1. While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse
performs a neurological assessment every four hours. Which assessment
finding warrants immediate intervention by the nurse?Rationale:finding in a
client with ALS, as it can lead to ineffective airway clearance and increase the
risk of aspiration pneumonia. Immediate intervention, such as suctioning or
respiratory support, may be necessary to maintain airway patency and prevent
complications.: Weakened cough
2. A client with stage 4 bone cancer is admitted to the hospital verbalizes
continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the
nurse implement?Rationales: Both opioids and nonopioids are appropriate
intervention managing severe pain as it addresses pain from multiple path-
ways and provide more effective pain relief.: Administer opioid and non-opioid
medication simultaneously.
3. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
mailto:https://www.stuvia.com/user/Wisdoms
, resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected. temperature 100.5° F (38.1° C).
Heart rate 97 beats/minute
Respirations 18 breaths/minute
Blood pressure 151/87 mm Hg
Oxygen saturation 95% on room air
Height is 5 ft 11 in (180.34 cm)
Weight is 228 lb (103.4 kg)
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Day 1, 0830: Renal dysfunction- Chronic gout
4. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
mailto:https://www.stuvia.com/user/Wisdoms
, Day 1, 0830: Visible tophi
- Chronic gout
5. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has no.tEach row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Low grade fever
- Acute gout attack
6. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Pain at the affected joint
- Acute gout attack
7. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Occur in more than 1 joint
mailto:https://www.stuvia.com/user/Wisdoms
, - Chronic gout
8. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months.The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
mailto:https://www.stuvia.com/user/Wisdoms
performs a neurological assessment every four hours. Which assessment
finding warrants immediate intervention by the nurse?Rationale:finding in a
client with ALS, as it can lead to ineffective airway clearance and increase the
risk of aspiration pneumonia. Immediate intervention, such as suctioning or
respiratory support, may be necessary to maintain airway patency and prevent
complications.: Weakened cough
2. A client with stage 4 bone cancer is admitted to the hospital verbalizes
continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the
nurse implement?Rationales: Both opioids and nonopioids are appropriate
intervention managing severe pain as it addresses pain from multiple path-
ways and provide more effective pain relief.: Administer opioid and non-opioid
medication simultaneously.
3. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
mailto:https://www.stuvia.com/user/Wisdoms
, resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected. temperature 100.5° F (38.1° C).
Heart rate 97 beats/minute
Respirations 18 breaths/minute
Blood pressure 151/87 mm Hg
Oxygen saturation 95% on room air
Height is 5 ft 11 in (180.34 cm)
Weight is 228 lb (103.4 kg)
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Day 1, 0830: Renal dysfunction- Chronic gout
4. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
mailto:https://www.stuvia.com/user/Wisdoms
, Day 1, 0830: Visible tophi
- Chronic gout
5. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has no.tEach row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Low grade fever
- Acute gout attack
6. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Pain at the affected joint
- Acute gout attack
7. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months. The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
condition has not.Each row must have at least one, but may have more than
one, response option selected.
Day 1, 0830: Occur in more than 1 joint
mailto:https://www.stuvia.com/user/Wisdoms
, - Chronic gout
8. A 59-year-old male client presents to the clinic reporting pain in the right
great toe. The client says that the pain feels like it is another attack of gout,
which he has had on 2 other occasions in the last 4 months.The client tells
the nurses that the pain started about 9 days ago in the evening and that it got
very painful and swollen shortly thereafter. In the past, the gout attacks have
resolved without treatment after about 5 days, but the client reports that his
mailto:https://www.stuvia.com/user/Wisdoms
