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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Disenfranchised grief:
Disenfranchised grief occurs when a person's loss is not socially recognized or supported, such as the death of a pet or an ex-spouse. The client's situation does not indicate disenfranchised grief.

B) Anticipatory grief:
Anticipatory grief happens before an impending loss, such as when a loved one is terminally ill. The client is grieving after the loss, not before it.

C) Prolonged grief:
Prolonged grief, also known as complicated grief, involves intense, persistent, and disabling grief symptoms that interfere with normal functioning. The client’s decreasing grief and positive outlook indicate that they are not experiencing prolonged grief.

D) Uncomplicated grief:
Uncomplicated grief, also known as normal grief, is the natural response to loss. It includes a range of emotions and reactions that typically diminish over time as the individual adapts to the loss. The client’s decreasing grief severity and forward-looking attitude towards spending time with their grandchildren are characteristic of uncomplicated grief.

A. Chronic drainage of fluid through the incision site B. Report by patient that something has given way C. Drainage that is odorous and purulent D. Protrusion of visceral organs through a wound opening

Correct Answer is B

Explanation

A. Chronic drainage of fluid through the incision site:
While chronic drainage of fluid through the incision site can be a sign of wound complications, such as infection or poor wound healing, it is not as specific an indicator of impending wound dehiscence as the patient's report of "something giving way."

B. Report by patient that something has given way:
A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.

C. Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.

D. Protrusion of visceral organs through a wound opening:
Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence

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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?

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Correct Answer is D

Explanation

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

Correct Answer is B

Explanation

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