A client with chronic pain tells the nurse that the pain medication causes drowsiness. What would be the nurse's best response?

Correct Answer: B

Rationale: The best response is Take the medication at bedtime,' as it leverages drowsinessa common opioid side effectto aid sleep, a frequent issue in chronic pain, while maintaining pain control. Timing adjusts impact without altering the regimen. Choice A, stop taking it, risks uncontrolled pain, dismissing a manageable side effect over the drug's benefit. Choice C, you'll get used to it, assumes tolerance develops, which may notdrowsiness can persist, disrupting daytime function. Choice D, reporting to the physician, may follow, but nurses first offer practical solutions; this isn't urgent. Choice B is correct, empowering the client with a strategy nurses often suggest, aligning dose with lifestyle, reducing daytime sedation, and enhancing comfort, with follow-up if issues persist.

Correct Answer: A

Rationale: The basis of the nurse's response is reduced saliva production, as some chronic pain meds (e.g., opioids, antidepressants) have anticholinergic effects, inhibiting salivary gland activity, causing dry moutha side effect tied to their pharmacology. This explains its occurrence. Choice B, increased thirst, is a result, not the causedryness drives thirst, not vice versa. Choice C, allergic reaction, is wrong; dry mouth is a common effect, not a rare hypersensitivity sign. Choice D, rapid absorption, affects onset, not salivadryness stems from receptor action. Choice A is correct, guiding nurses to explain this mechanism, offering hydration or sugar-free gum to ease discomfort, ensuring clients manage this tolerable side effect while continuing pain relief therapy.

Correct Answer: B

Rationale: The nursing process is a systematic framework with five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing diagnosis step (Choice B) is where the nurse analyzes data collected during assessment to identify the patient's responses to actual or potential health problems, such as 'Risk for Infection' or 'Acute Pain.' Assessment (Choice A) involves gathering subjective and objective data (e.g., vital signs, patient history), but it doesn't involve interpreting those findings into specific responsesthat happens in the nursing diagnosis phase. Planning (Choice C) follows, where the nurse sets goals and interventions based on the diagnosis, while evaluation (Choice D) assesses whether those goals were met. For example, if a patient reports pain and the nurse notes a fever, the nursing diagnosis might be 'Acute Pain related to inflammation,' a conclusion drawn only after assessment data is analyzed. Thus, identifying responseswhether current or at-riskoccurs distinctly in the nursing diagnosis step, making Choice B the correct answer.

Correct Answer: B

Rationale: A warm, tender, reddened area on the calf suggests deep vein thrombosis (DVT), a clot obstructing venous flow. Recent pelvic surgery (Choice B) is the most significant contributing factor because it increases DVT risk through venous stasis (prolonged immobility), vascular injury (surgical trauma), and hypercoagulability (postoperative state)the Virchow's triad. The pelvic region's rich venous network heightens this risk. Increased aspirin use (Choice A) is unlikely to contribute, as aspirin is an antiplatelet agent that reduces clotting risk, though it's less effective against venous thrombosis. An active walking program (Choice C) lowers DVT risk by promoting circulation, making it protective, not causative. Diabetes (Choice D) contributes to peripheral vascular disease but isn't a primary DVT trigger unless combined with immobility. Post-surgical patients are 100 times more likely to develop DVT within 4-6 weeks, making recent pelvic surgery the critical factor. Choice B aligns with this pathophysiology, making it the correct answer.

Correct Answer: C

Rationale: Small hemorrhagic spots on the skin are petechiae (Choice C), pinpoint, non-blanching red or purple marks caused by capillary bleeding under the skin. They indicate conditions like thrombocytopenia, vasculitis, or infection (e.g., meningitis), requiring prompt investigation. Extravasation (Choice A) is fluid leakage into tissues, typically from IV infiltration, not hemorrhagic spots. Osteomalacia (Choice B) is bone softening from vitamin D deficiency, unrelated to skin findings. Uremia (Choice D), excess urea in blood from kidney failure, may cause pruritus or pallor, not petechiae specifically. For example, petechiae in a client with low platelets (e.g., 20,000/µL) signal bleeding risk, distinct from extravasation's swelling or uremia's systemic symptoms. Accurate documentation as petechiae guides diagnosis and treatment, making Choice C the correct term.