A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

The client reports numbness at the site.

Purulent drainage noted from the site

Skin over the site is sloughing

The vein appears cord-like

Answer and Explanation

The Correct Answer is B

A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.

B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.

C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.

D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.

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Correct Answer is A

Explanation

A. Cancer pain: Cancer pain can result from tumor growth, tissue invasion, or nerve compression caused by cancer. It can be acute or chronic and may vary in intensity. However, in this scenario, the client's pain is specifically associated with dermatitis resulting from radiation therapy, rather than directly from the cancer itself.

B. Acute pain: Acute pain is typically sudden in onset and is often associated with tissue injury or damage. In this case, the painful dermatitis resulting from radiation therapy would be considered acute pain because it is directly related to the recent tissue damage caused by the radiation. Acute pain is usually short-term and resolves as the underlying cause heals or is treated.

C. Chronic pain: Chronic pain persists beyond the expected time for tissue healing and is often associated with conditions such as arthritis or neuropathy. While cancer pain can sometimes become chronic if it persists over time, the pain described in this scenario is more likely to be acute given its association with recent radiation therapy.

D. Neuropathic pain: Neuropathic pain results from damage or dysfunction of the nervous system and can present as shooting or burning sensations. While neuropathic pain can occur in cancer patients, the pain described in this scenario is more likely to be acute and related to tissue damage from radiation therapy rather than neuropathy.

A. Irritable B. Lethargic C. Angry D. Decreased attention to detail

Correct Answer is D

Explanation

A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.

B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.

C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.

D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.

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A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

Correct Answer is A

Explanation

After an assessment, the nurse realizes that a client demonstrates cognitive responses to stress. What behaviors did the client demonstrate for the nurse to make this clinical determination?

Correct Answer is D

Explanation

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