Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

frequency

duration

location.

character

intensity

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   The frequency of pain is essential to understand how often the patient experiences pain.
B.   Duration refers to how long the pain lasts, which is an important characteristic to document.
C.   The location of pain helps determine its origin and the appropriate treatment approach.
D.   The character of the pain, such as sharp, dull, or aching, aids in identifying its nature and cause.
E.   The intensity of pain is crucial for assessing the effectiveness of pain management and guiding treatment decisions.

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Correct Answer is C

Explanation

A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.

A. allow the patient to sit on the side of the bed for a minute before standing. B. instruct the patient to use the wheelchair for all mobility activity. C. keep the patient in bed in a high Fowler's position D. help the patient to rise quickly and support the patient for a minute.

Correct Answer is A

Explanation

A. Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B. Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C. Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D. Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.

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Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

Correct Answer is C

Explanation

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

Correct Answer is A

Explanation

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

The nurse taking an apical pulse would place the stethoscope at:

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to: