A nurse is attending to a patient who is experiencing discomfort.
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

“I feel a dull ache in my stomach.”.

“I notice that the pain intensifies after I eat.”.

“The pain is causing me to feel nauseous.”.

“I’m experiencing mild pain.”.

Answer and Explanation

The Correct Answer is A

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

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Correct Answer is C

Explanation

Choice A rationale

Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.

Choice B rationale

Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.

Choice C rationale

Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.

Choice D rationale

Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.

A. Assist the patient to a left side-lying position with the right knee flexed. B. Prepare the patient for a chest x-ray. C. Administer a cleansing enema. D. Perform a manual digital examination of the patient’s rectum.

Correct Answer is C

Explanation

Choice A rationale

Assisting the patient to a left side-lying position with the right knee flexed is often used for rectal examinations or administering enemas, but it does not directly address the issue of a large amount of fecal material in the colon.

Choice B rationale

Preparing the patient for a chest x-ray would not be beneficial in this situation. A chest x-ray would not provide further information about the fecal material in the colon.

Choice C rationale

Administering a cleansing enema can help to remove the fecal material from the colon. This is a common treatment for fecal impaction.

Choice D rationale

Performing a manual digital examination of the patient’s rectum can help to assess the amount of fecal material present, but it would not alleviate the patient’s abdominal pain or remove the fecal material.

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A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given. Heart rate of 110 bpm Complete the following sentence using the list of options. The patient exhibits symptoms of ________

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient reports abdominal pain.An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is attending to a patient who is experiencing discomfort.
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?