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 C

Explanation

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. While trapped air can be absorbed, crepitus can indicate underlying issues such as a pneumothorax or other trauma, so it should not be dismissed as insignificant.

B. Since this client has only a small area of crepitus, it probably is not a significant finding. The size of the area does not necessarily correlate with the severity of the underlying condition. Even a small area of crepitus should be investigated.

C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. This is the most accurate interpretation. Crepitus indicates the presence of air in the subcutaneous tissues, which is always abnormal and warrants further investigation.

D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately. While a chest x-ray can be part of the assessment, stating that a fractured rib "often" creates crepitus might be misleading. Crepitus can arise from other conditions, and a thorough assessment is needed before determining the exact cause.

A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. B. Instruct the PN to measure the client's waist circumference every 8 hours to assess for changes. C. Tell the PN that this assessment technique should be performed by the nurse. D. Review the measurement obtained by the PN and compare with ideal measurements for this client.

Correct Answer is D

Explanation

A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. Waist circumference is actually a valuable measure for assessing abdominal obesity, which is an important factor in health, independent of BMI. It helps screen for health risks related to overweight and obesity, such as heart disease and type 2 diabetes. Therefore, this option is incorrect.

B. Instruct the PN to measure the client’s waist circumference every 8 hours to assess for changes. Measuring waist circumference does not require frequent assessments like every 8 hours. It’s a simple and inexpensive measurement that provides valuable information about abdominal fat distribution. However, such frequent measurements are unnecessary and impractical for assessing obesity-related risks.

C. Tell the PN that this assessment technique should be performed by the nurse. Waist circumference measurements can be performed by practical nurses (PNs) and other healthcare providers. It’s a straightforward technique that doesn’t require specialized training. Therefore, this option is incorrect.

D. Review the measurement obtained by the PN and compare with ideal measurements for this client. This is the most appropriate action. The nurse should review the PNs measurement of the client’s waist circumference and compare it to established guidelines. Generally, a waist circumference greater than 35 inches for women or greater than 40 inches for men indicates increased risk of obesity-related health problems.

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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

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

Correct Answer is C

Explanation

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

Correct Answer is D

Explanation

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