Nursing Elites

1. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

2. What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?

• A. Remove the basin of water from the client's bed immediately
• B. Remind the UAP to dry between the client's toes completely
• C. Advise the UAP that this procedure may damage the skin
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.

3. A client is grieving the loss of her partner and expresses thoughts of not wanting to live. Which of the following actions should the nurse take?

• A. Request additional support for the client from her family.
• B. Ask the client if she plans to harm herself.
• C. Inform the client that feeling this way is a normal response to grief.
• D. Suggest that the client seek counseling for support.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to ask the client if she plans to harm herself. This is crucial to assess the client's risk of self-harm or suicide. Providing immediate safety and appropriate interventions is the priority when a client expresses such thoughts. Requesting additional support from the family (Choice A) may be helpful but does not address the immediate safety concern. Informing the client that feeling this way is normal (Choice C) may invalidate her feelings and does not address the safety risk. Suggesting counseling (Choice D) may be beneficial in the long term but is not the immediate priority when assessing for self-harm or suicide risk.

4. When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?

• A. Appearance of downy hair on the upper lip
• B. Hair growth in the axillae
• C. Enlargement of the testes and scrotum
• D. Deepening of the voice

Correct answer: C

Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.

5. The client has expressive aphasia and needs assistance to communicate. Which method should the LPN use to best support the client's ability to express basic needs?

• A. Use a picture board with common needs.
• B. Encourage the client to speak slowly.
• C. Write down what the client says.
• D. Use hand gestures to communicate.

Correct answer: A

Rationale: The correct answer is to use a picture board with common needs. Clients with expressive aphasia have difficulty speaking but can often understand and use visual aids effectively. Using a picture board helps the client communicate basic needs more easily. Encouraging the client to speak slowly (choice B) may not be effective as the issue lies with expressive language, not speed. Writing down what the client says (choice C) may not always be possible or helpful for immediate communication as it does not address the communication barrier directly. Using hand gestures (choice D) may not be as clear or universally understood as a picture board, which can cause confusion and misinterpretation.

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