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 ["A","D","E"]

Explanation

A. Bottle spoon-shaped fingernails: This is a classic sign associated with iron deficiency anemia, known as koilonychia. The nails may appear thin, brittle, and spoon-shaped, indicating a deficiency in iron.

B. Platelets 400,000/µL: This platelet count is within the normal range (typically 150,000 to 450,000/µL) and does not specifically indicate iron deficiency anemia. Thus, it is not an expected finding.

C. Red blood cell count 4.5 million/mm³: This value is within the normal range for females (approximately 4.2 to 5.4 million/mm³). In iron deficiency anemia, one would expect the RBC count to be low or at least on the lower end of normal.

D. Hemoglobin 8.0 g/dL: This low hemoglobin level is indicative of anemia. In iron deficiency anemia, hemoglobin levels are often significantly decreased, so this finding aligns with the client's condition.

E. Tachypnea: Increased respiratory rate can occur in response to anemia, as the body attempts to compensate for decreased oxygen-carrying capacity by increasing breathing rate. Therefore, tachypnea is a likely finding in this client.

A. Decrease fluid intake of 1000 mL/day to prevent fluid overload B. The client verbalizes the procedure for a 24-hour urine collection C. Oxygenation and perfusion to meet cellular and metabolic needs D. Complications are prevented or minimized E. Pain is relieved or controlled

Correct Answer is ["C","D","E"]

Explanation

A. Decrease fluid intake of 1000 mL/day to prevent fluid overload: This goal is not appropriate. Clients with sickle cell crisis often require increased fluid intake to prevent dehydration and promote circulation, so limiting fluids is counterproductive.

B. The client verbalizes the procedure for a 24-hour urine collection: While understanding this procedure may be relevant for monitoring kidney function or hydration status, it is not a priority goal directly related to managing sickle cell crisis.
C. Oxygenation and perfusion to meet cellular and metabolic needs: Ensuring adequate oxygenation and perfusion is crucial in managing sickle cell crisis, as compromised blood flow can exacerbate pain and lead to further complications.

D. Complications are prevented or minimized: Preventing complications, such as infections or acute chest syndrome, is a key goal in managing a client with sickle cell disease, making this a critical aspect of discharge planning.

E. Pain is relieved or controlled: Pain management is a primary focus during a sickle cell crisis. Ensuring that pain is effectively managed before discharge is essential for the client's comfort and overall well-being.

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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

A female client with iron-deficiency anemia is experiencing increased fatigue and a shiny red tongue. The nurse would anticipate seeing which additional assessment finding(s) (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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