A patients bed partner reports the patient often has irregular snoring and silence followed by a snort. Does this warrant further assessment?

Correct Answer: C

Rationale: Irregular snoring with silence and snorts suggests a sleep disorder needing evaluation. 'Yes, this is an indicator of obstructive apnea' is correct; obstructive sleep apnea (OSA) features airway collapse, pausing breathing (apnea)e.g., 10-second silencesthen gasping snorts, per AASM criteria. Choice A, 'snoring has varied patterns,' dismisses the pattern's specificity; normal snoring lacks prolonged pauses. Choice B, 'this is normal snoring,' is false; healthy snoring is rhythmic, not interruptede.g., no 30-second gaps. Choice D, 'the bed partner is unable to sleep,' focuses on the partner, not the patient's health risk (e.g., hypoxia). OSA, linked to hypertension and fatigue, requires polysomnography, per Taylor's nursing assessment. Choice C flags this red flag correctly.

Correct Answer: A

Rationale: Chronic pain persists beyond healing, typically >3-6 months. 'A patient with rheumatoid arthritis' fitse.g., joint pain for years, per Taylor's pain typology, from ongoing inflammation. 'A patient with pneumonia' has acute paine.g., pleuritic pain resolves with antibiotics in weeks. 'A patient with controlled hypertension' rarely has paine.g., asymptomatic unless crisis. 'A patient with the flu' has acute myalgiae.g., 5-7 days, not chronic. RA's unremitting naturee.g., daily stiffnesscontrasts with temporary illnesses, making Choice A correct.

Correct Answer: A

Rationale: Back massage for pain relief leverages neuroscience. 'Gate control theory' motivates it; non-painful touch (e.g., massage) activates large A-beta fibers, closing spinal 'gates' to pain signals from smaller A-delta/C fibers, per Melzack and Wall, cited in Taylor. 'Neuromodulation' involves devices (e.g., TENS), not handse.g., electrical, not manual. 'Large/small fiber theory' is a misnomer; it's part of gate control, not distinct. 'Prostaglandin stimulation' worsens paine.g., inflammation, not relief. Massagee.g., 10 minutes on the backreduces perceived intensity (e.g., 6/10 to 3/10) by competing stimuli, a nursing staple. Choice A is the correct theoretical basis.

Correct Answer: D

Rationale: Post-op urinary retention mimics pain. 'Palpate abdomen for distended bladder' is correcte.g., a firm, tender suprapubic mass suggests 400 mL retention, per Taylor's assessment, causing pain and restlessness. Choice A, 'last bowel movement,' tracks constipatione.g., unrelated to 8-hour void gap. Choice B, 'auscultate bowel sounds,' checks GIe.g., hypoactive post-op, not urinary. Choice C, 'percuss for tympany,' assesses aire.g., bowel, not bladder fullness. Palpatione.g., dullness over bladderconfirms retention (common post-anesthesia) before opioids, which worsen it. Nurses prioritize causee.g., catheterize, not mask with medsmaking Choice D the right step.

Correct Answer: C

Rationale: PCA (patient-controlled analgesia) empowers self-dosing. 'When you push the button, you will get the medicine' is correcte.g., a 1 mg morphine bolus every 10 minutes, per Taylor's teaching, gives control. Choice A, 'machine does it all,' is falsee.g., no patient input risks overdose. Choice B, 'teach your family,' undermines autonomye.g., alert patients manage it. Choice D, 'going in all the time,' confuses PCA with infusione.g., PCA has lockouts (e.g., 6 mg/hour max). Nurses demoe.g., 'Press when it's 5/10'ensuring safety/efficacy. Choice C is the clear, correct explanation.