When caring for a patient in pain, the most important principle that the nurse must recognize is that:

the person experiencing the pain is the authority about the pain.

administering analgesics for pain will eventually lead to addiction.

behavioral signs are always congruent with statements about pain.

the extent of pain is directly related to the amount of tissue damage.

Answer and Explanation

The Correct Answer is A

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

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Correct Answer is D

Explanation

A. Serum K+ 3.6 mEq/L: Serum potassium (K+) level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically validate fluid volume excess. Serum electrolyte levels can be affected by various factors, including hydration status, renal function, and medications. While hypokalemia (low potassium) may be associated with conditions such as diuretic use or excessive fluid loss, it is not a definitive indicator of fluid volume excess.

B. Urine specific gravity of 1.012: Urine specific gravity measures the concentration of solutes in the urine and can provide information about the client's hydration status. A specific gravity of 1.012 is within the normal range (typically 1.005 to 1.030), indicating that the urine is neither extremely concentrated nor dilute. While changes in urine specific gravity may suggest alterations in fluid balance, a single measurement alone may not be sufficient to validate the client's fluid status, especially in the context of fluid volume excess.

C. Respiratory rate 18: A respiratory rate of 18 breaths per minute falls within the normal range for adults (12-20 breaths per minute) and does not specifically indicate fluid volume excess. Changes in respiratory rate may occur in response to various factors, including respiratory, cardiovascular, or metabolic conditions, but it is not a direct indicator of fluid volume status.

D. +4 Pedal Pulses:

The presence of +4 pedal pulses indicates strong, bounding pulses in the feet. This finding suggests adequate perfusion to the peripheral extremities, which may indicate an appropriate fluid balance. In clients with fluid volume excess, maintaining adequate perfusion to peripheral tissues is essential to prevent complications such as peripheral edema and impaired tissue oxygenation. Strong pedal pulses suggest that perfusion to the lower extremities is not compromised due to hypovolemia or decreased cardiac output, which can be associated with fluid volume deficit.

A. "I can take this medication along with mineral oil." B. "I should drink 4 ounces of water when I take the medication." C. "It might take up to 3 days for the medication to work." D. "I will take the medication for diarrhea."

Correct Answer is C

Explanation

Docusate sodium is a stool softener commonly prescribed to alleviate constipation, particularly in patients taking opioid pain medications, which often cause constipation as a side effect. When educating a client about docusate sodium, it's essential to provide accurate information about its onset of action and expected effects.

A. "I can take this medication along with mineral oil."

This statement indicates a misunderstanding of the teaching. Combining docusate sodium with mineral oil is not recommended because mineral oil can interfere with the absorption of fat-soluble vitamins and may diminish the effectiveness of docusate sodium.

B. "I should drink 4 ounces of water when I take the medication."

Although it's important to stay hydrated when taking docusate sodium, there isn't typically a specific volume of water recommended for each dose. While hydration can aid in the effectiveness of the medication, this statement doesn't directly address the expected action of docusate sodium.

C. "It might take up to 3 days for the medication to work."

This statement demonstrates an understanding of the teaching. Docusate sodium may take a few days to produce a noticeable effect on bowel movements. Understanding this timeline helps manage the client's expectations and prevents premature discontinuation of the medication due to perceived lack of efficacy.

D. "I will take the medication for diarrhea."

Docusate sodium is not indicated for the treatment of diarrhea. It is specifically used as a stool softener to alleviate constipation by promoting easier passage of stool. This statement indicates a misunderstanding of the intended use of the medication.

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When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

The nurse receives an order for a medication that will assist the client at bedtime. The abbreviation for the best time to administer this medication is:

The client reports to the nurse that their bowel movements are hard & difficult to pass. Which of the medications taken by the client most likely contributed to this problem? A/An:

The nurse makes an error while documenting in the client's chart. The nurse should:

When assessing a client's sexuality, the nurse is aware that one's own personal values and attitudes:

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?