A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Drowsiness.

Grimacing.

Screaming.

Moaning.

Restlessness.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:

Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.

Choice B rationale:

Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.

Choice C rationale:

Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.

Choice D rationale:

Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.

Choice E rationale:

Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.

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Correct Answer is C

Explanation

Choice A rationale:

Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.

Choice B rationale:

Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.

Choice C rationale:

Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.

Choice D rationale:

Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.

A. "I should check my skin monthly for any changes.” B. "I should avoid the use of tanning booths.” C. "I should use sunscreen even on cloudy days.” D. "Eating a high fiber diet will reduce my risk for developing skin cancer.”

Correct Answer is D

Explanation

The correct answer is choice D - "Eating a high fiber diet will reduce my risk for developing skin cancer."

Choice A rationale:

Checking the skin monthly for any changes is a recommended practice for early detection of skin cancer. Changes in the size, color, shape, or appearance of moles or spots can be indicative of skin cancer. This statement demonstrates understanding and does not require further teaching.

Choice B rationale:

Avoiding the use of tanning booths is a crucial recommendation for preventing skin cancer. Tanning booths emit ultraviolet (UV) radiation, which significantly increases the risk of skin cancer. This statement reflects accurate knowledge and does not indicate a need for further teaching.

Choice C rationale:

Using sunscreen even on cloudy days is a sound practice to prevent skin cancer. UV rays can penetrate clouds and cause skin damage even when the sun is not directly visible. This statement shows good understanding and does not require further teaching.

Choice D rationale:

Eating a high fiber diet will reduce my risk for developing skin cancer - This statement indicates a need for further teaching. While a high fiber diet has various health benefits, it is not directly linked to reducing the risk of developing skin cancer. Skin cancer prevention primarily involves sun protection measures, avoiding tanning beds, and regular skin checks. The nurse should clarify the correct strategies for preventing skin cancer.

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A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

Correct Answer is C

Explanation

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

Correct Answer is D

Explanation

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A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?