A client is experiencing sudden-onset severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the client is experiencing which of the following?

Chronic pain

Intractable pain

Acute pain

End-of-life pain

Answer and Explanation

The Correct Answer is C

A) Chronic pain: Chronic pain is defined as pain that lasts for an extended period, often longer than three months, and is usually associated with conditions that are ongoing or recurring. The client’s symptoms, including sudden-onset severe pain and accompanying acute symptoms like nausea and vomiting, do not align with the characteristics of chronic pain.

B) Intractable pain: Intractable pain refers to pain that is resistant to treatment and does not respond well to analgesics or other interventions. While the client's pain is severe, the sudden onset and associated symptoms suggest a specific acute process rather than a pain condition that is inherently resistant to treatment.

C) Acute pain: Acute pain is characterized by its sudden onset and typically corresponds to a specific injury or condition, often with accompanying physiological responses such as nausea and restlessness. The client’s severe pain rating of 10, along with nausea and vomiting, strongly indicates that they are experiencing acute pain, likely related to an underlying acute abdominal condition.

D) End-of-life pain: End-of-life pain usually occurs in patients with terminal illnesses and is often managed with palliative care strategies. The client’s sudden onset of severe pain and accompanying symptoms indicate a different situation, likely not related to a terminal condition.

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Correct Answer is D

Explanation

A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.

B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.

C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.

D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.

A. Symmetry of lesions B. Border regularity C. Diameter less than 6 mm D. Color variation

Correct Answer is D

Explanation

A) Symmetry of lesions: While asymmetry can be a concern when assessing moles, it is not the most critical indicator when a lesion has already shown signs of burning and bleeding. Symmetry is one aspect of the overall assessment but does not immediately indicate danger in this scenario.
B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.

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Naxlex Comprehensive Predictor Exams

When assessing the abdomen, the nurse would expect to auscultate which sounds?

Correct Answer is D

Explanation

The client tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should pay close attention to danger signs for pigmented lesions, and would be concerned with which additional finding?

Correct Answer is D

Explanation

The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

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