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

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.

A. "Tell me about the visit with your significant other. I can see that you are feeling lonely." B. "I noticed that you were more insulting to the evening group after your significant other left. Why is that?" C. "Why don't you try to make some friends here so you won't feel so lonely?" D. "It sounds like your visit with your significant other was important to you. How did it go?" E. None F. None

Correct Answer is D

Explanation

Choice D
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

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

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?

Correct Answer is D

Explanation

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?

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

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?

A postoperative client has been prescribed three different analgesics for different levels of pain. What is the most important intervention the nurse should take when administering these medications to the client?

The nurse is caring for a patient one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

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?

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

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