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">ExhibitsWhat subjective assessment information in this client situation is the most important and immediate concern for the nurse?
Belching
chest pain
Flatulence
Pain with position
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.
B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.
C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.
D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.
E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.
Correct Answer is D
Explanation
A. Flat: A flat abdomen is level with no visible protrusions or concavities.
B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.
C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.
D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.
What subjective assessment information in this client situation is the most important and immediate concern for the nurse?