An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?

Correct Answer: B

Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.

Correct Answer: B

Rationale: Fidelity in nursing is keeping promises (B), per ethics e.g., returning as pledged. Telling truth (A) is veracity, doing good (C) beneficence, avoiding harm (D) nonmaleficence not promise-focused. B best defines fidelity's commitment to trust, a cornerstone of nurse-patient relationships, making it the correct description.

Correct Answer: B

Rationale: Safety focuses on preventing harm (B), per standards e.g., protocols reduce risks. Errors can be minimized (A), not surgery-only (C), not all (D) broad scope. B truly defines safety's priority, making it correct.

Correct Answer: C

Rationale: Pedal pulse absence is normal in 10-20% of people and less critical initially.

Correct Answer: B

Rationale: A Foley catheter monitors 24-hour urine output for adequacy.

Correct Answer: A

Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.

Correct Answer: A

Rationale: Total patient care, where one nurse handles all client needs like meds and hygiene is prevalent for student nurses and private duty nurses. Students benefit from focused, hands-on learning (e.g., managing a post-op patient solo), while private nurses provide personalized attention (e.g., home care). Team nursing splits tasks, primary nursing ensures continuity, and case management coordinates, but total care's simplicity suits training and one-on-one settings. Its direct accountability fosters skill mastery, widely used in educational and private contexts.

Correct Answer: C

Rationale: Wellness is dynamic (A), optimal function-focused (B), balanced (D) not same as health (C), per theory. Wellness is proactive, health a state. C's identity is untrue, making it the correct false statement.

Correct Answer: A

Rationale: Battery is the intentional, unconsented physical contact, like striking a patient, a civil tort with legal repercussions. Negligence is unintentional harm, tort is a broader category, and crime involves criminal law. Nurses avoid battery by obtaining consent, respecting autonomy, as violations breach ethical and legal standards, risking lawsuits or discipline.