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 ["A","B", "C","D"]
Explanation
- Choice A: Occupational therapist. This is correct because an occupational therapist can help the client with activities of daily living (ADLs) such as dressing, grooming, eating, and toileting. The client may have difficulty performing these tasks due to the facial droop and weakness caused by the stroke.
- Choice B: Speech therapist. This is correct because a speech therapist can help the client with communication and swallowing problems. The client has garbled speech, which indicates a possible aphasia or dysarthria. The client may also have dysphagia, which is difficulty swallowing, due to the impaired coordination of the muscles involved in swallowing.
- Choice C: Case manager. This is correct because a case manager can coordinate the client's care and discharge planning. The case manager can arrange for referrals, home health services, equipment, and follow-up appointments as needed. The case manager can also provide education and support to the client and family.
- Choice D: Physical therapist. This is correct because a physical therapist can help the client with mobility and balance issues. The client may have hemiparesis or hemiplegia, which is weakness or paralysis of one side of the body. The physical therapist can assist the client with exercises, gait training, and assistive devices to improve the client's functional status.
- Choice E: Chief nursing officer. This is incorrect because a chief nursing officer is not directly involved in the client's recovery. A chief nursing officer is a senior-level executive who oversees the nursing staff and operations of a health care organization. A chief nursing officer may have a role in quality improvement, policy development, and strategic planning, but not in individual client care.
- Choice F: Pharmacy technician. This is incorrect because a pharmacy technician is not directly involved in the client's recovery. A pharmacy technician is a health care professional who assists pharmacists with dispensing medications and other tasks. A pharmacy technician may have a role in preparing, labeling, and delivering medications, but not in providing therapy or education to the client.
- Choice G: Respiratory therapist. This is incorrect because a respiratory therapist is not directly involved in the client's recovery. A respiratory therapist is a health care professional who provides respiratory care to patients with breathing problems. A respiratory therapist may have a role in administering oxygen, nebulizers, ventilators, and other respiratory treatments, but not in addressing the client's stroke-related impairments.
- Choice H: Medical assistant. This is incorrect because a medical assistant is not directly involved in the client's recovery. A medical assistant is a health care professional who performs administrative and clinical tasks in a medical office or clinic. A medical assistant may have a role in scheduling appointments, taking vital signs, drawing blood, and performing basic laboratory tests, but not in providing rehabilitation or education to the client.
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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