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 A

Explanation

A. Tenting of the skin is a classic sign of dehydration. When the skin is pinched and does not return quickly to its normal position, it indicates a lack of fluid in the body. This is a common finding in dehydration, particularly in older adults.
B. Loss of skin elasticity is a natural part of the aging process and may not be directly related to dehydration. It is common in older adults and is not necessarily an indicator of fluid status.
C. Warm and dry skin can be a sign of dehydration, particularly if accompanied by other symptoms such as a dry mouth or increased heart rate. Dry skin occurs when there is insufficient moisture in the body, which is common in dehydration.
D. Thinning hair in the lower extremities is more often associated with circulation issues or aging. It is not a typical sign of dehydration and would not be used as a primary indicator for assessing hydration status.

A. Sudden onset of severe anxiety, fear, and concern. B. Periumbilical pain localizing to right lower quadrant. C. Diffuse abdominal pain with elevated neutrophil count. D. Anorexia progressing to nausea, vomiting, and fever.

Correct Answer is B

Explanation

A. While anxiety and fear can accompany many medical conditions, they are not typically associated with appendicitis. Appendicitis is characterized by physical symptoms like pain and digestive disturbances rather than emotional symptoms.
B. Periumbilical pain that shifts to the right lower quadrant is the classic presentation of appendicitis. As the inflammation progresses, pain tends to move from the mid-abdomen to the lower right abdomen, which supports a diagnosis of appendicitis.
C. Diffuse abdominal pain is less specific and could indicate a variety of conditions. While an elevated neutrophil count can suggest infection or inflammation, the localized pain seen in appendicitis is a more distinguishing feature.
D. These symptoms are also common in appendicitis, as it typically presents with loss of appetite, nausea, and fever. However, the hallmark symptom is localized pain, particularly in the right lower quadrant, making B a stronger indication.

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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

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is B

Explanation

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