A nurse enters a client's room and observes indicators of pain such as grimacing and tension. What should the nurse prioritize during the initial general survey?
Proceed to perform a head-to-toe examination
Assess the client's level of pain using a scale
Call the healthcare provider for a pain medication order
Ask the family to leave to complete a private history
The Correct Answer is B
Pain is the fifth vital sign and requires immediate systematic evaluation when non-verbal cues are observed. Utilizing standardized assessment tools allows the clinician to quantify subjective experiences, guiding the multimodal analgesia approach. Prompt intervention is necessary to prevent the physiological consequences of untreated acute pain, such as tachycardia.
A. Proceeding with a full head-to-toe examination before addressing the client's obvious distress is inappropriate and lacks empathy. Pain can interfere with the client's ability to participate in a full physical assessment. Addressing the most urgent subjective concern first ensures the patient is comfortable enough for further clinical evaluation.
B. Assessing the client's level of pain using a validated scale (such as the 0 to 10 numeric scale) is the priority action. This provides a baseline to determine the severity and nature of the pain. It allows the nurse to implement interventions and later evaluate their effectiveness accurately.
C. Calling the healthcare provider before performing a thorough pain assessment is premature. The nurse must first gather data regarding the pain's location, intensity, and quality to provide a meaningful report to the provider. A complete assessment is required to ensure the correct medication and dosage are ordered.
D. Asking the family to leave does not address the immediate physiological and psychological needs of the client in pain. While privacy is important for a detailed history, it is not the priority when a patient is showing visible signs of acute discomfort. Pain management must take precedence over administrative history-taking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reasoning:
Pressure injuries result from localized hypoxemia and mechanical tissue distortion over bony prominences, leading to cellular metabolic compromise. Persistent pressure occludes microvascular perfusion, triggering an inflammatory cascade that manifests as non-blanchable redness, which serves as the earliest clinical sign of integumentary structural failure.
A. A Stage 1 pressure injury is characterized by intact skin with localized non-blanchable erythema. The presence of redness that does not fade after pressure is released indicates that microcirculatory disruption has occurred, although the epidermis and dermis remain structurally intact without open ulcerations or blisters.
B. Stage 2 pressure injuries involve partial-thickness loss of the dermis. This stage typically presents as a shallow, open ulcer with a red-pink wound bed or as an intact or ruptured serum-filled blister. Erythema alone is insufficient for this classification as there must be visible epidermal loss.
C. Stage 3 pressure injuries are defined by full-thickness skin loss. In this stage, adipose tissue (subcutaneous fat) may be visible within the ulcer, but bone, tendon, and muscle are not yet exposed. This represents a more advanced level of tissue destruction than simple surface erythema.
D. Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, or bone. These injuries often include tunneling or undermining. This stage reflects profound necrotic damage far beyond the initial stage of superficial erythema.
Correct Answer is B
Explanation
The musculoskeletal system relies on specific anatomical structures to reduce friction and facilitate the mechanical gliding of tissues during physical activity. A bursa is a small, distinct sac lined with a synovial membrane and filled with viscous synovial fluid, typically situated between bones and soft tissues.
A. Ligaments are fibrous connective tissues that primary serve to connect bone to bone, providing structural stability to joints rather than acting as fluid-filled capsules. While they permit movement, they do not contain a capsule of fluid designed specifically for lubrication and friction reduction between sliding surfaces.
B. The bursa is the specific fluid-filled sac or capsule that functions as a cushion to reduce friction between moving parts of the musculoskeletal system, such as bones, tendons, and muscles. This structure is essential for maintaining flexibility and preventing the degradation of soft tissues during repetitive joint articulation.
C. Tendons consist of tough, inelastic bands of fibrous collagen tissue that attach muscles to bones, transmitting mechanical force to produce movement. They are not encapsulated fluid structures; instead, they are dense connective tissues designed to withstand high tension and facilitate the lever action of the skeletal system.
D. A synovial joint is a complex functional unit where two bones articulate within a joint cavity, but the term refers to the entire joint apparatus. While it contains synovial fluid, the specific "fluid-filled capsule" described in the context of enabling specific gliding and flexibility is the bursa.
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