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 ["B","C","D","E"]
Explanation
A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.
B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.
C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.
D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.
E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.
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.
What subjective assessment information in this client situation is the most important and immediate concern for the nurse?