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 B

Explanation

A. Restraining the client to prevent self-harm: While safety is a priority, physical restraint should be a last resort and not the first action taken in this scenario. It may escalate the situation and lead to feelings of loss of control.
B. Assist the client to identify the trigger situation and choose a coping strategy: This is the best initial intervention. Helping the client understand their triggers and encouraging the development of coping strategies can empower them and promote healthier responses to distress. This approach aligns with therapeutic practices that support emotional regulation.

C. Send the client to the crisis intervention unit for 23 hours of observation: While observation may be necessary if the client is at imminent risk of self-harm, it is essential first to explore the underlying issues and coping mechanisms. This action may be considered if the client remains a danger to themselves after initial interventions.

D. Advise the client to take an anxiolytic to decrease their anxiety level: Medications may help with anxiety, but this approach does not address the root of the problem or provide the client with skills to manage their distress. It is more beneficial to focus on therapeutic techniques first.

A. “I will drink milk every day to increase dietary calcium." B. "I will take my pill each day after dinner. C. "I will take my pill each day with my breakfast." D. “I will limit my intake of citrus juices”

Correct Answer is C

Explanation

A) “I will drink milk every day to increase dietary calcium": While increasing dietary calcium can be beneficial, it is not directly related to the administration of bumetanide. The focus should be on the timing and consistency of taking the medication.

B) “I will take my pill each day after dinner”: Taking bumetanide after dinner may not be ideal as it can lead to increased urination during the night, potentially disrupting sleep. It is generally recommended to take diuretics earlier in the day.

C) “I will take my pill each day with my breakfast”: This statement indicates an understanding of the importance of taking the medication at a consistent time each day, preferably in the morning. Taking bumetanide with breakfast helps to avoid nocturnal diuresis and ensures the medication is taken regularly.

D) “I will limit my intake of citrus juices”: While certain dietary considerations may be important, limiting citrus juices is not specifically related to the administration of bumetanide. The primary focus should be on the timing and consistency of taking the medication.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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