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 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 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: Rationale: 1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis. 2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas. 3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders. 4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies. 5. Therefore, the correct answer is C (Pituitary carcinoma). Summary: A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.

Correct Answer: A

Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.

Correct Answer: A

Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.

Correct Answer: B

Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client. A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia. C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment. D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.

Correct Answer: C

Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.

Correct Answer: C

Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.

Correct Answer: B

Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.