NR341 Complex Adult Health Exam 1
Question and Answers Latest Updates
2026 Graded A+ with Rationales
A nurse is performing a mental status examination (MSE) on a client
who has a new diagnosis of dementia. Which of the following
components should the nurse include? (Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain
A, B, D
(Grooming is included in an MSE which consists of appearance, behavior,
speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Long-term memory is
included in an MSE which consists of appearance, behavior, speech, and
mood, disorders of the form of thought, perceptual disturbances, cognition,
and ideas of harming self or others. Support systems are not included in an
MSE which consists of appearance, behavior, speech, mood, disorders of
the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others. Affect is included in an MSE which consists of
appearance, behavior, speech, and mood, disorders of the form of thought,
perceptual disturbances, cognition, and ideas of harming self or others. The
presence of pain is not included in an MSE which consists of appearance,
behavior, speech, mood, disorders of the form of thought, perceptual
disturbances, cognition, and ideas of harming self or others.)
A nurse is caring for a client who has late stage Alzheimer's disease
and is hospitalized for treatment of pneumonia. During the night shift,
the client is found climbing into the bed of another client who
becomes upset and frightened. Which of the following actions should
the nurse take?
A. assist the client to the correct room.
B. place the client in restraints.
C. re-orient the client to time and place.
D. move the client to a room at the end of the hall.
A
,(assisting the client to the correct room protects both clients. It helps re-
orient the client who is unable to find her own room, and it prevents the
other client from an invasion of her personal space.)
A nurse in a long-term care facility is caring for a client who has late
stage Alzheimer's disease. Which of the following actions should the
nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities.
C
(A consistent daily routine is appropriate for the care of a client who has
Alzheimer's disease.)
A nurse is monitoring a client who is post operative and unable to
respond to questions. Which of the following nonverbal behaviors
should the nurse identify as an indication that the client has pain?
(Select all that apply.)
A. Restlessness
B. Grimacing
C. Moaning
D. Clenching
E. Drowsiness
A, B, D
(Restlessness is correct. Clients who have uncontrolled pain often become
restless and anxious in response to the discomfort.
Grimacing is correct. Facial movements such as grimacing, tightly closing
the eyes, and biting the lower lip are behavioral indicators of pain.
Moaning is incorrect. Moaning, groaning, crying, and screaming are
vocalizations, not nonverbal behaviors, that indicate pain.
Clenching is correct. Clenching the teeth and biting the lower lip are
common findings in clients who have pain.
, Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are
common indicators of pain.)
A nurse is caring for a client who is one day post operative following
gynecologic surgery and reports incisional pain. Which of the
following actions should the nurse take first?
A. determine the time the client last received pain medication.
B. Measure the clients vital signs, including temperature.
C. ask the client to rate her pain on a scale of from 0 to 10.
D. re-position the client and offer her a back rub.
C
(Using evidence-based practice, the nurse should first determine the
severity of the client's pain by using a standard pain scale. Then the nurse
can plan the appropriate interventions.)
A nurse is planning care for a client who is post operative. Which of
the following statements about pain management should the nurse
consider when implementing client care? (Select all that apply.)
A. use of analgesics will eventually lead to addiction.
B. each clients expression of pain may be different and individualized.
C. Patient controlled analgesia (PCA) offers a constant level of
opioids within therapeutic range.
D. Pain level and tolerance can be assessed using a scale from 0 to
10.
E. The client will express the feeling of pain both verbally and
nonverbally.
B, C, D, E
(Use of analgesics will eventually lead to addiction is incorrect. The
administration of analgesics does not lead to addiction. This is a common
misconception about pain management.)
A nurse is caring for a client your request prescription pain
medication. Which of the following actions should the nurse perform
first?
A. re-position the client.
B. administer the medication.
C. determine the location of the pain.
D. review the effects of the pain medication.
C
Question and Answers Latest Updates
2026 Graded A+ with Rationales
A nurse is performing a mental status examination (MSE) on a client
who has a new diagnosis of dementia. Which of the following
components should the nurse include? (Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain
A, B, D
(Grooming is included in an MSE which consists of appearance, behavior,
speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Long-term memory is
included in an MSE which consists of appearance, behavior, speech, and
mood, disorders of the form of thought, perceptual disturbances, cognition,
and ideas of harming self or others. Support systems are not included in an
MSE which consists of appearance, behavior, speech, mood, disorders of
the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others. Affect is included in an MSE which consists of
appearance, behavior, speech, and mood, disorders of the form of thought,
perceptual disturbances, cognition, and ideas of harming self or others. The
presence of pain is not included in an MSE which consists of appearance,
behavior, speech, mood, disorders of the form of thought, perceptual
disturbances, cognition, and ideas of harming self or others.)
A nurse is caring for a client who has late stage Alzheimer's disease
and is hospitalized for treatment of pneumonia. During the night shift,
the client is found climbing into the bed of another client who
becomes upset and frightened. Which of the following actions should
the nurse take?
A. assist the client to the correct room.
B. place the client in restraints.
C. re-orient the client to time and place.
D. move the client to a room at the end of the hall.
A
,(assisting the client to the correct room protects both clients. It helps re-
orient the client who is unable to find her own room, and it prevents the
other client from an invasion of her personal space.)
A nurse in a long-term care facility is caring for a client who has late
stage Alzheimer's disease. Which of the following actions should the
nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities.
C
(A consistent daily routine is appropriate for the care of a client who has
Alzheimer's disease.)
A nurse is monitoring a client who is post operative and unable to
respond to questions. Which of the following nonverbal behaviors
should the nurse identify as an indication that the client has pain?
(Select all that apply.)
A. Restlessness
B. Grimacing
C. Moaning
D. Clenching
E. Drowsiness
A, B, D
(Restlessness is correct. Clients who have uncontrolled pain often become
restless and anxious in response to the discomfort.
Grimacing is correct. Facial movements such as grimacing, tightly closing
the eyes, and biting the lower lip are behavioral indicators of pain.
Moaning is incorrect. Moaning, groaning, crying, and screaming are
vocalizations, not nonverbal behaviors, that indicate pain.
Clenching is correct. Clenching the teeth and biting the lower lip are
common findings in clients who have pain.
, Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are
common indicators of pain.)
A nurse is caring for a client who is one day post operative following
gynecologic surgery and reports incisional pain. Which of the
following actions should the nurse take first?
A. determine the time the client last received pain medication.
B. Measure the clients vital signs, including temperature.
C. ask the client to rate her pain on a scale of from 0 to 10.
D. re-position the client and offer her a back rub.
C
(Using evidence-based practice, the nurse should first determine the
severity of the client's pain by using a standard pain scale. Then the nurse
can plan the appropriate interventions.)
A nurse is planning care for a client who is post operative. Which of
the following statements about pain management should the nurse
consider when implementing client care? (Select all that apply.)
A. use of analgesics will eventually lead to addiction.
B. each clients expression of pain may be different and individualized.
C. Patient controlled analgesia (PCA) offers a constant level of
opioids within therapeutic range.
D. Pain level and tolerance can be assessed using a scale from 0 to
10.
E. The client will express the feeling of pain both verbally and
nonverbally.
B, C, D, E
(Use of analgesics will eventually lead to addiction is incorrect. The
administration of analgesics does not lead to addiction. This is a common
misconception about pain management.)
A nurse is caring for a client your request prescription pain
medication. Which of the following actions should the nurse perform
first?
A. re-position the client.
B. administer the medication.
C. determine the location of the pain.
D. review the effects of the pain medication.
C
