The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

"What were you doing when the pain started?"

"How long has the pain lasted?"

"How would you describe the pain?"

"How has the pain affected your relationship with your spouse?"

"Can you rate the pain on a 0-10 scale with 10 being the worst?"

Answer and Explanation

Correct Answer : A,B,C,E

A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain.

B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction.

C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain.

D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary.

E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.

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Correct Answer is D

Explanation

A) Reassuring the client that they will be able to do the exercise program: While reassurance is important for motivation, it does not provide practical support or help the client engage effectively in the program.

B) Explaining the exercise program to the client's spouse: While involving the spouse can be beneficial, the primary focus should be on ensuring the client understands and can engage in the program themselves.

C) Providing the client with specific details of how to perform the exercises: While it's important for the client to understand the exercises, simply giving details may not address the client's personal preferences or limitations, which are crucial for adherence.

D) Adapting the program to the client's needs and abilities: This intervention is the best approach to help the client maintain the exercise program. By tailoring the exercise regimen to fit the client's individual abilities, preferences, and any physical limitations, the client is more likely to feel confident, motivated, and able to stick with the program long-term.

A. Encourage oral fluids. B. Record the client's weight C. Take a pulse oximetry reading D. Place the call bell in reach of the client

Correct Answer is D

Explanation

A. Encourage oral fluids: While hydration is important, it is not the most immediate concern following the administration of prazosin.

B. Record the client's weight: Weight monitoring is not specifically indicated after the initial dose of prazosin and is not a priority action in this context.

C. Take a pulse oximetry reading: While monitoring oxygen saturation is important in many situations, it is not directly related to the administration of prazosin, which primarily affects blood pressure.

D. Place the call bell in reach of the client: This is the most appropriate action. Prazosin can cause orthostatic hypotension, particularly after the first dose, leading to dizziness or fainting. Ensuring that the call bell is within reach allows the client to request help if they feel lightheaded or need assistance.

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The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

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