Author Question: The nurse caring for a client who is 24 hours post-extensive abdominal surgery assesses the client's ... (Read 145 times)

asmith134 · **on:** Jul 22, 2018

The nurse caring for a client who is 24 hours post-extensive abdominal surgery assesses the client's pain. The client rates the pain as a 1 on the pain scale.

The client is resting quietly, vital signs are within normal limits, and the client appears comfortable. The nurse concludes which of the following about this client? 1. The client is in denial.
2. The client is experiencing no pain.
3. The client has a high pain threshold.
4. The client is not admitting to the pain experienced.

Question 2

The nurse is performing a physical assessment on an elderly client. The nurse evaluates the muscular skeletal system, understanding that the following might be typical in the geriatric client: Standard Text: Select all that apply.

1. Elderly clients have decreased ROM.
2. Elderly clients have decreased subcutaneous fat that can affect their ability to stay warm.
3. Vigorous assessment techniques such as hopping on one foot are appropriate.
4. Evaluation of the ability to carry out ADLs can indicate a deviation from normal in the musculoskeletal system assessment.
5. Warmth in one or more joints.

aidanmbrowne · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3
Rationale: Pain threshold differs in each individual, and what one client reports as being excruciatingly painful, another might not consider bothersome. When pain is detected by the client, that is considered the client's pain threshold. This client rates a very painful condition as a 1, which means the client is feeling very little pain, and thus has a high pain threshold. The client is not denying pain; the client does not feel the pain. The client is feeling minimal pain with a score of 1. The nursing student is not capable of deciding that the diagnosis is incorrect.

Answer to Question 2

1,4
Rationale: Elderly clients can have decreased ROM.