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 C
Explanation
Choice A reason: An abdominal catheter is used for peritoneal dialysis, not hemodialysis. Hemodialysis requires access to a large blood vessel, usually in the arm or leg.
Choice B reason: Routine medications may need to be adjusted or avoided before or after hemodialysis, depending on their effects on blood pressure, fluid balance, and electrolytes.
Choice C reason: Insulin dosage may need to be reduced during hemodialysis because insulin is removed by the dialyzer and blood glucose levels may drop. This is the correct statement to include in client education.
Choice D reason: Potassium-rich foods should be limited in the diet of clients with chronic kidney disease and hemodialysis, because potassium can build up in the blood and cause cardiac arrhythmias.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because hepatorenal failure is a condition that involves both liver and kidney dysfunction, usually as a complication of cirrhosis or portal hypertension. The symptoms of hepatorenal failure may include jaundice, ascites, edema, oliguria, or encephalopathy. However, these are not consistent with the client's presentation of fever, abdominal pain, vomiting, and elevated amylase and lipase levels.
Choice B reason: This is correct because acute pancreatitis is an inflammation of the pancreas that can be caused by gallstones, alcohol abuse, trauma, infection, or drugs. The symptoms of acute pancreatitis may include fever, upper abdominal pain that radiates to the back, nausea, vomiting, and elevated amylase and lipase levels. These are consistent with the client's presentation and suggest that the cholecystectomy may have triggered an attack of acute pancreatitis.
Choice C reason: This is incorrect because surgical site infection is an infection that occurs at or near the incision site after surgery. The symptoms of surgical site infection may include redness, swelling, warmth, pus drainage, or pain at the wound site. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
Choice D reason: This is incorrect because biliary duct obstruction is a blockage of the bile ducts that carry bile from the liver and gallbladder to the intestine. The causes of biliary duct obstruction may include gallstones, tumors, inflammation, or scarring. The symptoms of biliary duct obstruction may include jaundice, dark urine, pale stools, itching, or abdominal pain. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
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