A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

Precipitating cause

Region

Quality

Severity

Answer and Explanation

The Correct Answer is C

A.   This component refers to what triggered the pain or any factors that may have contributed to its onset. For example, a nurse might ask if the pain started after eating, exercising, or any other activity. This does not apply to the nurse asking about the quality of the pain.
B.   This involves identifying the location of the pain. The nurse would ask the client where the pain is situated (e.g., upper abdomen, lower abdomen, etc.). While important, this is not what the nurse is asking when they inquire about the nature of the pain.
C.   This component focuses on describing the nature of the pain itself. The nurse is asking the client to describe what the pain feels like, such as whether it is sharp, dull, throbbing, burning, or cramping. This is the correct choice in this scenario.
D.   This refers to how intense the pain is, often measured on a scale (e.g., 0 to 10). The nurse would ask the client to rate their pain intensity. While this is an important aspect of pain assessment, it does not pertain to describing what the pain feels like.

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Correct Answer is A

Explanation

A. Urinary retention can lead to an increased risk of urinary tract infections. When urine remains in the bladder for prolonged periods, it can become a breeding ground for bacteria, increasing the likelihood of infection.
B. While bladder outlet obstruction can lead to urinary retention, this is more of a potential cause rather than a complication to monitor. In an immobile client, it may not be the primary concern unless there are specific signs or known conditions that suggest obstruction.
C. Proteinuria (presence of protein in the urine) is typically associated with kidney damage or disease, rather than urinary retention itself. While kidney function should always be monitored in any patient, protein in the urine is not a direct consequence of urinary retention or immobility.
D. Neurogenic bladder refers to bladder dysfunction due to nerve problems, affecting the ability to sense fullness or control urination. While this can be a concern for clients with certain neurological conditions, it is not an immediate monitoring concern for a client experiencing urinary retention solely due to immobility.

A. Client is asleep and resting B. Client had 150 mL of emesis in last hour C. Ondansetron 4 mg IV bolus for nausea and vomiting D. Client reports nausea and vomiting 30 minutes following surgery

Correct Answer is C

Explanation

A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.

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A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

Correct Answer is A

Explanation

A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Correct Answer is C

Explanation

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