A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

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Question 1 of 5

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

Correct Answer: C

Rationale: Accepting the client's report of pain is the first step in assessment. Pain is subjective; validating it builds trust and ensures accurate data collection, per standards. Coping methods and location/intensity follow. Status is vague. C aligns with pain management principles, prioritizing patient experience, making it the initial action.

Question 2 of 5

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?

Correct Answer: A

Rationale: Reporting redness over a joint requires supervision. It involves assessment, beyond UAP scope; RN must interpret. Monitoring response is RN-only, but encouragement and transfers are delegable. A ensures RN oversight, making it the supervised task.

Question 3 of 5

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

Correct Answer: D

Rationale: Good morning. You're in the hospital. I am your nurse Elaine Jones' provides the best reality orientation. It clearly states place and person, aiding a confused client, unlike vague recall prompts (A, C) or intro-only . D supports cognition, making it the top choice.

Question 4 of 5

A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?

Correct Answer: C

Rationale: Discussing diet to learn reasons is most appropriate. It explores barriers (e.g., access, understanding), informing care, per nursing process. Discharge is premature, notification skips assessment, Meals-on-Wheels assumes solution. C addresses root causes, making it the best action.

Question 5 of 5

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?

Correct Answer: D

Rationale: Collecting an AFB sputum specimen indicates need for teaching. It's a skilled task beyond UAP scope, unlike ambulation , feeding , or discharge care . D risks safety, needing RN oversight.

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