Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia.
Which manifestation did the client most likely report that caused the nurse to select this priority?
A. Chronic ocular pain related to stress, fatigue, and certain triggers.
Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia. Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.
B. Pain and sensitivity in the upper extremities and neck.
Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.
C. Dull joint pain that accompanies physical exertion and which is relieved with rest.
This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.
D. Eight tender points in the legs and arms; insomnia; and fatigue.
This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.
Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia.
Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.
Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.
Similar Questions
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes the abdomen is distended and bowel sounds are diminished.
Which is the most appropriate nursing intervention?
A. Administer the prescribed medication.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
B. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
C. Call the healthcare provider.
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
D. Call and ask the operating room team to perform surgery as soon as possible.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
Full Explanation
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:
A. Stimulates bone marrow production of red blood cells.
This helps increase the oxygen-carrying capacity of the blood and corrects anemia.
B. Is given to all people with anemia.
Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.
C. Is given for iron deficiency anemia.
Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.
D. Stimulates bone marrow production of white blood cells.
Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.
Full Explanation
This helps increase the oxygen-carrying capacity of the blood and corrects anemia.
Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.
Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.
Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.
Question 22.
The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury.
What legal concept applies?
A. Breach of duty.
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
B. Criminality.
Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.
C. Scope of practice.
Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification. The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will. The nurse’s failure to turn the client does not involve any such restraint.
D. False imprisonment.
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
Full Explanation
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.
Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification.
The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will.
The nurse’s failure to turn the client does not involve any such restraint.