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 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 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.

Correct Answer: C

Rationale: The correct answer is C: Psychomotor. The nurse is demonstrating psychomotor skills by inserting an IV catheter correctly. Psychomotor skills involve the ability to perform physical tasks effectively and efficiently. This skill requires coordination, dexterity, and precision. The other choices are incorrect because: A: Cognitive skills involve thinking, analyzing, and problem-solving. B: Interpersonal skills involve communication and interaction with others. D: Judgmental skills involve critical thinking and decision-making.

Correct Answer: B

Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided. Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action. Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections. Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.