When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Numeric pain intensity scale.

Apical-radial pulse deficit.

Anteroposterior (AP) chest diameter.

Body temperature.

Answer and Explanation

The Correct Answer is A

A.   The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B.   An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C.   The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D.   Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.

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Correct Answer is A

Explanation

A. This open-ended question allows the client to describe the reason for their visit in their own words, which can provide a broad range of information about their current concerns or symptoms. It encourages the client to share specific issues or problems they are experiencing since the surgery, which could include pain, complications, or other concerns.
B. While this question is important for assessing one aspect of the client’s postoperative condition, it is somewhat narrow. It focuses specifically on pain, which is only one possible postoperative issue. This question does not capture other potential concerns such as functional problems, wound healing, or systemic symptoms.
C. Knowing the type of surgery is important for understanding the client’s medical background and specific postoperative considerations. However, this question may not provide immediate information about the client’s current condition or why they are seeking follow-up care.
D. This question helps establish a timeline and can be useful for understanding the postoperative phase and assessing healing progress. However, it does not directly address the client's current symptoms or concerns. Knowing the timing of the surgery alone does not provide comprehensive information about the client's present condition or reasons for the visit.

A. Shake and call the client's name. B. Press firmly on the center of the sternum. C. Use aromatic spirits of peppermint. D. Run a pointed object up the sale of foot.

Correct Answer is B

Explanation

A. Shaking the client and calling their name is generally used to assess responsiveness in clients who are not deeply unconscious but may be drowsy or semi-conscious. However, in clients with a marked reduction in LOC, this approach might not be effective because it does not provide sufficient stimulation to elicit a response from someone with significantly diminished consciousness.
B. Applying firm pressure to the center of the sternum (sternal rub) is an effective method for assessing a client's response to painful stimuli, especially when there is a marked reduction in LOC. This technique involves using the knuckles to rub or press firmly on the sternum, which provides a strong and potentially painful stimulus to evaluate the client's responsiveness.
C. Aromatic spirits of peppermint are used to stimulate a client's sense of smell but are not effective for assessing response to painful stimuli. This method is more suitable for clients who are semi-conscious and may respond to sensory stimulation but does not provide the level of stimulation needed for assessing deep unconsciousness.
D. Running a pointed object up the sole of the foot is a method used to test the plantar reflex (Babinski reflex) and is not typically used to assess a response to painful stimuli. This method might be useful in neurological assessments but does not provide sufficient stimulation to assess responsiveness in a client with a marked reduction in LOC.

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When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who recently underwent a routine surgical procedure made a dinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

Correct Answer is A

Explanation

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Correct Answer is B

Explanation

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