The client is complaining of left shoulder pain. Which intervention should the nurse implement first?

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Chapter 4 Skin and the Integumentary System Review Questions Questions

Question 1 of 5

The client is complaining of left shoulder pain. Which intervention should the nurse implement first?

Correct Answer: A

Rationale: Assessing neurovascular status first ensures no underlying circulatory or nerve issues (e.g., from injury or referred pain) are present, which could require urgent intervention before addressing pain.

Question 2 of 5

The student nurse asks the nurse,"Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?" Which statement is the best response of the nurse?

Correct Answer: D

Rationale: Sensorineural hearing loss involves damage to the cochlea or vestibulocochlear nerve, distinguishing it from conductive and other types of hearing loss.

Question 3 of 5

The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple's procedure). Which nursing problem has the highest priority?

Correct Answer: B

Rationale: Post-Whipple's procedure, fluid volume imbalance is the highest priority due to potential complications like bleeding, leakage, or third-spacing of fluids, which can lead to hemodynamic instability.

Question 4 of 5

The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma?

Correct Answer: C

Rationale: Pheochromocytoma, an adrenal tumor, has a genetic link; family history of adrenal tumors is a key risk factor.

Question 5 of 5

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?

Correct Answer: D

Rationale: This is a normal sinus rhythm (PR 0.12-0.20 s, QRS <0.12 s, rate 60-100); monitoring is sufficient.

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