A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST mnemonic?
Severity
Precipitating cause
Region
Quality
The Correct Answer is A
A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.
B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.
C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.
D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Pain level:
While assessing pain is important to determine the effectiveness of the pain management, it is not the immediate priority after administering an opioid.
B) Pulse oximetry:
Monitoring oxygen saturation is critical as opioids can depress respiratory function. However, it is indirectly related to the primary effect of the medication on the central nervous system.
C) Blood pressure:
Monitoring blood pressure is important as opioids can cause hypotension, but it is not as critical as monitoring the level of sedation and respiratory status.
D) Level of sedation:
This is the priority because opioids can cause significant sedation and respiratory depression. Assessing the level of sedation helps determine if the client is at risk of further complications like respiratory arrest. Over-sedation can be a precursor to more serious complications, making this assessment crucial.
Correct Answer is C
Explanation
A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.
B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.
C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.
D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.
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