where will the nurse collect the most reliable source of pain assessment

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Where will the nurse collect the most reliable source of pain assessment?

A. From the nurse-to-nurse bedside report
B. From a medical surgical book
C. From the client
D. From the client's chart

Correct answer: C

Rationale:

2. What is one of the earliest signs of fat embolism syndrome?

A. Paresthesia
B. Severe pain in the affected limb unrelieved by medication
C. Edema
D. Hypoxemia

Correct answer: D

Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.

3. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

A. I am sorry you did not understand. Would you like a different doctor?
B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
C. You will need to have glasses.
D. This means you won’t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.