While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

Tell me about the activities that cause your pain?

Does your pain occur when walking short distances?

When did you first notice the pain in your chest?

How do you feel when the pain becomes noticeable?

Answer and Explanation

The Correct Answer is B

A. This is an open-ended question, not closed-ended.

B.   A closed-ended question like "Does your pain occur when walking short distances?" is specific and allows the nurse to understand the triggers and pattern of the pain, which is important for assessing unstable angina.
C.   "When did you first notice the pain in your chest?" is also a relevant question but less specific to understanding the current pattern and triggers of the pain.
D.   "How do you feel when the pain becomes noticeable?" is open-ended and less specific in identifying triggers and patterns of the pain.

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Correct Answer is []

Explanation

Potential Condition: Anthrax

The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:

Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.

Parameters to Monitor:

Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.

A. Institute contact precautions for staff and visitors. B. Explain the purpose of a low bacteria diet. C. Monitor the client's white blood cell count. D. Send wound drainage for culture and sensitivity. E. Use standard precautions and wear a mask.

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

Explanation

A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.

B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.

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While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Correct Answer is []

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

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