Page 1335 - Saunders Comprehensive Review For NCLEX-RN

nurse should ask the client to describe the pain and listen carefully to the words the
client uses to describe the pain. Nonverbal cues from the client are important but are
not the most appropriate pain assessment measure. The nurse’s impression of the
client’s pain is not appropriate in determining the client’s level of pain. Assessing
pain relief is an important measure, but this option is not related to the subject of the
question.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate option
3 because the nurse is not the client of the question. From the remaining options, the
subjective data from the client will provide the most accurate description of the pain.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Caring
Content Area: Foundations of Care: Vital Signs
Health Problem: N/A
Priority Concepts: Caregiving; Pain
Reference: Lewis et al. (2017), pp. 107-108.

449. Answer: 1

Rationale: The client is kept NPO until peristalsis returns, usually in 4 to 6 days.
When signs of bowel function return, clear fluids are given to the client. If no
distention occurs, the diet is advanced as tolerated. The most important assessment
is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated
to the data in the question.
Test-Taking Strategy: Note the strategic word, priority, and the words NPO status
to clear liquids in the question. The correct option is the only one that relates to
gastrointestinal function.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Perioperative Care
Health Problem: N/A
Priority Concepts: Clinical Judgment; Nutrition
Reference: Lewis et al. (2017), pp. 342, 1261.

450. Answer: 4

Rationale: Hodgkin’s disease is a chronic progressive neoplastic disorder of
lymphoid tissue characterized by the painless enlargement of lymph nodes with
progression to extralymphatic sites, such as the spleen and liver. Weight loss is most
likely to be noted. Fatigue and weakness may occur but are not related significantly
to the disease.
Test-Taking Strategy: Options 1 and 2 are comparable or alike and are rather
vague symptoms that can occur in many disorders. Option 3 can be eliminated
because, in such a disorder, weight loss is most likely to occur. Also, recalling that
Hodgkin’s disease affects the lymph nodes will direct you to the correct option.
Level of Cognitive Ability: Analyzing

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