Correct Answer: A

Rationale: The correct answer is A because it reflects a holistic approach by considering the client's emotional and mental well-being in relation to their headaches. By asking about stress, the nurse acknowledges that headaches may be influenced by psychological factors. Other choices (B, C,
D) focus on physical symptoms, treatments, or monitoring, which are important but do not address the whole person. By considering stress, the nurse recognizes the interconnectedness of physical, emotional, and mental aspects of health. This holistic approach aligns with the principles of holistic nursing, which aim to treat the whole person and promote overall well-being.

Correct Answer: C

Rationale: The correct answer is C because grimacing when moving is an observable behavior that is considered an objective indicator of pain. Grimacing is a nonverbal cue that can suggest pain without the client having to verbalize it. This behavior is a physical manifestation that can be observed by the nurse, making it an objective indicator. The other choices involve subjective experiences or verbal reports of pain, which can vary based on individual perception and interpretation. For example, choice A relies on the client's self-report, which is subjective.
Choice B describes a sensory experience, which is also subjective.
Choice D relates to the location of pain, which is again subjective unless accompanied by observable behaviors like grimacing.
Therefore, choice C is the correct answer as it provides an objective indicator that the nurse can directly observe.

Correct Answer: A

Rationale: The correct way to walk using crutches is to alternate between bearing weight on the crutches and the injured leg (
Choice
A). This promotes stability and helps distribute weight evenly, reducing strain on the injured leg. By bearing weight on the crutches and the injured leg alternately, you maintain balance and prevent further injury.
Incorrect choices:
B: Using crutches to hop forward without weight on the injured leg can lead to imbalance and potential falls.
C: Keeping the injured leg elevated at all times is not practical for walking with crutches as it does not promote weight-bearing and mobility.
D: Leaning heavily on the crutches to avoid putting weight on the injured leg can cause strain on the arms and shoulders while also not promoting proper weight distribution.

Correct Answer: C

Rationale: The correct answer is C: Surgical incision. Acute pain is sudden and usually results from a specific injury or illness. A surgical incision typically causes acute pain due to tissue damage, inflammation, and nerve stimulation. It is time-limited and usually resolves as the tissue heals. Peripheral neuropathy (
A) and fibromyalgia (
D) are chronic pain conditions that last for an extended period. Rheumatoid arthritis (
B) is a chronic inflammatory condition that causes persistent joint pain. In summary, the surgical incision is the best example of acute pain among the choices provided due to its sudden onset and association with tissue injury.

Correct Answer: B

Rationale: The correct answer is B: Decreased ability to hear high-frequency sounds. As people age, the sensory cells in the inner ear that detect high-frequency sounds tend to deteriorate, leading to a decreased ability to hear those sounds. This is known as presbycusis.

Choices A, C, and D are incorrect because aging does not necessarily result in decreased thickness of tympanic membranes, decreased tinnitus, or decreased ear wax production.
Therefore, the most relevant physiological change to hearing in older adults that the nurse should include in the teaching is the decreased ability to hear high-frequency sounds.