Two days after surgery, a client experiences incisional pain while dangling at the bedside and refuses to ambulate as prescribed. The nurse establishes a problem of "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care?

Avoid pain-causing activity.

Ambulate without discomfort.

Show evidence of incision healing.

Take analgesics as prescribed.

Answer and Explanation

The Correct Answer is B

A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

A. "How is this hearing loss interfering with your daily activities of living?" B. "Is this hearing loss accompanied by any loss of balance?" C. "Do you have a history of ear infections?" D. "Have you ever considered being evaluated for a hearing aid?"

Correct Answer is B

Explanation

A. Assessing the impact of hearing loss on daily activities is important but not the immediate follow-up question to understand the nature of the hearing loss.
B. Asking about balance issues is essential because it could indicate an inner ear problem, which often affects both hearing and balance.
C. A history of ear infections could be relevant but is not as immediately necessary for determining the cause of the current symptoms.
D. Considering a hearing aid is a step for management, but determining the nature and cause of the hearing loss is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

Correct Answer is A

Explanation

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

Correct Answer is B

Explanation

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Which client is at greatest risk for aspiration?