The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

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

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

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

"Does changing your position make the pain worse?

Answer and Explanation

The Correct Answer is A

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

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

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

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

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

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

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Correct Answer is D

Explanation

A. Blood urea nitrogen (BUN): Elevated BUN can indicate kidney problems, but it's not the primary test for melena (black, tarry stools) which suggests upper gastrointestinal bleeding.

B. Glucose: Glucose levels might be abnormal in some conditions that can cause bleeding, but it's not the most specific test for melena.

C. White blood cell count (WBC): WBC might be elevated in response to infection or inflammation, but it's not the most specific test for melena.

D. Hematocrit: Hematocrit measures the percentage of red blood cells in the blood. Melena can indicate significant blood loss, and monitoring hematocrit helps assess the severity of bleeding and potential need for blood transfusions.

A. Determine the client's most recent hemoglobin level. B. Document the presence of nailbed clubbing. C. Administer a PRN prescription for oxygen. D. Consult with a podiatrist to trim the client's toenails.

Correct Answer is B

Explanation

A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

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The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is D

Explanation

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Correct Answer is B

Explanation

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