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","E"]

Explanation

A. Documenting the roaring and crackles is important to note any abnormal findings. However, this does not directly mitigate artifacts, which may interfere with the accuracy of the sounds heard through auscultation.
B. Wetting the chest hair is a useful technique to reduce the sound interference caused by chest hair rubbing against the stethoscope. This helps eliminate some of the unwanted sounds and improves the clarity of auscultation.
C. Ensuring the room is warm and the stethoscope is warmed before use is important because cold stethoscopes can cause discomfort to the client and may lead to muscle tensing, making it harder to hear clear heart and lung sounds.
D. Reaching under the gown ensures that no clothing creates friction on the stethoscope, which can produce unwanted sounds during auscultation. This helps in obtaining clear and accurate heart or lung sounds.
E. A quiet environment is crucial for auscultation, as background noise can obscure important sounds. Ensuring that the room is free from distractions and noise will significantly improve the quality of auscultation.

A. Manipulate the testicles upon rising. B. Inspect the testicles using a mirror. C. Examine the testicles during bathing. D. Compare both testicles concurrently.

Correct Answer is C

Explanation

A. Manipulating the testicles upon rising is not a recommended time for TSE and could lead to unnecessary manipulation that doesn't focus on examination.
B. Inspecting the testicles using a mirror is not as effective as feeling for lumps and abnormalities through touch.
C. It is ideal to perform testicular self-examination during bathing, as the warm water relaxes the scrotal skin and makes it easier to detect any lumps or changes in texture.
D. Comparing both testicles concurrently is important, but the technique is not as effective when done without the warmth of a bath or shower.

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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

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

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

Explanation

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

Correct Answer is C

Explanation

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