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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.
Choice B: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.
Choice C: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA., which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.
Choice D: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.
Correct Answer is C
Explanation
Choice A reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not a necessary action for the nurse to take. A respirator mask is a type of personal protective equipment (PPE. that filters out airborne particles and droplets that may contain infectious agents. A respirator mask is required for clients who have or are suspected of having airborne diseases, such as tuberculosis, measles, or chickenpox. Influenza is a respiratory disease that is transmitted by droplet contact, not by airborne contact.
Choice B reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not a specific action for the nurse to take. Respiratory status is an assessment of the client's breathing pattern, rate, depth, effort, and oxygen saturation. Respiratory status can be affected by various factors, such as infection, inflammation, obstruction, or injury. The nurse should monitor the client's respiratory status regularly and teach the UAP to report any signs or symptoms of respiratory distress, such as dyspnea, cyanosis, wheezes, or cough.
Choice D reason: Assigning the UAP to provide care for another client and assuming full care of the client is not a feasible action for the nurse to take. The nurse should delegate tasks according to the scope of practice, competency, and availability of staff. The nurse should not reassign staff without a valid reason or without consulting with other team members. The nurse should also not assume full care of a client unless it is necessary or appropriate. The nurse should supervise and evaluate the UAP's performance and provide feedback and guidance.
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