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

When did your pain symptoms begin?"

"Do you think you know what caused the swelling?

"What brings you to the clinic today?"

"Can you go over what you said about nothing relieving the pain?

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

A. Postural hypotension: Postural hypotension (a drop-in blood pressure when moving to a standing position) is a common sign of extracellular fluid volume deficit due to decreased circulating blood volume.

B. Dependent edema: This occurs with fluid volume excess, not deficit, due to fluid accumulation in tissues.

C. Bradycardia: Fluid volume deficit often leads to tachycardia as the body compensates for low blood volume, rather than a slow heart rate.

D. Distended neck veins: Distended neck veins suggest fluid overload, not a fluid deficit.

A. 2 full minutes. B. 1 full minute. C. 5 full mutes. D. 1 1/2 minutes.

Correct Answer is C

Explanation

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

The absence of bowel sounds is established after listening for:

Correct Answer is C

Explanation

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