A nurse is caring for an adolescent who is receiving treatment for burns and is requesting medication for pain. Which of the following questions should the nurse ask to determine the quality of the adolescent's pain?
"Can you describe what your pain feels like?"
"Can you point to the area where your pain is most severe?"
"What is your pain level on a scale of 0 to 10?"
"When did your pain start increasing?"
The Correct Answer is A
A. Asking the adolescent to describe the quality of their pain can provide valuable information about the characteristics of the pain, such as sharp, dull, throbbing, or burning.
B. Asking the adolescent to point to the area of most severe pain assesses location, not quality.
C. Asking about pain level assesses intensity, not quality.
D. Asking about the timing of pain increasing assesses onset, not quality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
Correct Answer is A
Explanation
A. This statement indicates correct understanding. Remaining upright after taking ferrous gluconate reduces the risk of esophageal irritation or discomfort, which can occur if the medication refluxes into the esophagus. This is an important teaching point for clients taking iron supplements.
B. This statement is incorrect. Antacids can interfere with the absorption of ferrous gluconate by altering stomach acidity, which is necessary for optimal iron absorption. Clients should avoid taking antacids within two hours of iron supplements.
C. This statement is incorrect. Milk and other calcium-containing products inhibit the absorption of iron. It is recommended to take ferrous gluconate with water or a source of vitamin C, such as orange juice, to enhance absorption.
D. This statement is incorrect. Black stools are a common and harmless side effect of taking iron supplements and do not typically require notifying the provider unless accompanied by other symptoms like abdominal pain or blood in the stool.
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