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A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve IX?

A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

When completing a neurological assessment, which cranial nerves are tested within the mouth?

A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

A nurse in an emergency department is caring for a client who has abdominal pain.

Nurses' Notes 

0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."

0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.

0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.

1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Diagnostic Results

0900:

Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.

A nurse is providing teaching to a client who has constipation. Which information should the nurse include? (Select all that apply.)

Which disorder is depicted in the image below?