The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

"What were you doing when the pain started?"

"How long has the pain lasted?"

"How would you describe the pain?"

"How has the pain affected your relationship with your spouse?"

"Can you rate the pain on a 0-10 scale with 10 being the worst?"

Answer and Explanation

Correct Answer : A,B,C,E

A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain.

B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction.

C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain.

D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary.

E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.

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Correct Answer is C

Explanation

A) Tinnitus: While tinnitus can be concerning, it is not a classic side effect of digoxin. It may indicate other issues such as hearing problems or medication interactions, but it does not typically warrant immediate communication with the healthcare provider in the context of digoxin use.

B) Constipation: Although constipation can occur in some patients taking digoxin, it is generally not considered a critical side effect that requires urgent attention. Patients are encouraged to manage this symptom through dietary changes or over-the-counter remedies unless it becomes severe.

C) Visual disturbances: Experiencing visual disturbances, such as seeing halos around lights or blurred vision, can be a sign of digoxin toxicity. Since these symptoms can indicate an elevated level of the drug in the bloodstream, it is crucial for the patient to contact their healthcare provider promptly to assess the situation and prevent further complications.

D) Vertigo: While vertigo can occur in various medical conditions and may be a side effect of other medications, it is not specifically linked to digoxin. If a patient experiences vertigo, they should monitor it but are not necessarily required to contact their healthcare provider immediately unless it is severe or persistent.

A. "You can take 81 mg of enteric coated aspirin with orange juice at lunch time B. "Take the aspirin with a glass of milk or food in the morning" C. "Take a baby aspirin with a full glass of cold water at bedtime." D. "It's ok to take the aspirin with some ginseng tea in the evening."

Correct Answer is B

Explanation

A) "You can take 81 mg of enteric coated aspirin with orange juice at lunch time": While enteric-coated aspirin can help reduce gastrointestinal irritation, taking it with orange juice is not advisable. Citrus can increase gastric acidity, which might irritate the GI tract further, especially in a patient with a history of GI bleeding.

B) "Take the aspirin with a glass of milk or food in the morning": This instruction is appropriate as taking aspirin with food or milk can help minimize gastrointestinal irritation and promote safer use, especially in a client with iron deficiency anemia from a GI bleed. It also helps with absorption and can reduce the risk of an upset stomach.

C) "Take a baby aspirin with a full glass of cold water at bedtime": Taking aspirin with only water, particularly at bedtime, may increase the risk of gastric irritation and does not provide the protective effect that food or milk would. This is not the best practice for someone with a history of GI issues.

D) "It's ok to take the aspirin with some ginseng tea in the evening": Ginseng can interact with blood-thinning medications and may increase bleeding risk. Advising the client to combine aspirin with ginseng tea could be harmful, especially given their history of GI bleeding. This is not a safe or appropriate recommendation.

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The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?

Correct Answer is C

Explanation

The nurse is caring for a client diagnosed with iron deficiency anemia as the result of a gastrointestinal (GI) bleed. What discharge instruction should the nurse provide if this client is also prescribed aspirin 81 mg daily?

Correct Answer is B

Explanation

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