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 C

Explanation

A. The fifth intercostal space, midclavicular line, is the location for auscultating the mitral valve.
B. The third left intercostal space is typically used for the pulmonic valve.
C. The tricuspid valve is best auscultated at the left fourth intercostal space near the left sternal border.
D. The second right intercostal space is used to listen to the aortic valve.

A. Hematoma. B. Vesicle. C. Ecchymosis. D. Petechiae.

Correct Answer is D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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