A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:
"Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
"Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
"Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."
"Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
The Correct Answer is C
A. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
This documentation provides details but lacks specific information on the pain’s nature and duration.
B. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
This statement includes diet details but lacks a pain intensity rating and specific location.
C. "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids." This statement is the most thorough, including location, nature, intensity, duration, and lack of relief from interventions.
D. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
This is incomplete, as it lacks a specific location and description of the pain’s onset.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. is appropriate only in special circumstances, such as with young children.
While touch can be especially comforting to children, it can be beneficial in various circumstances, depending on the patient's needs and cultural preferences.
B. can convey caring and support when words are difficult.
Touch can be a powerful, nonverbal way to express empathy and support, especially when patients are distressed or words may not suffice.
C. is a nursing intervention of choice in almost all situations.
Touch may not always be appropriate, as some patients may have cultural or personal preferences against physical contact. It should be used selectively.
D. should be avoided because of problems of cultural misinterpretation.
Touch should not be avoided entirely but should be used with cultural sensitivity and respect to avoid any misinterpretation.
Correct Answer is A
Explanation
A. Silence. Silence can be challenging for nursing students as it requires them to resist the urge to fill quiet moments, allowing the patient time to think or express emotions.
B. Closed questions. Closed questions are relatively straightforward and easy to use, often requiring only simple responses.
C. Using general leads. General leads encourage patients to continue sharing and are easier for most students than silence.
D. Restating. Restating is often easier for students, as it involves repeating back what the patient has said for clarity.
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