fluids would worsen pulmonary congestion.

✅ Antihypertensives are unnecessary as BP is stable.

✅ Blanket addresses comfort, but not the most urgent risk.

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Answer 9

Correct Answers:

Determine if the expected outcomes of care were achieved.

Rationale :

📝 Evaluation starts by checking whether the client outcomes have been met.

📝 Documentation, rationale review, or adding interventions all come after outcome assessment.

📝 Without outcome evaluation, it is impossible to know whether interventions were effective.

📝 This step closes the loop of the nursing process

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Answer 10

Correct Answers:

Examine one's own culturally based values, beliefs, attitudes, and practices.

Rationale :

🤝 Frustration often arises from cultural differences in family involvement in care.

🤝 Self-reflection helps the nurse recognize bias and approach the situation with cultural sensitivity.

🤝 Telling the family to stop or substituting practices shows disrespect.

🤝 Allowing frustration to build until harm occurs is unsafe.

🤝 Reflection fosters professional, culturally competent care.

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QLexNursing

1 :
A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite a clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is m important for the nurse to obtain?

2 :
The home health nurse visits an older adult client who had a stroke three months ago and is now able to ambulate assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?

3 :
The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to higher level of pain?

4 :
An older Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should nurse obtain first?

5 :
The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for include in this client's plan of care?

6 :
When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

7 :
An adult client has a nursing diagnosis of "spiritual distress." Which intervention is best for the nurse to implement when caring client?

9 :
In evaluating client care, which action should the nurse take first?

10 :
A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client action should the nurse implement to cope with these feelings of frustration?

QLexNursing

1 : A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite a clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is m important for the nurse to obtain?

2 : The home health nurse visits an older adult client who had a stroke three months ago and is now able to ambulate assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?

3 : The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to higher level of pain?

4 : An older Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should nurse obtain first?

5 : The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for include in this client's plan of care?

6 : When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

7 : An adult client has a nursing diagnosis of "spiritual distress." Which intervention is best for the nurse to implement when caring client?

9 : In evaluating client care, which action should the nurse take first?

10 : A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client action should the nurse implement to cope with these feelings of frustration?

1 :
A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite a clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is m important for the nurse to obtain?

2 :
The home health nurse visits an older adult client who had a stroke three months ago and is now able to ambulate assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?

3 :
The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to higher level of pain?

4 :
An older Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should nurse obtain first?

5 :
The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for include in this client's plan of care?

6 :
When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

7 :
An adult client has a nursing diagnosis of "spiritual distress." Which intervention is best for the nurse to implement when caring client?

9 :
In evaluating client care, which action should the nurse take first?

10 :
A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client action should the nurse implement to cope with these feelings of frustration?