The nurse is caring for a client who reports relief of pain after taking a placebo during a research study. The nurse would chart this response as being caused by which of the following?

Correct Answer: B

Rationale: The nurse would chart relief from a placebo as caused by psychological factors, as placeboslacking active ingredientsrelieve pain via the client's belief or expectation, triggering endorphin release in the brain. This placebo effect highlights pain's subjective, mind-influenced nature. Choice A, lack of real pain, dismisses the client's experiencepain existed, but perception shifted psychologically, not because it was fake. Choice C, poor study design, is irrelevant; relief reflects a known phenomenon, not a flaw, unless the study's ethics are questioned, which isn't implied. Choice D, ineffective medication, contradicts placebo definitionno medication is involved, just an inert substance. Choice B is correct, aligning with clinical understandingnurses document this accurately to inform care, noting psychological relief can complement treatment, though placebos aren't routine practice due to ethical concerns, emphasizing pain's complex interplay of body and mind.

Correct Answer: A

Rationale: The nurse would assess the level of sedation next, as opioids commonly cause drowsiness by depressing the central nervous systema key side effect impacting safety (e.g., falls) and dosing adjustments. Post-relief monitoring prioritizes this. Choice B, blood pressure, may drop with opioids, but sedation's immediacy and frequency make it more urgent to check. Choice C, appetite, isn't a primary concernnausea, not hunger, is more typical. Choice D, range of motion, improves with pain relief but isn't a side effect to assess; it's secondary. Choice A is correct, reflecting nursing vigilanceassessing sedation (e.g., drowsiness scale) ensures the opioid's benefit (pain relief) doesn't compromise safety, guiding interventions like timing or dose tweaks.

Correct Answer: B

Rationale: The nurse would assess gastrointestinal discomfort next, as NSAIDs (e.g., ibuprofen) commonly cause stomach irritation or ulcers by inhibiting prostaglandins that protect the gastric lininga frequent side effect needing monitoring post-relief. Choice A, respiratory rate, is key with opioids, not NSAIDs, which rarely affect breathing. Choice C, level of sedation, suits CNS depressants (e.g., narcotics), not NSAIDs, which don't typically drowsy. Choice D, blood pressure, may shift slightly with NSAIDs (e.g., fluid retention), but GI issues are more immediate and common. Choice B is correct, reflecting nursing vigilanceassessing for nausea, pain, or bleeding ensures NSAID benefits (pain relief) don't mask GI risks, prompting interventions like food intake or antacids to protect the stomach.

Correct Answer: D

Rationale: Heart sounds S1 and S2, known as 'lub' and 'dub,' have distinct characteristics based on their anatomical origins and auscultation points. S1, caused by the closure of the mitral and tricuspid valves, is loudest at the apex of the heart (near the left fifth intercostal space), where the mitral valve's sound is most prominent. S2, resulting from the closure of the aortic and pulmonic valves, is loudest at the base (second right and left intercostal spaces), where these valves are closest to the chest wall. Choice D correctly states this: 'S1 is loudest at the apex, and S2 is loudest at the base.' Choice A is incorrect because S1 and S2 do not sound equally loud across the entire cardiac area; their intensity varies by location. Choice B is wrong because S1 is actually louder, not fainter, at the apex, and Choice C is inaccurate since S2 is louder, not fainter, at the base. Understanding these auscultatory landmarks is crucial for accurate cardiac assessment, and Choice D reflects the physiological reality of heart sound distribution, making it the correct answer.

Correct Answer: B

Rationale: Implementation in the nursing process involves carrying out the care plan, and for drug therapy, this includes administering medications and documenting them (Choice B). Documentationrecording the drug, dose, time, route, and patient responseis a legal and clinical requirement ensuring accountability and continuity of care. Developing a content outline (Choice A) relates to teaching plans, not direct drug administration. Establishing outcome criteria (Choice C) and setting realistic goals (Choice D) occur during planning, not implementation, as they define what the therapy aims to achieve (e.g., pain reduced to 3/10'). For example, after giving morphine, the nurse documents it in the medication administration record and notes the patient's pain level, fulfilling implementation. This action supports safety (e.g., preventing double-dosing) and informs evaluation. While all steps are interconnected, only documenting drugs given directly ties to the act of implementing drug therapy, making Choice B the correct answer.