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 A
Explanation
A. "You must feel frustrated." This response is therapeutic and validates the nurse’s feelings, encouraging the nurse to open up about their frustration without feeling judged or defensive.
B. "Why do you feel upset about this?": Asking “why” may make the nurse defensive and feel as though they need to justify their feelings.
C. "You should be working harder.": This is unsupportive and could worsen the nurse’s frustration, possibly making them feel criticized or undervalued.
D. "I will reprimand your team members.": This response is reactive and could disrupt team dynamics without addressing the underlying issue. It does not support open communication.
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.