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 A

Explanation

Guided imagery involves creating a specific imagined reality for yourself.

These techniques can be self-taught or guided by a professional.

The more you’re able to use your imagination and engage your senses, the greater the benefits 1.

Choice B is not the answer because motivational phrases may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice C is not the answer because tranquil sounds may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice D is not the answer because emotional reflection may not be as effective as positive external places in reducing chronic pain through guided imagery.

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 is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

Correct Answer is A

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 teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

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?

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain. To assess the intensity of the client's pain, which approach should the nurse use?