The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

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Question 1 of 5

The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

Correct Answer: D

Rationale: Pain (D) is the priority post-surgery, impacting recovery and rehab. A, B, and C are assessed later, making D the initial focus, using pain scales or graphics if language barriers exist.

Question 2 of 5

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Correct Answer: A

Rationale: Reflex incontinence occurs due to involuntary bladder contractions from nerve damage, such as after a spinal cord injury, causing the bladder to empty without the client's control. Stress incontinence (B) involves leakage from physical pressure, urge incontinence (C) involves a sudden need to urinate, and overflow incontinence (D) results from incomplete emptying, none of which align with nerve damage-related involuntary emptying.

Question 3 of 5

The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective?

Correct Answer: C

Rationale: Assessing respirations when administering opioids directly addresses safety by preventing respiratory depression, aligning with The Joint Commission’s focus. Range-of-motion exercises (A), meal intake (B), and delegation (D) are valuable but not primarily safety-focused.

Question 4 of 5

A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate?

Correct Answer: B

Rationale: Calling the surgeon to explain options supports the client’s right to be informed and change her treatment plan, exemplifying advocacy. Reassurance (A), prayer (C), or a survivor visit (D) do not address her expressed desire for a different procedure.

Question 5 of 5

Which statement best describes the process of nursing case management?

Correct Answer: B

Rationale: Nursing case management is a collaborative process to assess, plan, and coordinate care for quality and cost-effective outcomes. Options A, C, and D are narrower and less comprehensive.

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