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The nurse is caring for a 33-year-old male client who has visited the primary healthcare provider for several months stating that he is experiencing "heartburn" after lunch and dinner. He reports that these episodes last about an hour after eating, and are much worse if he lays down to sleep after a meal. Most of the time, he also experiences belching and bloating with "heartburn" that feels like chest pain. He has been taking over-the-counter antacids with minimal relief. He says that his wife sent him today because she was getting concerned about the number of antacids he has been using. Reading the electronic health record, the nurse notes:
id="exhibits">Exhibits

What subjective assessment information in this client situation is the most important and immediate concern for the nurse?

Belching

chest pain

Flatulence

Pain with position

Answer and Explanation

The Correct Answer is B

A. Belching: Belching is a common symptom associated with GERD or indigestion, but it is not as critical as chest pain.

B. Chest pain: Chest pain is the priority because it can sometimes be a sign of serious conditions, such as gastroesophageal reflux disease (GERD) mimicking angina, or even cardiac issues. This must be ruled out before considering other symptoms.

C. Flatulence: This is also a typical symptom with digestive issues but does not present an immediate concern compared to chest pain.

D. Pain with position: Although positional pain is common with GERD, it does not warrant immediate concern like chest pain, which could indicate a potential cardiac issue.

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Correct Answer is A

Explanation

A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.

B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.

C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.

D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.

A. Positive skin hypersensitivity test. B. Positive Rovsing sign. C. Psoas sign. D. Positive Obturator sign.

Correct Answer is B

Explanation

A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.

B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.

C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.

D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.

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Naxlex Comprehensive Predictor Exams

The nurse is conducting a focused assessment of a client who is experiencing pain. Which question should the nurse ask the client?

Correct Answer is A

Explanation

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Correct Answer is B

Explanation

The nurse receives the primary provider's order of phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer. (Round to the nearest whole number)

A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

The absence of bowel sounds is established after listening for:

Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?

A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)