an 80 year old aphasic cva client had abdominal surgery 2 days ago which of the following puts this client at the highest risk for inadequate pain man
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NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

Correct answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

2. Which of the following statements is true about syphilis?

Correct answer: D

Rationale: The correct statement about syphilis is that it can be cured with a course of antibiotic therapy. Syphilis is a treponemal disease that can be effectively treated with antibiotics, particularly long-acting penicillin G. The primary lesion of syphilis, known as a chancre, typically appears about three weeks after exposure and can involute even without specific treatment. If left untreated, secondary manifestations may occur, followed by latent periods. Specific treatment with antibiotics is crucial to prevent progression and transmission of the disease. Therefore, option D is correct. Option A is incorrect because the cause and mode of transmission of syphilis are well understood. Option B is incorrect as there is a known cure for syphilis. Option C is incorrect because the healing of the primary lesion does not indicate a cure for the disease.

3. Priorities designated as intermediate by the nurse are:

Correct answer: A

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

4. What is the most common cause of injury from a house fire?

Correct answer: D

Rationale: Inhalation injury is the most common cause of injury from a house fire. When a fire occurs, the smoke produced contains harmful gases and particles that can be inhaled, leading to serious respiratory issues. This makes inhalation injury the primary concern during a house fire. Choices A, B, and C are less likely to be the primary cause of injury. While explosions may occur in some cases, inhalation of smoke and toxic fumes is generally the most prevalent danger. Falls from windows and thermal damage to the skin are also significant risks but typically occur after inhalation injuries in the sequence of events during a house fire.

5. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

Correct answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

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