a nurse is caring for a client who is in severe pain which of the following questions should the nurse ask first
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1. A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?

Correct answer: B

Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.

2. A healthcare professional is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer?

Correct answer: B

Rationale: Elevated BMI is a significant risk factor for colorectal cancer. Excess body weight, especially around the waist, increases the risk of developing this type of cancer. Family history of asthma (Choice A) is not directly related to colorectal cancer risk. History of travel (Choice C) and high cholesterol (Choice D) are also not established risk factors for colorectal cancer.

3. A healthcare provider is collecting data from a client who has multiple sclerosis. Which of the following findings should the healthcare provider expect?

Correct answer: B

Rationale: Ataxia, which refers to difficulty with coordination, is a common symptom seen in individuals with multiple sclerosis. Nystagmus, the involuntary eye movement, can also occur in multiple sclerosis but is not as common as ataxia. Fatigue is a common symptom in multiple sclerosis, but ataxia is more specific. Fever is not a typical finding associated with multiple sclerosis.

4. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?

Correct answer: C

Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.

5. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

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