A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?

Onset of symptoms.

Methods to cope with stress.

Recent life changes.

Aggravating factors.

Answer and Explanation

The Correct Answer is A

A. Onset of symptoms: Determining when the symptoms began helps establish a timeline, differentiate between acute and chronic issues, and guide further assessment or intervention. This is essential for prioritizing care and identifying possible causes or patterns.

B. Methods to cope with stress: Exploring coping mechanisms is important in mental health assessment, but it is secondary to understanding the origin and duration of the client's current symptoms.

C. Recent life changes: Life events may contribute to mood and sleep disturbances, but the nurse first needs to know the timeline of the symptoms to interpret this information meaningfully.

D. Aggravating factors: Identifying what worsens symptoms is useful for management, but understanding when symptoms started lays the foundation for further focused questions and assessment.

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Correct Answer is ["A","C","E"]

Explanation

A. Tops of the ears: The tubing from a nasal cannula rests over the ears, and continuous pressure or friction in this area can lead to skin breakdown, especially in clients with fragile skin or prolonged use.

B.A standard nasal cannula does not cross or rest on the bridge of the nose. Pressure injuries at the bridge of the nose are typically caused by simple or non-rebreather oxygen masks, continuous positive airway pressure (CPAP) masks, or bilevel positive airway pressure (BiPAP) interfaces.

C. Around the nostrils: The prongs of the nasal cannula sit directly inside the nostrils and may cause irritation, dryness, or even minor ulceration from prolonged contact or high flow rates.

D. Across the forehead: The forehead is not typically in contact with nasal cannula equipment, so it is not a high-risk site for skin damage in this context.

E. After looping over the ears, the tubing runs down across the zygomatic arches (cheekbones) before connecting to the nasal prongs. If the client turns their head against a pillow or has localized facial edema, the tubing can press deeply into the cheeks, leaving indentations that can progress to tissue damage.

A. Review the pain medications prescribed B. Administer PRN oral pain medication. C. Monitor the client's nonverbal behavior. D. Ask the client what is causing the grimacing

Correct Answer is D

Explanation

A. Review the pain medications prescribed: Reviewing available medications is useful for planning, but it should follow a more direct exploration of the client's current discomfort and verbal input.

B. Administer PRN oral pain medication: Administering medication without the client reporting pain or confirming the need can be inappropriate, especially if the client denies discomfort. Further assessment is needed first.

C. Monitor the client's nonverbal behavior: Continued observation is important but passive. The nurse should actively seek clarification to determine if intervention is needed.

D. Ask the client what is causing the grimacing: This approach respects the client's autonomy and provides an opportunity to explore the cause of the discomfort. It helps clarify if the grimacing is due to pain or another issue, guiding appropriate next steps.

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A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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