A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?

Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions. Incorrect choices: A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment. B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management. D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided. Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.

Correct Answer: C

Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy. Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.

Correct Answer: C

Rationale: The correct answer is C: Developing nursing diagnoses before completing the database. This is incorrect because developing nursing diagnoses should be based on a comprehensive assessment and analysis of the patient's data. By developing nursing diagnoses before completing the database, the new nurse may overlook important information that could impact the accuracy of the diagnosis and subsequent care plan. Choice A (intravenous antibiotics) is incorrect because assigning a nursing diagnosis of Risk for infection for a patient on IV antibiotics is a common and appropriate practice given the increased risk of infection associated with invasive procedures. Choice B (Completing an interview and physical examination before adding a nursing diagnosis) is incorrect because nursing diagnoses should be developed based on the data collected during the assessment process, which includes the interview and physical examination. It is not necessary to complete the entire assessment before assigning a nursing diagnosis. Choice D (Including cultural and religious preferences in the database) is incorrect because while it is important to consider cultural and religious preferences in care planning, this does not directly relate to the

Correct Answer: D

Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.