Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he 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 his care plan?

To ambulate without discomfort.

To take analgesics as prescribed.

To show evidence of incision healing.

To avoid pain-causing activity.

Answer and Explanation

The Correct Answer is A

The goal of the care plan should be to help the client overcome his activity intolerance related to pain.

This can be achieved by helping him to ambulate without discomfort.

Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.

Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.

Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.

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Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Identify effective pain relief measures. D. Observe body language and movement.

Correct Answer is A

Explanation

To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.

This will help the nurse to understand the characteristics of the pain and how it is affecting the client.

Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.

Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.

Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

Correct Answer is A

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care. What is the next approach for the nurse to use when discussing end of life issues with the client?

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?