a nurse is assessing a patient with chronic pain which finding is most concerning
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?

Correct answer: C

Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.

2. A client with severe dyspnea is scheduled for multiple diagnostic tests. Which test should the nurse prioritize?

Correct answer: B

Rationale: The correct answer is B: Prioritize a chest x-ray for the client. When a client presents with severe dyspnea, a chest x-ray should be prioritized as it helps in assessing the lungs and heart, which are crucial in cases of respiratory distress. Echocardiograms are more focused on assessing heart function and may not provide immediate information needed in cases of dyspnea. CT scans and MRIs are more detailed imaging studies that are not typically the first-line diagnostic tests for severe dyspnea.

3. When caring for a patient with a colostomy, which nursing action is most important?

Correct answer: B

Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.

4. A public health nurse is developing guidelines for the management of a botulism outbreak. Which of the following information should the nurse include?

Correct answer: D

Rationale: The correct answer is D. Rinsing the skin with soap and water following exposure to the botulism toxin is crucial as it helps remove the toxin from the skin, preventing further absorption. Choices A, B, and C are incorrect. Immunoglobulin E (IgE) is not used in the management of botulism. Airborne precautions are not necessary for botulism as it is not transmitted through the air. Aminoglycoside medications are not the treatment of choice for botulism.

5. A patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain?

Correct answer: C

Rationale: The correct answer is C. According to the gate control theory, meditation helps relieve pain by blocking pain impulses from coming through the gate in the central nervous system. Choice A is incorrect as meditation does not directly alter the chemical composition of pain neuroregulators. Choice B is incorrect because meditation does not stop the occurrence of pain stimuli. Choice D is incorrect as meditation does not open the gate but rather closes it to block pain impulses.

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