The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.
The patient reports having bad pain.
What will the nurse do first?
Attempt to determine what type of pain the patient has.
Request an order for intravenous opioid analgesic.
Administer acetaminophen (Tylenol).
Ask the patient to rate the pain on a scale of 1-10.
The Correct Answer is D
Choice A rationale
Determining the type of pain is secondary to assessing pain severity.
Choice B rationale
Intravenous opioids are strong and should be considered only after evaluating pain severity.
Choice C rationale
Administering acetaminophen without assessing pain severity first is not appropriate.
Choice D rationale
Asking the patient to rate their pain helps gauge severity, guiding further pain management steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Atorvastatin (Lipitor) does not decrease sitosterol. It mainly targets serum cholesterol and LDL levels to reduce cardiovascular risks.
Choice B rationale
Atorvastatin does not decrease campesterol. Its primary effect is on serum cholesterol and LDL levels, aiming to lower the risk of heart disease.
Choice C rationale
Atorvastatin effectively decreases serum cholesterol and LDL levels, which are the primary targets for reducing cardiovascular risks in patients with high cholesterol.
Choice D rationale
Atorvastatin lowers both serum cholesterol and LDL levels, not just serum cholesterol, making it effective in reducing overall cardiovascular risk.
Correct Answer is D
Explanation
Choice A rationale
This choice is incorrect. A complete occlusion of a coronary vessel results in a myocardial infarction (heart attack), not unstable angina. Unstable angina occurs when there is a significant narrowing or partial blockage of a coronary artery, leading to reduced blood flow and oxygen supply to the heart muscle, causing pain or discomfort. Complete occlusion would cause permanent damage to the heart muscle, which is not the case with unstable angina.
Choice B rationale
This choice is correct. While unstable angina is mainly caused by narrowing of the coronary arteries, it can also be caused by a spasm of the blood vessel. This spasm, also known as vasospasm, reduces the amount of blood flow to the heart muscle, resulting in pain. These spasms can occur even if the coronary arteries do not have significant plaque buildup, adding another layer of complexity to the condition.
Choice C rationale
This choice is partially correct. The body’s response to a lack of oxygen (ischemia) in the heart muscle does result in pain, known as angina. However, this choice does not fully capture the specific nature of unstable angina, which involves episodes of pain that occur more frequently and are more severe than those associated with stable angina, and can occur at rest or with minimal exertion, indicating a higher risk for a heart attack.
Choice D rationale
This choice is correct. Unstable angina is characterized by a serious narrowing of a coronary artery that reduces oxygen supply to the heart. This narrowing is typically due to atherosclerotic plaque and can be complicated by blood clots or spasms. Unlike stable angina, the pain of unstable angina is more unpredictable and can occur without a triggering factor like exercise or stress, signaling a higher risk of a heart attack.
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