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. Elevating the head of the bed during meals can help prevent aspiration by allowing gravity to assist in keeping food and liquids in the esophagus rather than the airway. This position reduces the risk of aspiration pneumonia significantly for clients who may have swallowing difficulties.
B. Tilting the head back while swallowing can increase the risk of aspiration, as it can cause food or liquids to flow into the airway rather than the esophagus. Proper swallowing techniques usually involve tilting the head slightly forward or maintaining a neutral position.
C. While good oral hygiene is essential for overall health and can help reduce the risk of aspiration pneumonia by minimizing bacteria in the mouth, it is not a direct action during meal times that prevents aspiration. Oral hygiene is important but should be part of a comprehensive care plan.
D. Distractions during meals, such as watching television, can lead to decreased attention to swallowing and increase the risk of aspiration. It can divert the client’s focus from the act of eating, making it harder for them to manage their swallowing effectively.

A. Place two fingers in the client's mouth. B. Hold the toothbrush at a 90° angle. C. Vigorously brush the client's teeth. D. Turn the client to the side.

Correct Answer is D

Explanation

A. This action is not appropriate as it could stimulate the gag reflex and lead to choking or aspiration. It does not contribute to effective oral care. Instead, gentle techniques using appropriate tools should be used to clean the mouth.
B. Holding the toothbrush at a 90° angle can be effective for brushing teeth as it allows for better access to the surfaces of the teeth. However, for an unconscious patient, this angle might not be practical or safe depending on the circumstances.
C. Vigorous brushing is not recommended, especially for an unconscious client. It could cause damage to the gums, lead to discomfort, or risk aspiration of fluids. Gentle brushing is advised to clean the teeth and gums without causing injury.
D. Turning the client to the side helps prevent aspiration of saliva or any fluids that may be in the mouth. It also provides better access for oral care and minimizes the risk of choking. This position is often recommended for unconscious patients to maintain their safety during oral care.

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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?

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