Uhhcs Health Assessment And Pain Quiz (August)
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Questions and Answers
- 1.
Mr. Mohammed is a 83-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?
- A.
Alert and oriented to date, time, and place
- B.
Buccal cyanosis and capillary refill greater than 3 seconds
- C.
Clear breath sounds and nonproductive cough
- D.
Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3
Correct Answer
B. Buccal cyanosis and capillary refill greater than 3 secondsExplanation
Buccal cyanosis and capillary refill greater than 3 seconds are signs of poor oxygenation and circulation. In a patient diagnosed with pneumonia, these symptoms indicate a potential respiratory or cardiovascular compromise. This is of greatest concern to the nurse because it suggests that the patient's condition may be deteriorating and immediate intervention may be necessary to ensure adequate oxygenation and perfusion.Rate this question:
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- 2.
Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?
- A.
Acute pain
- B.
Chronic pain
- C.
Superficial pain
- D.
Deep pain
Correct Answer
D. Deep painExplanation
Deep pain refers to pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity. This type of pain is typically felt in the deeper tissues of the body, such as muscles, joints, or organs. It may be a result of injury, inflammation, or a medical condition. Unlike acute pain, which is sudden and short-lived, deep pain tends to be chronic and long-lasting.Rate this question:
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- 3.
A 49-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?
- A.
Telling the client to strictly limit the amount of movement of his inflamed joints
- B.
Teaching the client’s family how to transfer the client into a wheelchair
- C.
Teaching the client the proper method for massaging inflamed, sore joints
- D.
Encouraging gentle range-of-motion exercises after administering aspirin and before rising
Correct Answer
D. Encouraging gentle range-of-motion exercises after administering aspirin and before risingExplanation
Encouraging gentle range-of-motion exercises after administering aspirin and before rising is the most appropriate intervention for the 49-year-old widower with arthritis. This intervention helps to alleviate stiffness and pain in the joints by promoting blood circulation and maintaining joint flexibility. Administering aspirin before the exercises can also provide additional pain relief. It is important to note that strictly limiting movement of inflamed joints can lead to further stiffness and decreased mobility. Teaching the client's family how to transfer the client into a wheelchair or teaching the client to massage inflamed joints may not address the underlying issue of joint stiffness and pain.Rate this question:
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- 4.
In planning pain reduction interventions, which pain theory provides information most useful to nurses?
- A.
Specificity theory
- B.
Pattern theory
- C.
Gate-control theory
- D.
Central-control theory
Correct Answer
D. Central-control theoryExplanation
The central-control theory of pain provides the most useful information to nurses when planning pain reduction interventions. This theory suggests that pain is controlled by the central nervous system, specifically the brain and spinal cord. It emphasizes the role of psychological and cognitive factors in pain perception and modulation. Understanding this theory helps nurses in implementing interventions that target the central control of pain, such as cognitive-behavioral therapy, relaxation techniques, and distraction techniques. By addressing the central control of pain, nurses can effectively manage and reduce pain in their patients.Rate this question:
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- 5.
Mr. Al Katheeri, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a chronic pain center. Which evaluation criteria would indicate the client’s successful rehabilitation?
- A.
The client remains free of the aftermath phase of the pain experience.
- B.
The client experiences decreased frequency of acute pain episodes.
- C.
The client continues normal growth and development with intact support systems.
- D.
The client develops increased tolerance for severe pain in the future.
Correct Answer
C. The client continues normal growth and development with intact support systems.Explanation
The evaluation criteria that would indicate the client's successful rehabilitation is that the client continues normal growth and development with intact support systems. This means that despite the chronic pain, loss of self-esteem, and bodily disfigurement, the client is able to maintain a sense of normalcy in their life and has a strong support system in place. This indicates that they are able to cope with their pain, maintain their mental and emotional well-being, and continue to progress and thrive in their personal and professional life.Rate this question:
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- 6.
Ahmed, a 6-year-old boy, received a small paper cut on his finger, his mother let him wash it and apply small amount of antibacterial ointment and bandage. Then she let him watch TV and eat an orange. This is an example of which type of pain intervention?
- A.
Pharmacologic therapy
- B.
Environmental alteration
- C.
Control and distraction
- D.
Cutaneous stimulation
Correct Answer
C. Control and distractionExplanation
The mother's actions of allowing Ahmed to wash his finger, apply ointment and bandage, and then distracting him by letting him watch TV and eat an orange, are aimed at diverting his attention away from the pain and providing a sense of control over the situation. This intervention falls under the category of control and distraction, as it helps to alleviate pain by shifting focus and providing a sense of empowerment.Rate this question:
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- 7.
Physical assessment is being performed to Faisal by Nurse Jessy. During the abdominal examination, Jessy should perform the four physical examination techniques in which sequence?
- A.
Auscultation immediately after inspection and then percussion and palpation
- B.
Percussion, followed by inspection, auscultation, and palpation
- C.
Palpation of tender areas first and then inspection, percussion, and auscultation
- D.
Inspection and then palpation, percussion, and auscultation
Correct Answer
A. Auscultation immediately after inspection and then percussion and palpationExplanation
The correct answer is auscultation immediately after inspection and then percussion and palpation. This sequence is followed during abdominal examination because it allows the nurse to first visually assess the abdomen for any abnormalities or visible signs. After inspection, auscultation is performed to listen to the bowel sounds and identify any abnormal sounds. Following auscultation, percussion is done to assess the density of underlying organs and detect any areas of tenderness. Finally, palpation is performed to further assess for any masses, tenderness, or abnormalities. This sequence ensures a systematic and thorough assessment of the abdomen.Rate this question:
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- 8.
Abdullah has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
- A.
“What brought you to the clinic today?”
- B.
“Would you describe your overall health as good?”
- C.
“Do you understand what is happening?”
- D.
“Is there anything else you would like to tell me?”
Correct Answer
D. “Is there anything else you would like to tell me?”Explanation
The best way to end the history interview is by asking the patient if there is anything else they would like to tell the nurse. This allows the patient to share any additional information or concerns they may have that were not covered in the interview. It shows that the nurse is open to listening and ensures that the patient's needs are fully addressed.Rate this question:
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- 9.
Which assessment data should the nurse include when obtaining a review of body systems?
- A.
Brief statement about what brought the client to the health care provider
- B.
Client complaints of chest pain, dyspnea, or abdominal pain
- C.
Information about the client’s sexual performance and preference
- D.
The client’s name, address, age, and phone number
Correct Answer
B. Client complaints of chest pain, dyspnea, or abdominal painExplanation
The nurse should include client complaints of chest pain, dyspnea, or abdominal pain when obtaining a review of body systems because these symptoms can provide important information about the functioning of the cardiovascular, respiratory, and gastrointestinal systems. They may indicate potential issues such as heart disease, respiratory disorders, or gastrointestinal problems. By including these complaints in the assessment data, the nurse can gather relevant information to help identify any potential health concerns and provide appropriate care.Rate this question:
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- 10.
When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?
- A.
The client distracts himself during pain episodes.
- B.
The client denies the existence of any pain.
- C.
The client reports no need for family support.
- D.
The client reports pain reduction with decreased activity.
Correct Answer
A. The client distracts himself during pain episodes.Explanation
The behavior of distracting oneself during pain episodes indicates appropriate adaptation to pain. This suggests that the client is actively trying to cope with the pain by redirecting their attention and focusing on other activities or thoughts. This can help them manage their pain more effectively and prevent it from negatively impacting their daily functioning.Rate this question:
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- 11.
Nurse Jane is acquiring information from a client. Which is an example of biographic information that may be obtained during a health history?
- A.
The chief complaint
- B.
Past health status
- C.
History immunizations
- D.
Location of an advance directive
Correct Answer
D. Location of an advance directiveExplanation
During a health history, biographic information refers to personal details about the client. The location of an advance directive is an example of biographic information as it provides insight into the client's preferences for medical treatment in the event that they are unable to communicate their wishes. It is important for nurses to know the location of an advance directive to ensure that the client's wishes are respected and followed.Rate this question:
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- 12.
Abdul Salam is diagnosed with dehydration and underwent series of tests. Which laboratory result would warrant immediate intervention by the nurse?
- A.
Serum sodium level of 138 mEq/L
- B.
Serum potassium level of 3.1 mEq/L
- C.
Serum glucose level of 120 mg/dl
- D.
Serum creatinine level of 0.6 mg/100 ml
Correct Answer
B. Serum potassium level of 3.1 mEq/LExplanation
A serum potassium level of 3.1 mEq/L is considered low (hypokalemia). Hypokalemia can cause muscle weakness, fatigue, and cardiac arrhythmias, which can be life-threatening. Therefore, it would warrant immediate intervention by the nurse to prevent any potential complications.Rate this question:
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- 13.
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
- A.
Assessing the medial malleoli for pitting edema
- B.
Performing Allen’s test
- C.
Assessing the Homans’ sign
- D.
Palpating the pedal pulses
Correct Answer
D. Palpating the pedal pulsesExplanation
To assess arterial function in the lower extremities, the nurse should palpate the pedal pulses. Palpating the pedal pulses allows the nurse to evaluate the strength, rate, and regularity of the pulses, which can indicate the presence or absence of arterial blood flow. This intervention helps in detecting any abnormalities or signs of peripheral arterial disease. Assessing the medial malleoli for pitting edema, performing Allen's test, and assessing Homans' sign are not specific interventions for evaluating arterial function.Rate this question:
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- 14.
A 12-year-old, Fatima, fall off the stairs, grabs his wrist, and cries, “Oh, my wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?
- A.
Type A-delta fibers
- B.
Autonomic nerve fibers
- C.
Type C fibers
- D.
Somatic efferent fibers
Correct Answer
A. Type A-delta fibersExplanation
Based on the given information, Fatima is experiencing sharp pain in her wrist after falling off the stairs. This type of pain is typically caused by fast-conducting nerve fibers known as Type A-delta fibers. These fibers transmit sharp, localized pain sensations from the injured area to the spinal cord. Autonomic nerve fibers are responsible for regulating involuntary bodily functions and are not directly related to pain perception. Type C fibers are slow-conducting fibers that transmit dull, aching pain sensations. Somatic efferent fibers are responsible for transmitting motor signals from the spinal cord to the muscles and are not involved in pain perception.Rate this question:
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- 15.
Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?
- A.
Referring the client for hypnosis
- B.
Administering pain medication as prescribed
- C.
Removing all glaring lights and excessive noise
- D.
Using transcutaneous electric nerve stimulation
Correct Answer
D. Using transcutaneous electric nerve stimulationExplanation
Using transcutaneous electric nerve stimulation (TENS) is a nonpharmacologic pain-relief intervention for chronic pain. TENS involves the use of a small device that delivers low-voltage electrical currents to the skin through electrodes. These electrical currents stimulate the nerves and help to block pain signals from reaching the brain. TENS is a safe and effective method for managing chronic pain without the use of medication.Rate this question:
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- 16.
Nashreen, a 20 year old lady, should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?
- A.
One half of all breast cancer deaths occur in women ages 35 to 45
- B.
The tail of Spence area must be included in self-examination
- C.
The position of choice for the breast examination is supine
- D.
A pad should be placed under the opposite scapula of the breast being palpated
Correct Answer
B. The tail of Spence area must be included in self-examinationExplanation
The nurse should remember that the tail of Spence area must be included in self-examination. The tail of Spence is an extension of breast tissue into the axilla (armpit), and it is an important area to examine for any abnormalities or changes. Including this area in self-examination increases the chances of detecting any potential breast issues, including breast cancer. Therefore, it is crucial for Nashreen to be aware of this and include the tail of Spence area in her self-examination routine.Rate this question:
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- 17.
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
- A.
2 minutes
- B.
3 minutes
- C.
4 minutes
- D.
5 minutes
Correct Answer
D. 5 minutesExplanation
The nurse would notify the health care provider if the client had no bowel sounds for 5 minutes. This is because the absence of bowel sounds for an extended period of time may indicate a bowel obstruction or other serious gastrointestinal issue. It is important for the nurse to notify the healthcare provider so that appropriate interventions can be implemented to prevent further complications.Rate this question:
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- 18.
You are currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?
- A.
Pain is an objective sign of a more serious problem
- B.
Pain sensation is affected by a client’s anticipation of pain
- C.
Intractable pain may be relieved by treatment
- D.
Psychological factors rarely contribute to a client’s pain perception
Correct Answer
B. Pain sensation is affected by a client’s anticipation of painExplanation
The correct answer indicates that the individual understands the concept of pain because it recognizes that a client's anticipation of pain can have an impact on their pain sensation. This understanding aligns with the idea that psychological factors, such as anticipation and perception, can influence the experience of pain.Rate this question:
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- 19.
Saleh, who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?
- A.
Assessing the client to rule out possible complications secondary to surgery
- B.
Checking the client’s chart to determine when pain medication was last administered
- C.
Explaining to the client that the pain should not be this severe 3 days postoperatively
- D.
Obtaining an order for a stronger pain medication because the client’s pain has increased
Correct Answer
A. Assessing the client to rule out possible complications secondary to surgeryExplanation
The nurse should assess the client to rule out possible complications secondary to surgery as the first intervention. This is because the client's sharp, throbbing abdominal pain that ranks 8 on a scale of 1 to 10 could indicate a potential complication. By assessing the client, the nurse can gather more information about the pain, such as its location, intensity, and any associated symptoms, which can help identify if there is a complication that needs immediate attention. This assessment will guide further interventions and ensure the client's safety and well-being.Rate this question:
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- 20.
Abdella underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
- A.
Left hip dressing dry and intact
- B.
Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
- C.
Left leg in functional anatomic position
- D.
Left foot cold to touch; no palpable pedal pulse
Correct Answer
D. Left foot cold to touch; no palpable pedal pulseExplanation
The client underwent a surgical procedure on the left hip, and one day after the operation, they are complaining of pain. While the other data suggests stability and normal vital signs, the fact that the left foot is cold to touch and there is no palpable pedal pulse indicates a potential issue with circulation. This could be a sign of compromised blood flow to the foot, which is a serious concern and should be reported to the healthcare provider immediately.Rate this question:
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- 21.
Nurse Ryan is about to perform Romberg’s test to Hamood. To ensure the latter’s safety, which intervention should nurse Ryan implement?
- A.
Allowing the client to keep his eyes open
- B.
Having the client hold on to furniture
- C.
Letting the client spread his feet apart
- D.
Standing close to provide support
Correct Answer
D. Standing close to provide supportExplanation
Nurse Ryan should stand close to provide support during Romberg's test to ensure Hamood's safety. Romberg's test is a neurological examination that assesses a person's ability to maintain balance with their eyes closed. By standing close to Hamood, Nurse Ryan can quickly provide support if he starts to lose balance or fall. This intervention is important to prevent any potential injuries and ensure the safety of the client during the test.Rate this question:
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- 22.
Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?
- A.
These measures are more effective than analgesics.
- B.
These measures decrease input to large fibers.
- C.
These measures potentiate the effects of analgesics.
- D.
These measures block transmission of type C fiber impulses.
Correct Answer
C. These measures potentiate the effects of analgesics.Explanation
Noninvasive and non-pharmacologic pain-control measures can enhance the effectiveness of analgesics. By using these measures in conjunction with other pain-control measures, such as medication, the overall pain relief can be improved. This suggests that the noninvasive and non-pharmacologic measures have a synergistic effect with analgesics, making them more potent when used together.Rate this question:
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- 23.
During the nursing assessment, which data represent information concerning health beliefs?
- A.
Family role and relationship patterns
- B.
Educational level and financial status
- C.
Promotive, preventive, and restorative health practices
- D.
Use of prescribed and over-the-counter medications
Correct Answer
C. Promotive, preventive, and restorative health practicesExplanation
Promotive, preventive, and restorative health practices represent information concerning health beliefs during a nursing assessment. These practices indicate the individual's beliefs and actions towards maintaining and improving their health. Understanding a person's approach to promoting, preventing, and restoring health can provide valuable insights into their overall health beliefs and behaviors. Family role and relationship patterns, educational level and financial status, and use of medications may provide additional information about the individual's health, but they do not specifically address their health beliefs.Rate this question:
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- 24.
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?
- A.
Tipping the client’s head away from the examiner and pulling the ear up and back
- B.
Inserting the otoscope inferiorly into the distal portion of the external canal
- C.
Inserting the otoscope superiorly into the proximal two-thirds of the external canal
- D.
Bracing the examiner’s hand against the client’s head
Correct Answer
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canalExplanation
Inserting the otoscope superiorly into the proximal two-thirds of the external canal should be avoided during an otoscopic examination to prevent discomfort and injury to the client. This action can cause pain and potentially damage the delicate structures of the ear. It is important to insert the otoscope gently and carefully, following the natural curve of the ear canal.Rate this question:
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- 25.
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?
- A.
Aortic arch
- B.
Pulmonic area
- C.
Tricuspid area
- D.
Mitral area
Correct Answer
D. Mitral areaExplanation
The mitral area is the best area for auscultating the apical pulse. This is because the mitral area is located at the apex of the heart, where the mitral valve is located. The apical pulse is the pulsation felt at the apex of the heart, which corresponds to the mitral area. By auscultating the apical pulse in the mitral area, healthcare professionals can accurately assess the heart's function and detect any abnormalities or irregularities.Rate this question:
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- 26.
Majedah who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?
- A.
Referring the client for counseling and occupational therapy
- B.
Staying with the client as much as possible and building trust
- C.
Providing cutaneous stimulation and pharmacologic therapy
- D.
Providing distraction and guided imagery techniques
Correct Answer
A. Referring the client for counseling and occupational therapyExplanation
Referring the client for counseling and occupational therapy is the most appropriate intervention for Majedah. Since she is expressing concerns about job-performance abilities and physical disfigurement, counseling can help her address and cope with the emotional and psychological impact of her burns. Occupational therapy can assist her in regaining and improving her job-related skills and abilities, as well as providing support in adapting to any physical limitations or changes in appearance. This intervention focuses on both the psychological and practical aspects of Majedah's recovery, ensuring a holistic approach to her rehabilitation.Rate this question:
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- 27.
Which term would the nurse use to document pain at one site that is perceived in other site?
- A.
Referred pain
- B.
Phantom pain
- C.
Intractable pain
- D.
Aftermath of pain
Correct Answer
A. Referred painExplanation
Referred pain is the term used to describe pain that is perceived in a location different from the actual site of the injury or problem. This occurs because the nerves that carry pain signals from different areas of the body may share common pathways, causing the brain to interpret the pain as originating from a different location.Rate this question:
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- 28.
Salama was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?
- A.
Dullness
- B.
Resonance
- C.
Hyperresonance
- D.
Tympany
Correct Answer
B. ResonanceExplanation
When percussing the client's chest during a physical assessment, the nurse would expect to find resonance as a normal sign over the lungs. Resonance is the expected sound heard when percussing healthy lung tissue, indicating that the lungs are filled with air and functioning properly. Dullness may indicate consolidation or fluid in the lungs, hyperresonance may suggest hyperinflation or trapped air, and tympany may indicate air in the pleural space. Therefore, resonance is the expected normal finding during chest percussion.Rate this question:
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- 29.
Newly hired nurse Lara is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Lara to wear gloves?
- A.
Breast
- B.
Integumentary
- C.
Opthalmic
- D.
Oral
Correct Answer
D. OralExplanation
During an oral assessment, the nurse needs to wear gloves to maintain proper hygiene and prevent the transmission of any potential infections or diseases. This is because the oral cavity contains various microorganisms that can be easily transmitted through contact. Wearing gloves ensures the safety of both the nurse and the client during the examination.Rate this question:
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- 30.
Salem complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? (Select all that apply.)
- A.
Assessing the client’s bowel sounds
- B.
Taking the client’s blood pressure and apical pulse
- C.
Obtaining a pulse oximeter reading
- D.
Notifying the health care provider
- E.
Determining the last time the client received pain medication
- F.
Encouraging the client to turn, cough, and deep breathe
Correct Answer(s)
A. Assessing the client’s bowel sounds
B. Taking the client’s blood pressure and apical pulse
E. Determining the last time the client received pain medicationExplanation
The correct interventions to implement in this situation are assessing the client's bowel sounds, taking the client's blood pressure and apical pulse, and determining the last time the client received pain medication. These interventions are important in assessing the client's condition and determining the possible causes of the abdominal pain. Assessing bowel sounds can help identify any abnormalities in the gastrointestinal tract. Taking the client's blood pressure and apical pulse can provide information about the client's cardiovascular status. Determining the last time the client received pain medication is crucial in determining if the current pain is related to inadequate pain relief.Rate this question:
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