At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

Knowledge deficit.

Anxiety.

Pain intolerance.

Anticipatory grieving.

Answer and Explanation

The Correct Answer is B

Choice B is correct because anxiety is the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anxiety is a feeling of fear, nervousness, or apprehension that can interfere with coping and decision making. The nurse should assess the level and source of anxiety and provide emotional support and reassurance to the client. The nurse should also review the pain management techniques and explain the benefits and risks of different analgesic options.

Choice A is incorrect because knowledge deficit is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Knowledge deficit is a lack of information or understanding about a topic or situation that can affect learning and behavior. The nurse should evaluate the client's learning needs and provide appropriate education and resources, but this is not as urgent as addressing the client's anxiety.

Choice C is incorrect because pain intolerance is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Pain intolerance is an inability or unwillingness to endure pain that can affect quality of life and recovery. The nurse should assess the client's pain level and response to analgesics and adjust the pain management plan accordingly, but this is not as urgent as addressing the client's anxiety.

Choice D is incorrect because anticipatory grieving is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anticipatory grieving is a process of mourning that occurs before an expected loss or death that can affect emotional and physical well-being. The nurse should acknowledge the client's feelings and provide empathy and support, but this is not as urgent as addressing the client's anxiety.

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Correct Answer is C

Explanation

Choice A: Think about reasons the episodes occur. This is not the best instruction, as it may increase the anxiety level of the client. Thinking about reasons may trigger negative thoughts, emotions, or memories that can worsen the anxiety. The nurse should teach the client to focus on coping skills rather than causes.

Choice B: Center attention on positive upbeat music. This is not the best instruction, as it may not be effective for all clients. Listening to positive upbeat music may help distract or soothe some clients, but it may also irritate or annoy others. The nurse should teach the client to choose music that matches their mood and preference.

Choice C: Practice using muscle relaxation techniques. This is the best instruction, as it can reduce the physical symptoms of anxiety. Muscle relaxation techniques involve tensing and relaxing different muscle groups in a systematic way, which can lower blood pressure, heart rate, and breathing rate. The nurse should teach the client how to perform muscle relaxation techniques and practice them regularly.

Choice D: Find outlets for more social interaction. This is not the best instruction, as it may not be feasible or helpful for all clients. Finding outlets for more social interaction may help some clients feel supported or connected, but it may also stress or overwhelm others. The nurse should teach the client to seek social support that is appropriate and comfortable for them.

A. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. B. Perform daily surgical dressing change for a client who had an abdominal hysterectomy. C. Initiate patient controlled analgesia (PCA. pumps for two clients immediately postoperatively. D. Start the second blood transfusion for a client twelve hours following a below knee amputation. E. Monitor a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM).

Correct Answer is ["A","B","E"]

Explanation

Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

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At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

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