Which of the following nursing assessments would be the priority when considering the administration of pain medication to a client experiencing acute pain?

Shallow breathing

Blood pressure

Pain intensity level

Heart rate

Answer and Explanation

The Correct Answer is C

Choice A reason: Shallow breathing may indicate respiratory depression, a concern with opioids, but assessing pain intensity is the priority to determine the need for medication need. Pain level guides safe dosing, ensuring appropriate relief without overmedicating, making this a secondary assessment in acute pain.

Choice B reason: Blood pressure may rise with pain but is less specific than pain intensity for guiding medication administration. Pain level directly informs the need for and dose of analgesia, while blood pressure changes can have multiple causes, making this less critical.

Choice C reason

d): Assessing pain intensity level is the priority, as it quantifies the client’s subjective experience using a scale (e.g., 0-10 scale)), determining the need for and dose of pain medication. This ensures effective, patient-centered pain management, making it the most critical assessment before administering medication.

Choice D reason: Heart rate may increase with pain, but it is not the priority compared to pain intensity, which directly drives medication decisions. Heart rate changes are less specific and can result from other factors (e.g., anxiety), making this a secondary assessment in acute pain management.

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Correct Answer is C

Explanation

Choice A reason: Pain relieved by eating is not typical of appendicitis, which often worsens with food intake due to inflammation. This suggests a gastrointestinal issue like gastritis, making it incorrect for appendicitis.

Choice B reason: Pain radiating to the back is more associated with conditions like pancreatitis or aortic aneurysm. Appendicitis pain is localized or radiates to the right lower quadrant, making this incorrect.

Choice C reason: Pain at McBurney’s point (right lower quadrant, midway between umbilicus and iliac crest) is a classic appendicitis sign due to localized inflammation. This specificity makes it the correct finding.

Choice D reason: Pain worsened by deep breathing may occur in pleuritic or abdominal conditions but is not specific to appendicitis. McBurney’s point pain is more diagnostic, making this less indicative.

A. Blood pressure 148/92 B. Abdominal distention C. Tenting of the skin D. Heart rate 62 beats/min

Correct Answer is C

Explanation

Choice A reason: Blood pressure of 148/92 mmHg indicates hypertension, not directly related to prolonged diarrhea. Diarrhea causes fluid loss, leading to hypotension or normal blood pressure, not elevated readings, making this an unlikely finding for a patient with dehydration from diarrhea.

Choice B reason: Abdominal distention is less likely with diarrhea, which typically reduces bowel contents. Distention may occur in conditions like bowel obstruction, not fluid loss from diarrhea, making this an incorrect expected finding for this patient’s condition.

Choice C reason: Tenting of the skin, indicating poor skin turgor, is expected with prolonged diarrhea due to dehydration from fluid and electrolyte loss. This physical sign reflects reduced tissue hydration, making it a key assessment finding for a patient with ongoing diarrhea.

Choice D reason: A heart rate of 62 beats/min is normal and not expected in diarrhea, which causes tachycardia due to dehydration and compensatory sympathetic activation. A low or normal heart rate is inconsistent with fluid loss, making this an incorrect finding.

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Which of the following nursing assessments would be the priority when considering the administration of pain medication to a client experiencing acute pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports abdominal pain. Which of the following findings should the nurse identify as a possible indication of appendicitis?

Correct Answer is C

Explanation

The nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding should the nurse expect?

Correct Answer is C

Explanation

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