A nurse is attending to a patient who is experiencing discomfort.
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Choice A rationale

While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.

Choice B rationale

If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.

Choice C rationale

Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.

Choice D rationale

Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.

Choice A rationale

A lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.

Choice B rationale

The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.

Choice C rationale

A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.

Choice D rationale

The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.