Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
Perform a complete mental status exam.
Determine if the client has had a shingles vaccination.
Teach the client about phantom pain symptoms.
Complete an assessment of the client's pain.
The Correct Answer is D
Choice A reason: This is incorrect because performing a complete mental status exam is not a relevant or appropriate action for the nurse to implement. A mental status exam is used to evaluate the client's cognitive, emotional, and behavioral functioning, but it does not address the client's physical pain or its underlying cause.
Choice B reason: This is incorrect because determining if the client has had a shingles vaccination is not a priority or helpful action for the nurse to implement. A shingles vaccination is recommended for people who are 50 years or older to prevent or reduce the severity of shingles, but it does not affect the occurrence or treatment of postherpetic neuralgia, which is a chronic pain condition that can develop after shingles.
Choice C reason: This is incorrect because teaching the client about phantom pain symptoms is not an accurate or useful action for the nurse to implement. Phantom pain is a type of neuropathic pain that occurs when a person feels pain in a body part that has been amputated or removed. However, this is not the case for the client who has pain in the area where the shingles rash occurred.
Choice D reason: This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Using incentive spirometer is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not related to the procedure or the condition. The incentive spirometer is a device that helps improve lung function and prevent respiratory complications by encouraging deep breathing and coughing. Therefore, this choice is incorrect.
Choice B reason: Monitoring urinary stream for decrease in output is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it can indicate urinary retention or obstruction, which are potential complications of the procedure. The client should report any difficulty or inability to urinate, severe pain, or fever to the health care provider. Therefore, this choice is correct.
Choice C reason: Reporting when hematuria becomes pink tinged is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not a sign of a problem. Hematuria, or blood in the urine, is a common and expected finding after the procedure, and it usually resolves within a few days. The client should drink plenty of fluids to flush out the blood clots and debris. Therefore, this choice is incorrect.
Choice D reason: Restricting physical activities is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, but it is not the best answer. The client should avoid strenuous activities, such as lifting heavy objects, driving, or sexual intercourse, for at least two weeks after the procedure to prevent bleeding and infection. However, this information is less important than monitoring urinary stream for decrease in output. Therefore, this choice is not the best answer.
Correct Answer is D
Explanation
Choice A reason: Jogging or running are not excellent aerobic exercises for an older adult client with osteoarthritis. These activities can put a lot of stress and impact on the joints, especially the knees, hips, and ankles, which can worsen the pain and inflammation of osteoarthritis. The nurse should advise the client to avoid high-impact exercises that can damage the cartilage and bones.
Choice B reason: Tennis or racquetball are not ideal exercises for an older adult client with osteoarthritis. These activities involve sudden movements, twists, and turns that can strain the joints, especially the elbows, wrists, and shoulders, which can aggravate the symptoms of osteoarthritis. The nurse should advise the client to avoid exercises that can cause joint instability and injury.
Choice C reason: Limiting the exercise to just the daily activities is not a good advice for an older adult client with osteoarthritis. Exercise is important for maintaining joint health, mobility, and function, as well as preventing muscle loss, obesity, and cardiovascular diseases. The nurse should encourage the client to engage in regular moderate exercise that can improve the quality of life and reduce the complications of osteoarthritis.
Choice D reason: Swimming is an excellent exercise for an older adult client with osteoarthritis. Swimming is a low-impact aerobic exercise that can strengthen the muscles, improve the cardiovascular fitness, and enhance the flexibility of the joints without putting too much pressure or stress on them. Swimming can also reduce the pain and stiffness of osteoarthritis by providing a soothing and relaxing effect on the body. The nurse should recommend swimming as a safe and effective exercise for the client.
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