A nurse is caring for an adult client with cancer who is complaining of acute pain.The MOST appropriate pain assessment would be:
Answer(s): A
The most appropriate way to assess pain is by asking the client to rate their pain. Pain is a subjective experience, meaning only the person experiencing it can accurately describe its intensity and quality. This is often done using a numerical scale (0-10) where the patient rates their pain, with 0 being no pain and 10 being the worst pain imaginable.Nonverbal cues and the nurse's impression can provide additional information, but they are not as reliable as the patient's self-report. Pain relief after interventions helps evaluate the effectiveness of the pain management but does not assess the initial pain level.
McCaffery, M., & Pasero, C. (1999). Pain: Clinical Manual. Mosby.
A client with schizophrenia is placed on chlorpromazine 50 mg PO bid, and Benztropine 2 mg PO bidPRN.Which of the following nursing assessment findings would indicate a need to administer Benztropine?
Answer(s): D
Chlorpromazine is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), such as muscle spasms and tremors. Benztropine is an anticholinergic medication often prescribed to manage these side effects.If a client on chlorpromazine develops muscle spasms and tremors, it indicates EPS, and administering Benztropine would help alleviate these symptoms. The other options, such as severe agitation, sore throat, or suicidal thoughts, are not directly related to the need for Benztropine.
Stahl, S. M. (2013). Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.
A nurse is visiting an Asian family and found that both parents have cardiac problems. The nurse is aware of Asian genetic predisposition to cardiovascular diseases. The nurse assessment falls below which of the following cultural assessment category?
When assessing the health of a family, considering their genetic predispositions to certain conditions falls under the category of bio-cultural factors. These factors include genetic traits, physical characteristics, and biological variations that can influence health. In this case, the nurse's awareness of the genetic predisposition of Asian individuals to cardiovascular diseases helps in understanding the family's health risks.
Spector, R. E. (2017). Cultural Diversity in Health and Illness. Pearson.
A woman presents to the clinic with signs and symptoms of menopause. The doctor advised to start hormonal replacement therapy. The woman enquired about the adverse effects of this therapy. Which of the following is an adverse effects of the hormonal replacement therapy?
Answer(s): C
Hormone replacement therapy (HRT) can have several adverse effects. One significant risk associated with HRT, especially if estrogen is given without progesterone to women with an intact uterus, is the increased risk of endometrial cancer. Estrogen stimulates the lining of the uterus, and without the balancing effect of progesterone, this can lead to endometrial hyperplasia and potentially cancer. Other risks include breast cancer, blood clots, and stroke, but endometrial cancer is a specific concern with unopposed estrogen therapy.
Goodman, N. F., et al. (2011). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocrine Practice, 17(6), 1-25.
A nurse understands that patient with blood transfusion reaction is at risk to develop which of the following types of jaundice?
A blood transfusion reaction can lead to hemolytic jaundice. This type of jaundice occurs when there is an excessive breakdown of red blood cells, leading to an increase in bilirubin production. Hemolytic reactions during a blood transfusion cause the destruction of the transfused red blood cells, releasing large amounts of hemoglobin into the bloodstream, which is then converted to bilirubin, resulting in jaundice.
American Association of Blood Banks (AABB). (2017). Technical Manual, 19th Edition. AABB Press.
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