The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

"What were you doing when you first noticed the problem?"

"Have you taken any medications to relieve the pain?"

"Does changing your position make the pain worse?"

"Do you remember ever having this type of pain in the past?"

Answer and Explanation

The Correct Answer is A

A.   Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B.   Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C.   Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D.   Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

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Correct Answer is D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

A. "Count backwards by 7, starting with 100." B. "What does, "The early bird catches the worm," mean?" C. "Has anyone come to visit you today?" D. "In what year were you born?"

Correct Answer is B

Explanation

A. This tests the client’s ability to perform mathematical tasks but does not specifically assess abstract
thinking. It is more of a concrete cognitive task.

B. This question assesses abstract thinking because it requires the client to interpret a proverb, which involves understanding symbolic meaning beyond the literal words.
C. This question is assessing more of the client’s orientation and memory rather than abstract thinking. It does not test higher-level cognitive abilities.
D. This is an orientation question, assessing the client’s ability to recall personal facts, but it does not
assess abstract reasoning skills.

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The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is D

Explanation

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Correct Answer is B

Explanation

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