The nurse is conducting a focused assessment of a client who is experiencing pain. Which question should the nurse ask the client?
When did your pain symptoms begin?"
"Do you think you know what caused the swelling?
"What brings you to the clinic today?"
"Can you go over what you said about nothing relieving the pain?
The Correct Answer is A
A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.
B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.
C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.
D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.
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Correct Answer is C
Explanation
A. Appendix: Located in the right lower quadrant, the appendix is unlikely to be impacted in left upper quadrant trauma.
B. Left ureter: The left ureter is located lower in the abdomen along the flank area and is not directly impacted in the left upper quadrant.
C. Left lobe of liver: The liver’s left lobe extends into the left upper quadrant, making it a likely organ to be impacted in blunt trauma to this area, particularly given its large size and location near the abdominal wall.
D. Sigmoid colon: Positioned lower in the left lower quadrant, the sigmoid colon is less likely to be affected by left upper abdominal trauma.
Correct Answer is A
Explanation
A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.
B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.
C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.
D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.