Which assessment finding should a nurse record as a symptom of pain? A client who:.

grimaces during a dressing change.

has an elevated heart rate while exercising.

is crying during a procedure.

says, “I feel achy all over.”.

Answer and Explanation

The Correct Answer is A

A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.

The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.

Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.

Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.

The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.

Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.

Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.

The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

A. Do not eat or drink for 12 hours prior to the test. B. Eliminate all dietary cholesterol for one week before this test. C. Avoid caffeinated beverages for several days prior to the test. D. Stop eating eggs and drinking milk for two days before the test.

Correct Answer is A

Explanation

Do not eat or drink for 12 hours prior to the test. This is because fasting is required for a total serum cholesterol test to get accurate results. Fasting means not eating or drinking anything except water for 9 to 12 hours before the test.

Choice B is wrong because eliminating all dietary cholesterol for one week before the test is not necessary and will not affect the test results. Dietary cholesterol only accounts for a small portion of the total cholesterol in the blood.

Choice C is wrong because avoiding caffeinated beverages for several days prior to the test is not required and will not influence the test results. Caffeine does not affect cholesterol levels.

Choice D is wrong because stopping eating eggs and drinking milk for two days before the test is not needed and will not change the test results. Eggs and milk contain cholesterol, but they also have other nutrients that may lower the risk of heart disease.

Normal ranges for total serum cholesterol are less than 200 mg/dL (5.18 mmol/L) for adults. Higher levels may indicate an increased risk of heart disease and stroke.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which assessment finding should a nurse record as a symptom of pain? A client who:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Correct Answer is D

Explanation

A client is scheduled for a “total serum cholesterol” lab test. Which instruction to the client should be discussed to ensure adequate preparation for the test?

Correct Answer is A

Explanation

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

A television reporter calls the nursing unit requesting an update on the status of an elected official from the community who was admitted to the unit. Which statement is the most appropriate response by the nurse when the reporter requests the official diagnosis?

A client on digitalis has a lab report of potassium 3.0 mEq/L. The nurse would instruct the client to eat which of these foods?

A nurse who serves on an infection control committee is assessing the adequacy of environmental controls against infection. What does the nurse know to be the first line of defense in medical asepsis?

A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?

A 10-year old is admitted to the Emergency Room in a sickle cell crisis. Put the interventions in order by priority. All options must be used.

A nurse inadvertently administers an incorrect medication to a client. Which action should the nurse take first?