A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST mnemonic?
Severity
Precipitating cause
Region
Quality
The Correct Answer is A
A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.
B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.
C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.
D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.
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Related Questions
Correct Answer is B
Explanation
A) "The health care proxy does not go into effect until I am incapable of making decisions.": This statement is accurate. A health care proxy, also known as a durable power of attorney for health care or health care agent, is appointed to make medical decisions on behalf of the client if they become unable to do so themselves. This can include decisions related to treatment options, end-of-life care, and other medical interventions.
B) "I have to choose a family member as my health proxy.": This statement is incorrect. While some individuals may choose a family member as their health care proxy, it is not a requirement. The client can choose any competent adult who is willing to serve as their health care proxy, including a friend, relative, or even a legal representative.
C) "If I become incapacitated, end-of-life choices will be made by my proxy.": This statement is accurate. The health care proxy is responsible for making medical decisions on behalf of the client if they are unable to do so, including decisions related to end-of-life care and treatment preferences.
D) "I can change who I designate as my health care proxy at any time.": This statement is accurate. The client has the right to change their health care proxy at any time by completing a new advance directive document and revoking any previous designations. It is essential for the client to review and update their advance directives regularly to ensure they reflect their current wishes and preferences.
Correct Answer is C
Explanation
A) Exposed bone: Exposed bone is a manifestation of a stage 4 pressure ulcer, where full-thickness skin loss occurs, exposing muscle, tendon, or bone. In stage 3 pressure ulcers, the skin loss extends into the subcutaneous tissue, but it does not reach the level of exposing underlying structures like bone.
B) Blood-filled blisters: Blood-filled blisters can occur in various stages of pressure ulcers, but they are not specific to stage 3. They may be present in stage 1 or stage 2 pressure ulcers as well.
C) Necrotic subcutaneous tissue: This is the correct manifestation of a stage 3 pressure ulcer. Stage 3 pressure ulcers involve full-thickness skin loss with visible necrosis or damage to the subcutaneous tissue. The ulcer may appear as a deep crater with or without undermining of adjacent tissue.
D) Partial-thickness skin loss: Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, where the ulcer extends through the epidermis and into the dermis but does not involve deeper tissue layers like the subcutaneous tissue.
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