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

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

A. "Tell me about the visit with your significant other. B. I can see that you are feeling lonely." C. "I noticed that you were more insulting to the evening group after your significant other left. D. Why is that?" E. "Why don't you try to make some friends here so you won't feel so lonely?"

Correct Answer is D

Explanation

This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.

Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.

Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.

Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

Correct Answer is B

Explanation

Which response is most therapeutic?

Correct Answer is D

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

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?

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

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

How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?