For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Severity of the condition

Vital signs

Nonverbal behavior

Self-report of pain

Answer and Explanation

The Correct Answer is D

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

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Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are spread by large respiratory droplets produced by coughing, sneezing, or talking. Examples include influenza, pertussis, and mumps. However, tuberculosis is not spread through large droplets but through airborne particles that can remain suspended in the air for long periods.

Choice B reason: Airborne precautions are necessary for diseases that are transmitted by smaller droplets, which can be suspended in the air for extended periods and can be inhaled. Tuberculosis, particularly pulmonary or laryngeal tuberculosis with a productive cough, requires airborne precautions because the bacteria can be expelled into the air and inhaled by others. The nurse should initiate airborne precautions, which include placing the patient in a negative pressure room and using personal protective equipment such as N95 respirators.

Choice C reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Examples include infections caused by multidrug-resistant organisms, scabies, and norovirus. Tuberculosis is not spread by direct contact, so contact precautions are not the primary method of prevention.

Choice D reason: Protective isolation, also known as neutropenic or reverse isolation, is used to protect immunocompromised patients from infections. It is not used for patients with tuberculosis, as the goal is to protect others from the tuberculosis bacteria, not to protect the patient from external infections.

A. Offer the client a beverage of choice B. Establish that insurance coverage exists C. Establish a rapport with the patient D. Ask the patient to disrobe and put on a gown

Correct Answer is C

Explanation

Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.

Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.

Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.

Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.

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For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

Correct Answer is B

Explanation

Prior to taking the health history, the nurse should first do which of the following?

Correct Answer is C

Explanation

A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?