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 is the foundation of pain assessment.

Correct Answer: B

Rationale: Time management is organizing tasks efficiently (B), per nursing e.g., timely care for Mr. Gary. Not wasting (A), not duty (C), not one-time (D) efficiency-focused. B best defines its role, optimizing care, making it correct.

Correct Answer: B

Rationale: Empowerment is giving control to the patient (B), per nursing e.g., decision-making. Not dependence (A), not passive (C), not temporary (D) active strength. B best defines empowerment's autonomy focus, making it correct.

Correct Answer: C

Rationale: A well-written expected outcome follows the SMART criteria: specific, measurable, achievable, realistic, and time-bound. 'The patient will identify all the high-salt food from a prepared list by discharge' meets these standards: it specifies the action (identifying high-salt foods), provides a measurable method (from a prepared list), and sets a clear timeline (by discharge), ensuring it's achievable and realistic for patient education. In contrast, 'The patient will feel less nauseated in 24 hours' is vague and subjective, lacking a measurable indicator. 'The patient will eat the right amount of food daily' fails to define 'right amount,' making it unmeasurable and unspecific. 'The patient will have enough sleep' is similarly imprecise, with no clear metric or timeframe. The correctly written outcome supports effective care planning by providing a concrete, evaluable goal, critical for tracking patient progress.

Correct Answer: B

Rationale: Uncontrollable vomiting in infants leads to significant fluid and electrolyte loss, requiring careful nursing assessment. Acidosis (choice A) occurs when acid accumulates, typically from diarrhea, not vomiting. Alkalosis (choice B) results from losing gastric acid (HCl) through vomiting, raising blood pH, a common complication in infants with prolonged emesis, such as in pyloric stenosis. Hypokalemia (choice C) can also occur due to potassium loss in vomit, especially if vomiting persists, but it's secondary to the acid-base shift. Hyperkalemia (choice D) is unlikely, as vomiting depletes rather than increases potassium. Alkalosis is the correct answer (B) because the loss of acidic stomach contents directly causes metabolic alkalosis, a priority concern in infants due to their limited compensatory mechanisms. Nurses must monitor respiratory rate (to detect compensation) and administer fluids/electrolytes to correct this imbalance, preventing further complications like seizures or cardiac issues, emphasizing the urgency of early intervention.

Correct Answer: D

Rationale: Implementing fall prevention measures is critical for an immobile patient's safety, involving tools like bed alarms, low beds, or assistance during transfers to mitigate risks in a controlled environment. Immobile patients can't walk independently, so promoting frequent movement isn't feasible and could increase danger. Physical or soft restraints, while sometimes considered, are last-resort options due to ethical and safety concerns, not primary safety strategies. Fall prevention directly addresses the vulnerability of those unable to reposition themselves, reducing injury risk a key nursing responsibility. This approach ensures a safe setting, balancing protection with patient dignity, and aligns with evidence-based practice to minimize harm in immobile populations.

Correct Answer: D

Rationale: R.S. Peters' moral theory, from the 1960s, centers on principles like justice and honesty e.g., a nurse acts kindly out of habit. Freud's drives, Erikson's stages, and Kohlberg's trust differ. Peters' view of morality as emotion, judgment, and behavior, rooted in automatic virtues, guides nurses in ethical consistency, impacting professional conduct standards.

Correct Answer: A

Rationale: Nodding and responding is active listening (A) engaged feedback, per definition. Touch (B) physical, literacy (C) understanding, QI (D) enhancement not listening-specific. A fits the nurse's attentive communication with Mr. Gary, making it correct.

Correct Answer: C

Rationale: Maslow's self-actualized person (1940s) is autonomous, creative, and problem-focused e.g., pursuing personal goals over crowd opinion. They value privacy and insight (poetry, science), not majority rule, though they uphold justice personally. This autonomy guides nurses in supporting patients' unique aspirations, fostering self-directed recovery.