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 B
Explanation
A. Prepare an incident report for risk management: While this is necessary, it’s not the priority action as it doesn’t directly address the immediate need for type and cross-matching.
B. Inform the provider of the delay in obtaining the type and cross-match: The nurse should inform the provider first to allow for any changes to the client's preoperative plan. Immediate notification is essential for any follow-up actions, as blood products might be required, or surgery could be rescheduled if the match is not completed.
C. Obtain the client's type and cross-match: This action would be appropriate if it had not already been ordered. Since the order exists, the provider should be informed of the delay first to guide further steps.
D. Document the incident in the client's medical record: Documentation is important but should occur after informing the provider and obtaining the blood work, as it does not directly address the current client care needs.
Correct Answer is C
Explanation
A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.
B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.
C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.
D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.