The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Ask the client if he took any pain medication at home.

Observe for nonverbal signs to measure pain intensity.

Use a standard pain assessment questionnaire and scale.

Collect a urine sample and strain for granules or calculi.

Answer and Explanation

The Correct Answer is D

A.   While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B.   Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C.   Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D.   The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

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Correct Answer is ["B","C","D"]

Explanation

A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.

A. Hernia. B. Aneurysm. C. Tympany. D. Appendicitis.

Correct Answer is B

Explanation

A. A hernia may present as a bulge in the abdomen, but it is not typically pulsating. It is usually a soft, non-pulsatile mass.
B. A pulsating centrally localized abdominal distention is characteristic of an abdominal aneurysm, which occurs when the wall of the aorta weakens and bulges. The pulsation is often palpable and can be dangerous if ruptured.
C. Tympany refers to a sound produced during percussion, which is typically heard over air-filled structures like the stomach, but it doesn’t cause pulsating distention.
D. Appendicitis typically presents with localized pain in the lower right abdomen and is not associated with pulsating abdominal distention.

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The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

Correct Answer is B

Explanation

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