Question

The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

Answer 1

Correct Answers:

"l am so depressed living with this pain that I don't know if I can go on anymore."

Rationale :

※ This statement indicates psychological distress and possible suicidal ideation, which is a psychiatric emergency.

※ The nurse must assess the client further for suicide risk, initiate safety protocols, and notify the provider or mental health team immediately.

※ Other responses reflect coping strategies or emotional burden but lack immediate danger.

※ Chronic pain significantly increases the risk for depression, anxiety, and suicide, especially when functional limitations persist.

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Answer 2

Correct Answers:

chronic
intractable
neuropathic

Rationale :

Chronic

⟫ Pain is classified as chronic when it lasts longer than 3–6 months, beyond normal tissue healing. This client has experienced pain for over a year, satisfying the criteria for chronicity.

⟫ Chronic pain often affects daily functioning, mood, and quality of life, and requires long-term multidisciplinary management.

⟫ Documenting it as chronic is essential for appropriate treatment planning and insurance coverage.

Intractable

⟫ The term intractable describes pain that is severe, constant, and resistant to conventional treatments.

⟫ In this case, the pain has persisted despite opioids, NSAIDs, and even non-pharmacological therapies like acupuncture—indicating poor response to therapy.

⟫ Labeling pain as intractable communicates to the team that advanced pain management strategies, such as nerve blocks, anticonvulsants, or interdisciplinary palliative care, may be required.

Neuropathic

⟫ Neuropathic pain arises from nerve injury or dysfunction, often described as burning, stabbing, or electric shock-like—precisely how the client describes their pain.

⟫ The etiology (spinal nerve injury) confirms the pain is of neurogenic origin, not related to tissue or organ damage.

⟫ Recognizing neuropathic pain is critical, as it typically requires treatment with anticonvulsants (e.g., gabapentin) or antidepressants, not just opioids.

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Answer 3

Correct Answers:

a urinary tract infection.

Rationale :

⁕ Cloudy, amber-colored urine with a foul odor is a classic sign of a urinary tract infection (UTI).

⁕ UTIs are common in hospitalized or catheterized clients and often present with dysuria, urgency, frequency, or fever.

⁕ Ketones in urine suggest diabetic ketoacidosis and produce a fruity smell, not a foul odor.

⁕ Nocturia refers to nighttime urination but is not linked to cloudiness or odor.

⁕ Functional incontinence is a mobility or cognition-related issue, not infectious in nature.

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Answer 4

Correct Answers:

does not necessarily include religion.

Rationale :

✓ Spirituality is a broad concept that may involve personal meaning, purpose, and connectedness, which can be independent of organized religion.

✓ Religion, on the other hand, involves structured beliefs and practices often shared within a group.

✓ Not all individuals who identify as spiritual practice a religion, and vice versa.

✓ It's important for nurses to recognize both elements during holistic assessments.

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Answer 5

Correct Answers:

blood in urine

Rationale :

› Hematuria is defined as the presence of red blood cells in the urine, giving it a pink, red, or cola-colored appearance.

› It is a symptom, not a diagnosis, and requires prompt investigation for causes like infection, trauma, or renal disease.

› Cloudy urine suggests infection; proteinuria is excess protein in urine, and dysuria refers to painful urination—none of which accurately define hematuria.

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Answer 6

Correct Answers:

Fruit and vegetables

Rationale :

🌐Fruits and vegetables are rich in dietary fiber, which adds bulk to stools and promotes bowel regularity.

🌐 Fiber increases water retention in the stool, making it easier to pass and preventing constipation.

🌐 Milk, cheese, lean meats, and refined carbs (like bread/pasta) are low-fiber and may worsen constipation.

🌐 Encourage hydration along with fiber for optimal effect.

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Answer 7

Correct Answers:

Skin turgor, tenting at clavicular area
Elevated hematocrit
Oral mucous membranes dry and sticky

Rationale :

Skin turgor, tenting at clavicular area

✓ Decreased skin elasticity, or tenting, is a classic sign of dehydration, especially in older adults.

✓ In elderly clients, assessing turgor at the clavicle or sternum (not hands) is more accurate due to age-related skin changes.

✓ Tenting occurs because of reduced interstitial fluid, making the skin slower to return to position when pinched.

Elevated hematocrit

✓ Hematocrit represents the ratio of red blood cells to plasma.

✓ In fluid volume deficit (FVD), there's a relative reduction in plasma, which increases hematocrit concentration (hemoconcentration).

✓ An elevated hematocrit is a laboratory indicator of dehydration and should prompt further assessment or fluid resuscitation.

Oral mucous membranes dry and sticky

✓ Dry, sticky mucous membranes are early signs of moderate dehydration, particularly in children and older adults.

✓ They indicate a reduction in salivary gland secretions due to decreased extracellular fluid volume.

✓ This clinical sign supports findings from skin turgor and lab values and helps form a complete picture of FVD.

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Answer 8

Correct Answers:

gender identity

Rationale :

💭 Gender identity is how a person internally perceives themselves as male, female, both, neither, or somewhere along the spectrum.

💭 It is distinct from biological sex and sexual orientation, which refers to who one is attracted to.

💭 Body image involves perception of physical appearance, and androgyny refers to blended gender traits, not identity itself.

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Answer 9

Correct Answers:

"It might take up to 3 days for the medication to work."

Rationale :

💊 Docusate sodium is a stool softener, not a stimulant, and typically takes 1–3 days for full effect.

💊 It draws water into the stool, making it easier to pass.

💊It should not be taken with mineral oil, as this combination increases the risk of fat-soluble vitamin malabsorption.

💊 The medication is for constipation, not diarrhea, and should be taken with a full glass of water (≥8 oz), not just 4 oz.

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Answer 10

Correct Answers:

Be available to the client.

Rationale :

🤝 The most appropriate nursing response to spiritual distress is presence, active listening, and emotional support.

🤝 The client is likely seeking meaning, not medical treatment or specific advice.

🤝 Advising prayer or sharing personal beliefs is nontherapeutic and may unintentionally minimize the client’s experience.

🤝Being available builds trust, respects autonomy, and opens the door to further therapeutic dialogue.

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QLexNursing

1 :
The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

3 :
The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

4 :
The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

5 :
The nurse is completing an admission assessment. The client reports a 2-day history of hematuria. Which term describes this assessment finding?

6 :
Which food item should the nurse instruct the patient to consume to prevent or treat constipation?

7 :
The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

8 :
The nurse understands that how a client feels on the inside about being male, female, both or neither is known as:

9 :
A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A client who has a terminal illness asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

QLexNursing

1 : The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

3 : The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

4 : The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

5 : The nurse is completing an admission assessment. The client reports a 2-day history of hematuria. Which term describes this assessment finding?

6 : Which food item should the nurse instruct the patient to consume to prevent or treat constipation?

7 : The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

8 : The nurse understands that how a client feels on the inside about being male, female, both or neither is known as:

9 : A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

10 : A client who has a terminal illness asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

1 :
The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

3 :
The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

4 :
The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

5 :
The nurse is completing an admission assessment. The client reports a 2-day history of hematuria. Which term describes this assessment finding?

6 :
Which food item should the nurse instruct the patient to consume to prevent or treat constipation?

7 :
The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

8 :
The nurse understands that how a client feels on the inside about being male, female, both or neither is known as:

9 :
A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A client who has a terminal illness asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?