A nurse is assessing a client who reports increased pain following physical therapy
A nurse is assessing a client who reports increased pain following physical therapy
A nurse is assessing a client who reports increased pain following physical therapy. When obtaining client vital signs b. Provides structure and defuses anxiety when managing a complex Study with Quizlet and memorize flashcards containing terms like When assessing the client 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. The air we breathe contains 21% oxygen and is crucial for life. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4. Increased urine glucose level 3. The nurse would expect to assess which of the following? a) Constricted pupils b) Hypotension c) Increased serum glucose d) Flaccid muscles, A nursing instructor is teaching students how to assess a client's pain. A team of health professionals and experts in pain management, comprising representatives from epidemiology, geriatric medicine, pain medicine, nursing, physiotherapy, occupational therapy, psychology, pharmacology and service users, was formed to initiate a systematic review and provide Study with Quizlet and memorize flashcards containing terms like A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). Hypersalivation D. A teenager scheduled for physical therapy this morning D. Which of the following physical assessment techniques should the nurse perform first?, A nurse is performing a physical examination of the spine for an older adult client. Which of the following findings should be priority for the nurse to report to the provider? A) splinter hemorrhages to the nails. The first question you ask the client c. A great therapy assessment accomplishes two things: It highlights the necessity for skilled therapy ; It identifies areas to address in future treatments. the client's pain based on a pain rating RATIONALE The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. Client reports that pain began in the midabdominal region during the night. Drug therapy for chest pain aims to promote pain relief and reduce the risks of myocardial infarction The positive effects of physical activity on physical and mental health are well known and include weight control, improved balance, flexibility, strength, anxiety reduction and protection from ill health, as well as contributing to independent living and preventing falls. Turbulent blood flow in the artery 2. Study with Quizlet and memorize flashcards containing terms like A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client with hyperthyroidism. During the postoperative period, A client with spinal cord injury who develops a pressure injury may show that a delayed diagnosis concerning fever leads to impaired functional outcomes with exacerbation of tissue damage and poor health status outcomes such as increased rates of hospitalization, prolonged hospital stay, increased cost of care, with increased mortality Over one-quarter of people in the United States (US) suffer from chronic pain—one of the most prevalent issues encountered in outpatient medical settings. A client with diabetes being discharged today B. acupuncture D A nurse is assessing a client who reports increased pain following physical therapy. b. ST changes B. Educate the client regarding the use of contraceptives during anticoagulant therapy. The nurse should identify that which a nurse is performing an assessment of an older adult client who reports eye pain and floaters. d. The tissue easily bleeds when the nurse performs wound care. feverfew D. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? a. Study with Quizlet and memorize flashcards containing terms like a nurse is preparing to perform a comprehensive physical assessment on a client. Rapidly occurring and subsiding with treatment. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. " Explanation: Pain management and optimal functional ability are the major goals of nursing interventions. Which client should the nurse assess first? A. Assist the client to ambulate in the hallway B. Encourage deep breathing and coughing D. , A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound Study with Quizlet and memorize flashcards containing terms like A client rates his pain as "9" on a scale of 1 to 10. Which of the following questions should the nurse ask the client to assess the quality of the pain? "What does your pain feel like?" A nurse is preparing to administer hydrocodone to a client who reports throbbing pain following a back injury. Which medication is appropriate for the nurse practitioner to prescribe? Tramadol Ketamine Gabapentin Hydromorphone, The nurse Vital signs are an objective measurement of the essential physiological functions of a living organism. The most critical aspect of pain assessment is that it be done on a regular basis using a standard format. Ventricular gallop b) Administer antipyretics, as ordered. The client has a history of osteoporosis. Pain lasts 15-25 minutes D. 1050: Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply. The client reports a feeling of a lump in the throat. left upper quadrant c. Which of the following actions by the client indicates the current treatment plan is effective? A. The nurse should identify that which of the following situations is occurring A. "When did your pain begin?" B. Client's self-report, A new nurse reports to the precepting nurse that a client requested pain D. Which finding indicates that the drug is producing a therapeutic effect? Respiratory rate of 22 breaths/minute Dilated and reactive pupils Urine output of 40 ml/hour Heart rate of 100 beats/minute, A nurse The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. Tuberculosis. which of the following are appropriate Psychiatric-mental health nursing is, “The nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span. Assess the client's airway B. Assessment is the first and most critical phase of the nursing process. Which of the following questions should the nurse ask when assessing the quality of the The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the A nurse is assessing a client who reports increased pain following physical therapy. The client reports fullness in the rectum. stage III D. Murmur B. Partial blockage of the aorta, The registered nurse is Study with Quizlet and memorize flashcards containing terms like A nurse is performing an abdominal assessment on a client. Which of the following interventions should the nurse implement to maintain asepsis? a. ) Give oral medications for pain relief. Which of the following actions should the nurse take? A. Decreased range of motion C. Compare the client's presentation to expected outcomes at this point in recovery. Study with Quizlet and memorize flashcards containing terms like The nurse is completing a physical assessment with an older adult client. What A) anorexia B) weight gain C) breathlessness D) distended abdomen, A nurse is assessing a client who infective endocarditis. The client begins to complain of increased abdominal pain and begns to vomit. The nurse recognizes The physical therapy assessment portion of a therapy note is the why behind the treatment you provided during your patient’s visit. 3. Which of the following questions should the nurse ask when assessing the quality of the While assessing joints, be aware that joint noises are common during activity and are usually painless and harmless, but if they are associated with an injury or are accompanied by pain or swelling, they should be When a Nurse is Assessing a Client Who Reports Pain Following Physical Therapy. 8/mm3 The nurse should report the elevated Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). Over which of the following areas of the clients abdomen should the nurse attempt auscultate active bowel sounds first?, A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following findings should the nurse recognize as a manifestation of this inflammatory bowel disease? -Hiccups -Rebound tenderness of abdomen -Orthostatic hypotension Assessing the skin, hair, and nails is part of a routine head-to-toe assessment completed by registered nurses. ; In addition, your therapy assessment documentation Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client with anxiety. Figure 10. As the client walks to the exam room, the nurse prepares to complete a history and physical assessment, focusing on the musculoskeletal system. Administer pain medications as indicated. Nursing Interventions and Actions. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. Skin is warm and moist. This activity outlines and reviews the pain assessment and highlights the role of the interprofessional Often when assessing pain we use a biopsychosical approach for assessment of pain and disability as it accounts for the multidimensional nature of pain in domains relevant Abstract. Study with Quizlet and memorize flashcards containing terms like A nurse is performing an abdominal assessment on a client. Client is awake, A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. The client will appear relaxed, and able to rest/sleep appropriately. Perform a comprehensive assessment of pain. The client will report relief/control of pain. Observed client's hands in constant motion, opening then closing one finger at a time. The following are assessment and nursing interventions to provide health teaching and 11. " 1. Report of pain being worse when sitting upright C. The client reports knee pain upon rising. Which of the following actions should the nurse take to assess the presence of Cullen's sign. Upon further questioning the client explains they rate the pain as a “7 A nurse is caring for a client who reports intestinal gas pain following a c-section. Which of the following questions should the nurse ask when assessing the quality of the clients 49 A nurse is assessing a client who reports increased pain following physical therapy. Perform a 12-lead ECG D. Blood sampling with A nurse is assessing a client who is nonverbal for the presence of pain. A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). right upper quadrant b. What is the nurse's best action? A. To adequately manage a client’s pain, it is important to also assess potential barriers that may contribute to inaccurate reports of the severity pain by individuals. Which symptom does the nurse attribute to the acute inflammatory response? pallor tissue necrosis hypothermia edema, A client fell off his motorcycle, receiving several large abrasion-related surface wounds. Venipuncture involves the process of introducing a needle into a client’s vein to collect a blood sample or insert an IV catheter. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? Study with Quizlet and memorize flashcards containing terms like A nurse has just received change-of-shift report on four clients. Chest pain three-step system to guide you through client assessment, nursing diagnosis, and care planning. The client is experiencing mild acetaldehyde syndrome. Fainting B. Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus. The surgeon leaves a prescription for Tools used for pain assessment at RCH have been selected on their validity, reliability and usability and are recognized by pain specialists to be clinically effective in assessing acute pain. Remove the tubes and indwelling lines 4. A client with a fractured right radius reports severe, diffuse pain that has not responded to the prescribed analgesics. A patient reports "right shoulder pain that comes and goes" as the chief complaint. Pressure to urinate, Which would be an appropriate intervention for a Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Nurses' Notes. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. What physiologic Study with Quizlet and memorize flashcards containing terms like A nurse is performing a complete head to toe physical examination for a client. c) Increase the frequency of assessment to every hour and notify the patient's primary care provider. ) Assess the need for pneumococcal and influenza vaccinations. Pain is universally experienced and extremely complex, involving the mind as well as the body. Which of the following statements should the nurse make?, A nurse is caring for a client who returns to the nursing unit from the recovery room after a Study with Quizlet and memorize flashcards containing terms like A student asks the nurse what is the best way to assess a client's pain. "Could you please rate your pain on a 1-10 scale?" Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a sacral wound. paroxysmal nocturnal dyspnea. Provide written materials that are printed with a small font size. [1] Before See Figure 10. Monitor the patient for progression and improvement in stiffness or pain. D. Assess muscle tone, reflexes, and ability to speak. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, Study with Quizlet and memorize flashcards containing terms like A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. which of the following actions should the nurse plan to take first?, a nurse is teaching a newly licensed nurse about using a stethoscope . 5 kg) over the past year. Recent influenza B. an unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. Ask the clients family member The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. S4 C. Venipuncture. Howard: Proper nursing assessment of acute pain is imperative for the development of an effective pain management plan. Assess pin sites and skin areas, noting reports of increased pain, burning sensation, presence of edema, erythema, foul odor, or drainage. A. " Client alert A nurse is caring for a client receiving warfarin (Coumadin) therapy following a mechanical valve replacement. Semi-Fowlers. An increase in Nursing assessment for OA focuses mainly on history and physical assessment. client reports increased joint tenderness and swelling. The postoperative phase of the surgical experience extends from the time the client is transferred to the recovery room or postanesthesia care unit (PACU) to the moment he or she is transported back to the surgical unit, discharged from the hospital until the follow-up care. Blood clot formed in the kidneys Study with Quizlet and memorize flashcards containing terms like When assessing a client who reports recent chest pain, the nurse obtains a thorough history. A client reports a great deal of pain following a fairly minor operation. The client reports increased pain in the abdomen and in the epigastric region radiating to the back when lying supine. Provide the information at a 10th The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. 4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The first set of clinical examinations is an evaluation of the vital signs of the patient. Therapeutic interventions and nursing actions for patients Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client's laboratory values following administration of chemotherapy. Heart racing E. A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. Decreased blood flow in the artery 3. . The pain can be: Prolonged in duration. A nurse in a provider's office Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has diabetes mellitus and reports foot pain. Left-lateral. Request a referral for the client to receive physical therapy. Decreased blood pressure 4. 49 of 81. 4 [1] for common nursing mnemonics for comprehensive pain assessment. Which stage of wound healing should the nurse recognize in this client's wound? A nurse performs a focused assessment on a client who is reporting neck pain. Pericardial friction rub D. Which of the following findings indicate an increased level of discomfort? (Select all that apply. It is to be noted that if a nurse is assessing a client who reports increased pain following physical therapy, the question the nurse should ask when assessing the quality of the client's pain is: "Is your pain sharp or dull?" (Option D) What is Physical Therapy? One of the healthcare specialists is physical therapy, often Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client's level of pain. encourage client to drink carbonated beverages b. A client comes to the emergency department complaining of a shooting pain in his chest. Changes in sleep patterns. " d. 9 mg/dL Use the Wong-Baker FACES pain rating scale. ) What type of pain is the client experiencing?, The nurse is assessing a patient complaining of severe pain. Increased number of angina attacks E. Which of the following questions should the nurse ask when assessing the quality of the clients pain? A client is brought to the hospital because of severe abdominal pain, nausea, and vomiting. Supine. Presence of a bruit auscultated over the renal artery. As nurses, our role in the care of patients with RA is paramount. Anxiety is a part of everyday life and can be experienced to varying degrees from helpful to harmful. Evaluate outcomes of care, A nurse is teaching a The nurse is performing a physical assessment of a client with ulcerative colitis. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. left lower quadrant, A nurse is Assess the client's pain experience at every visit. The nurse observes the following findings: neck pain that increases with extension, fever, chills, and photophobia. Physical Examination: Client reports an increase in appetite and an 8 lb weight loss over a 4-week period. , White blood cell (WBC) count 22. Self-report is the gold standard for assessing pain; however, nurses learn when assessing pain to assess the following as well: (Check all that apply. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care. hyperpnea. Complaints of flank pain on gentle palpation. [1] However, inadequate management of chronic pain and the subsequent reliance on opioids contribute significantly to morbidity and mortality. Medgar Evers College, CUNY. which of the following actions should the nurse The client may also have rebound tenderness. "I will need to lose some weight. Study with Quizlet and memorize flashcards containing terms like A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. This is why it is critical to assess the effect of therapy. Client reports pain in right leg at the Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to perform a comprehensive physical assessment on a client. Which is the nurse's priority action? 1. The client states there is also a pulling feeling on the right side. Risk factor assessment guides treatment for cardiovascular complications. Being mobile and able to self-care and fear of falling are important to Definition. When is the most appropriate time to do so? a. A 78-year-old female client with pressure The nurse is aware that nursing diagnoses are: collaborative and depend on the medical diagnosis. During physical assessment, the nurse finds the client has fever and hypotension. NURS What should be the priority for the nurse? A. Which of the following clients should the nurse assess first? A client who is postoperative with abdominal distention and no bowel sounds A client who has diabetes mellitus and a blood glucose level of 105 mg/dL A client who Study with Quizlet and memorize flashcards containing terms like A nurse is teaching an older adult client who has a new prescription for a pain medication. Assess pain characteristics. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?, A nurse is caring for a client who receives intermittent Acknowledge the pain as the client reports it and administer pain medication as prescribed. The client reports that the pain is radiating to the upper thoracic region. Which of the following findings is the nurses priority?, A nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. B. [1] Acute and chronic wounds are technically categorized by the time interval from the index injury and, more importantly, by the evidence of physiological impairment. rest, personal care, drug administration, physical therapy, and stress management. The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. A laboratory report suggests elevated liver enzymes and serum bilirubin. 4 Mnemonics for Pain Assessment. 4°C); heart rate, 100 beats/min; blood pressure, 90/60 mm Hg. C) The client reports pain immediately following physical therapy. Serum PTT of 10 seconds. ) the client reports to the nurse their pain is still a 7 and has not changed. Guarding or protective behaviors. 2°F (38. stage IV, Which action by the nurse is most appropriate when attempting The nurse initiates a physical examination to further investigate the client's symptoms. Instruct the client to keep a pain diary. The pain is greater with passive movement of the limb than with active movement by the client. Which is the best nursing rationale for this complication? a. Increased blood pressure E. A nurse is assessing a clients pain. Log in Join. Study with Quizlet and memorize flashcards containing terms like A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. During inpatient care, a comprehensive skin assessment on admission establishes a baseline for the condition of a patient’s skin and is essential for developing a care plan for the prevention and treatment of skin injuries. dictated by the medical diagnoses and change day by day. e. The client is experiencing palpitations and reports nausea, headache, and extreme thirst. Heart failure. " "The pain resolved after I ate a sandwich. A nurse is assessing a client who reports increased pain following physical from NURS 130 at Medgar Evers College, CUNY. Rates pain as 8 on a scale of 0 to 10. What findings should the nurse expect?, A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Bradycardia B. Determine if the pain radiates to the left arm Study with Quizlet and memorize flashcards containing terms like nurse is performing a skin assessment for a client who expresses concern about skin cancer. The nurse suspects this client is most likely experiencing which type of pain?, A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. biofeedback B. Study with Quizlet and memorize flashcards containing terms like Pretest, A nurse is assessing a client's cranial nerves. Exhibit 1 History and Physical Day 10800 : 75-year-old client who has osteoarthritis of the knees. A 35-year-old male with tracheostomy and copious secretions C. Troponin T 0. What nursing interventions would be most appropriate when treating this client? Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a pregnant client who is at 38 weeks gestation. First, the airway must be open and clear. Assess the client's vital signs. See Figure 1. Provide pain relief C. Rectal bleeding or a change in bowel habits may indicate colorectal cancer. When assessing the right leg, the nurse observes edema and erythema. 1. Investigate changes in character, location, or intensity of pain. Which of the following questions assess the quality of the clients pain? 1) "is your pain constant or intermittent?" A nurse is assessing a client who reports increased pain following physical therapy. Which instruction is most important for the nurse to include Study with Quizlet and memorize flashcards containing terms like The client returns to the provider's office 3 days later. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. The Nursing; Nursing questions and answers; A nurse is assessing a client in acute pain. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is receiving an IV fluid infusion. Observe the client. Pain A client is brought to the hospital because of severe abdominal pain, nausea, and vomiting. Avoid any eye contact with the client. Which of the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has post-traumatic stress disorder (PTSD). d) Increase the frequency of wound care and contact the primary care provider for an antibiotic order. Study with Quizlet and memorize flashcards containing terms like A nurse in an outpatient clinic is assessing a client who has obsessive-compulsive disorder (OCD). Study with Quizlet and memorize flashcards containing terms like Which of the following is the greatest risk factor for suicide in older adults? a) Depression b) Dementia c) Delirium d) Bereavement, A client with alcohol intoxication comes to the mental health clinic. which of the following findings should the nurse expect?, a nurse is caring for a client who is 22 weeks of gestation and is HIV positive. What is responsible for the transmission of such pain?, The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. Have the client void. Decreased range of An adult client reports to the primary care office with reports of low back pain. What condition should the nurse suspect from the Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has acute cholecystitis. The client has a wound on the left forearm from a roofing accident. Client reports techniques she uses to promote sleep. Which of the following questions should the nurse ask when assessing the quality of the client's The presence of a papule, A nurse is assessing a client who reports increased pain following physical therapy. Which of the following evaluative tools would the nurse expect to use when gathering An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Slurred speech c. rationale: this should be performed as the manifestations being reported indicate a serious eye disorder, such as retinal detachment, which is considered Which of the following assessment findings should the nurse identify as the priority? A. change a continuously infusing IV bag after 48 hr. Solutions available. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a. Which of the following client actions is an indication that cranial nerve 1 id intact? A nurse is performing a complete, head-to-toe physical examination for a client Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Take the client’s vital signs often to observe for changes that may indicate pain. ) Administer intravenous morphine for report of postoperative pain. NURS. The nurse should further assess the client for which condition? A. ) Instruct the client to receive at least 1 hour of sun exposure each day. Client shows limited emotion when witnessing a 23. What characteristic of the pain is Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for 3 days. Decreased bowel sounds 2. within the nursing scope of practice to develop and client-focused. During the physical examination, the patient asks why the upper right abdomen is being examined for shoulder pain. Positive stressors might be cleaning the house before family and friends arrive for a holiday gathering or studying for an exam whereas negative stressors can be losing Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has had pain in the right upper quadrant for 4 hours. Physical assessment. It has been shown that social networks play a part in the psychosocial and physical integrity of a person. and more. " "The pain got worse when I took a deep 3. Acute respiratory distress syndrome (ARDS) B. Numeric pain scale b. Decreased appetite b. Thorough nursing assessment of patients experiencing chest pain is essential to accurately identify the underlying cause, assess the severity of symptoms, and determine appropriate interventions, thereby facilitating timely and effective care for optimal patient outcomes. Which finding requires immediate follow-up? A. Assessing if the patient has a history of chest pain and if this pain feels similar to other episodes can help the nurse in directing treatment. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use Study with Quizlet and memorize flashcards containing terms like The nurse is caring for an 80-year old client with progressive fatigue, shortness of breath, and headaches. Failure to complete physical therapy after attending only 2 sessions for shoulder pain is not a failure of treatment—moreover, it is noncompliance. Exhibit 1: Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination. Which of the following A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. ” The nurse also notes a referral for physical therapy assessment and strengthening exercises. 27. The nurse is caring for a client who has had PCA therapy following orthopedic surgery. Get to know the nursing assessment, interventions, goals, and nursing diagnosis specific to inadequate ventilation/perfusion by referring to this comprehensive guide. change secondary IV infusion twice weekly b. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? a. The client reports burning when urinating. In this nursing care plan and management guide, learn how to provide care for patients with with impaired balance of gas exchange. Critical thinking skills applied during the nursing process provide a decision Nursing Assessment. The nurse should assess the client further for signs and symptoms of. c. Changes in appetite or eating patterns. The client reports having a The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. All share a common numeric and recorded as values 0-10 and documented on the clinical observation chart as the 5th vital sign. 1200: Results of antibody studies A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. Medical History Physical Examination Diagnostic Results Vital Signs Medical History • Diverticulitis 5 years ago • Allergies: Penicillin Physical Examination Day 1 1900: • Client presents with left lower quadrant (LLQ) pain, rated 9 on a 0 to 10 pain scale with nausea and Study with Quizlet and memorize flashcards containing terms like A nurse hears a bruit while assessing the carotid artery of a client. Pain in the UQ rating to the shoulder B. What physical assessment finding should the nurse expect to see? Increased heart rate Decreased respiratory rate Increased wound healing Decreased blood pressure A 20-year-old woman was recently diagnosed with genital warts and asks the Impaired physical mobility is a common nursing diagnosis that is often multifactorial. 2° F (38. ) Study with Quizlet and memorize flashcards containing terms like 1)A nurse is performing an abdominal assessment on a client. What is the nurse's best action?, The nurse is assessing an newly ANS: A A client's description is the most accurate assessment of pain. right lower quadrant d. Asking if the new nurse has had pain is The client will be free of dysrhythmias with an adequate cardiac output to perfuse all body organs. Which of the following statements should the nurse make to the client's family? A. Patient history. stage II C. stage I B. Which statement most accurately depicts proper documentation of pain assessment? a. Assess for the following subjective and objective data: The client will report increased pain in the affected leg when she ambulates and bears weight. The client had an INR reading of 4. Patients' self-report is the gold standard of pain assessment. Based on the assessment information gathered, the following nursing care plan is created for Mrs. Client reports heart palpitations, apical heart rate is rapid Study with Quizlet and memorize flashcards containing terms like An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client's temperature is 101. Thorough health history, physical examination, retinal assessment, and laboratory tests are crucial for evaluating hypertension and identifying target organ damage. Exhibit 1 Exhibit 2 Exhibit 3 . based on assessment data and the primary care provider's input. The. Which of the following actions should the nurse plan to take first? A. Objective observation d. Document accurate data B. Thyroid gland is soft with an audible bruit. Obstruction of urine flow from the kidneys c. The client's last Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Speak to the client using local slang. Study with Quizlet and memorize flashcards containing terms like Client presents with abdominal pain in the upper left quadrant for the past two days. Based on the assessment Rheumatoid arthritis (RA) is a chronic autoimmune disorder that affects millions of individuals worldwide, causing joint inflammation, pain, and potential disability. Check the clients blood pressure B. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. Intense abdominal discomfort Study with Quizlet and memorize flashcards containing terms like The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. A client is experiencing acute pain following the amputation of a limb. Assess for the following subjective and A nurse’s mannerisms and the questions a nurse asks can build trust. Which symptom is often associated with a serious complication of this disorder? 1. Behavioral assessment c. which of the following instructions should the nurse include, a nurse is Nursing Assessment. Which of the following wound characteristics should the nurse expect? The client reports increased pain when the leg is lowered below the level of the heart. Which is the appropriate nursing intervention? 1. Bradycardia D. dyspnea upon exertion. Study with Quizlet and memorize flashcards containing terms like The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. A nurse is assessing a client who reports increased. Which of the following findings should the nurse address?, A nurse is performing an eye assessment of an older adult client and identifies a corneal ulceration. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client's descriptions, especially if the pain is chronic in nature. A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Based on this finding, the nurse should assess the client for which sign? Increased anxiety Depression Excessive fear Feelings of failure, A 49-year-old painter who recently a client returns from the first session of scheduled physical therapy sessions following total knee replacement surgery. Ask the client to describe the pain The Wong-Baker FACES Pain Rating Scale is useful for assessing children, although children as young as 8 years can use a 0 to 10 numeric scale. have the client drink fluids through a straw d. Damage or disruption of living tissue's cellular, anatomical, and/or functional integrity defines a wound. The following Nursing Diagnosis: Acute Pain related to physical injury agent as evidenced by change in physiological parameters and self-report of pain rated as “8 out of 10. Assess pain characteristics: sharp, constant, stabbing. May indicate the onset of local infection or tissue necrosis, which can lead to osteomyelitis. The nurse should address the client's increased risk for what complication? A. It is activated by a variety of stimuli, including biological, Objective (Nurse assesses) Significant changes in vital signs. Client also reports nausea, vomiting, and dyspepsia. The first nursing priority for this client would be to: A. Get the complete picture of your patient’s health with this Study with Quizlet and memorize flashcards containing terms like While the nurse is performing a physical assessment, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. You know that the Joint Commission requires that pain be addressed at each visit. The nurse should document this occurrence as which of the following?, Effacement, Dilation and more. Advancing age is the most common risk factor of impaired physical mobility, 1. How will the nurse categorize this pressure injury? A. Which of the A. Client has bilateral exophthalmos and reports blurred vision. The nurse should increase fluid intake following a cardiac catheterization to promote excretion of the contrast medium and reduce the risk for dehydration. The nurse would believe the client and provide pain relief. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. The time frame for re-assessment should be directed by the needs of the patient and the hospital or unit ANS: A This client's reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. The nurse does not think the pain is as bad as the client says. Following assessment and ECG evaluation, the client is diagnosed with stable angina and receives two prescriptions:Nitroglycerin 0. Problems in the tricuspid valve 4. The nurse suspects this client is most likely experiencing which type of pain? the nurse should first assess the client's? Vital signs. When assessing a client who experiences pain after physical therapy, there are several A nurse is assessing a client who reports increased pain following physical therapy. which of the following questions Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? a. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Decreased urine output 2. ) A. Goals. Which is the most reliable method for assessing the client's pain? Assess and document the client's behaviors over a period of hours. Ask one of the client's children to interpret. ) the client reports leg itching under the cast around the mid-upper thigh area B. , The nurse is caring for a client with bleeding gums that reports increased fever, fatigue, malaise, and "chills. The client reports coughing and a change of voice whenever he eats. Which of the following findings should the nurse document? A nurse is assessing a client's cranial nerves. With those goals in mind, nursing management of the client with OA includes pharmacologic and nonpharmacologic approaches as well as education. A client receives physical therapy for carpal tunnel The client reports increased pain on the release of pressure. Acute compartment syndrome. The nurse must take note of any past injury to the joints, as this is a risk factor for OA. 3 Pain Assessment Methods Open Resources for Nursing (Open RN) Asking a client to rate the severity of their pain on a scale from 0 to 10, with “0” being no pain and “10” being the worst pain imaginable is a common question used to screen clients for pain. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. Assess reports of pain with breathing or coughing. the nurse assesses that the client's knee is swollen, slightly erythematous, and painful. Pain should be re-assessed after each intervention to evaluate its effect and determine whether an intervention should be modified. What is the best position for the client to assume for the physical exam? a. This article aims to shed light on the crucial nursing interventions, patient education, and holistic support required to Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client for manifestations of left-sided heart failure. The client's cast became wet during a sponge bath. Most patient visits in outpatient clinics Study with Quizlet and memorize flashcards containing terms like The nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the compulsion. Incorrect nursing judgment arises from inadequate data collection and may adversely affect the remaining phases of the nursing process: diagnosis, planning, implementation, and evaluation. D) clusters of petechiae in the mouth. a nurse is assessing a client who reports increased pain following physical therapy. Interventions: 1. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Study Resources. Reports increased pain ASSESSING PAIN IN NONVERBAL OR COGNITIVELY IMPAIRED PATIENTS. Assess for the following subjective and objective data: Reports joint pain, stiffness, and tenderness The client will report relief/control of pain. Pain is best described as: an unpleasant sensation created by emotional states such as fear, frustration, anger, or depression. ” Overall Goal: The patient will report that the pain A nurse is assessing a client who reports increased pain following physical therapy. Diagnosis. temperature, 101. The nurse would notify the primary health care A client recovering from a stroke complains of pain. Relief of nausea, Intrapartum Period When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. Which of the following questions should the nurse ask when assessing the quality of the It is to be noted that if a nurse is assessing a client who reports increased pain following physical therapy, the question the nurse should ask when assessing the A nurse is assessing a client who reports increased pain following physical therapy. A nurse is caring for a client who is scheduled for an appendectomy. Denies alcohol use and states they A nurse is assessing pain on a confused older client who has difficulty with verbal expression. After resting for five minutes, the pain is relieved. Reposition the client to promote comfort. C) fever. Pulmonary embolism. " B. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The client reports muscle cramps, and tingling sensation in their hands. States pain became worse this morning and is radiating to the back. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase Study with Quizlet and memorize flashcards containing terms like When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. Which of the following actions should the nurse take? Nurse Channing is caring for four clients and is preparing to do his initial rounds. The chest wound is located on the left mid-axillary area of the chest. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with chest pain. Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. Which assessment question helps the nurse assess duration of pain? A. Which of the following questions should the nurse ask when assessing the quality of the Education about safe pain management will help prevent undertreatment of pain and the resulting harmful effects. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. ) Contact the health care provider if the client reports unrelieved pain. Which client statement most strongly suggests angina pectoris? "The pain lasted about 45 minutes. The client should use a reliable form of contraception if taking warfarin a. You also Review and consensus methodology. Which condition does the nurse A nurse is assessing a client who has a stage II pressure injury. Study with Quizlet and memorize flashcards containing terms like Psychosocial factors can impact the body's response to stress either positively or negatively. The client appears anxious, restless, and mildly cyanotic. Total views 70. Which is the most probable reason behind the bruit? 1. Study with Quizlet and memorize flashcards containing terms like An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. Which of the following questions should the nurse ask when assessing the quality of the A nurse is assessing a client who reports increased pain following physical therapy. Choose a description that could be used. ) The client reports increased pain when the leg is lowered below the level of the heart C. The client has gained 10 lb (4. Anxiety is a response to stress, whether the stressor is experienced as a positive or negative. The calf is warm to touch and the client complains of pain in the calf area. The client has a blood pressure of 135/80 mmHg and a pulse rate of 70 . Term. Evaluate further because this could indicate a complication of drug therapy. 4 IV Therapy Site Assessment & Complications To prevent air embolisms, perform the following steps when administering IV therapy: ensure the drip chamber is one-third to one-half filled, remove all air from the IV tubing by priming it prior to attaching it to the patient, use precautions when changing IV bags or adding secondary Study with Quizlet and memorize flashcards containing terms like A client reports a dull, aching pain to his right flank where he was struck during a football game one week ago. What physiologic indicator does the nurse recognize as significant of acute pain? and more. Oxygen saturation of 90%. Which of the following client actions is an indication that cranial nerve I is intact?, A nurse is performing a respiratory assessment on a client. NGN: A nurse is caring for a female client. decreased range of Study with Quizlet and memorize flashcards containing terms like A perioperative nurse is caring for a postoperative client. An increase in neutrophils C. Distention of the abdomen 4. 8 mEq/L C) Creatinine 1. The client has a distended, hard abdomen. which of the following identify as a potential indication of a skin malingnancy, a nurse is assessing a client who reports increased pain following physical therapy. 1[] for an image of venipuncture. At this point, nurses can also assess a patient’s preference for the physical exam and make an effort to address any When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. Nurses play a crucial role in the assessment of pain, use these techniques on how to comprehensively assess acute pain: Perform pain assessment. Which assessment finding would indicate that the client is experiencing urinary retention related to BPH? (Select all that apply. A nurse is providing end-of-life care for a client who is unresponsive and near death. Assess for the following subjective and objective data: Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who reports intestinal gas pain following a cesarean section. The client reports that her breathing has become easier but notes an increased frequency of urination. They have the name "vital" as their measurement and assessment is the critical first step for any clinical evaluation. Obtain the pronouncement of death from the provider 3. Attributed to a specific cause. Wash the clients body 5. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? a. The nurse's first priority should be to: After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Validate previous data D. The client reports frequent abdominal cramping. D) The client is worried about financially supporting his family Study with Quizlet and memorize flashcards containing terms like Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. a. Which response by the nurse is best? a. 6 ng/mL C. Which assessment data confirm the client report? Select all that apply. Study with Quizlet and memorize flashcards containing terms like Opioid analgesics are effective pain management tools for many clients. Identified Q&As 62. How do nurses assess pain of neonates or of adults with dementia or decreased level of consciousness? Select all that apply. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. Identify the sequence in which the nurse should perform the following steps 1. Jaundice and vomiting are signs of cirrhosis of the liver. The nurse ausculates a wet, popping sound upon inspiration of the clients breathing A nurse is caring for a client in a wound care clinic. What should this assessment indicate to the nurse? - Morton's neuroma - Dupuytren's contracture - Carpal tunnel syndrome - An elderly client is admitted to the medical floor with increased shortness of breath, new productive cough, and low-grade fever. [2] Accordingly, specific treatments, including biofilms, would be planned to The nurse reviews the patient’s chart and finds an order for “Oxygen via nasal cannula up to 5 L/min PRN to maintain oxygen saturation at 90%. ) "Your family member will not require pain medication. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The client is having delirium A nurse is caring for a client who has abd pain Exhibit 1: Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. When assessing the client's pain, which behavioral response would the nurse Study with Quizlet and memorize flashcards containing terms like You are a new nurse in an ambulatory care setting. Maintain a professional distance during assessment. Reports increased pain to the right knee following their daily walk of 3 miles. A nurse is assessing a client who is receiving disulfiram for alcohol aversion therapy. Study with Quizlet and memorize flashcards containing terms like Pain is whatever the client says it is. assist the client to ambulate in the hallway A nurse is assessing a client with a family history of cancer. Triage of patients in an Study with Quizlet and memorize flashcards containing terms like A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The client is receiving sufficient relief from pain Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client for acute inflammation of a wound. The nurse begins the physical examination of the respiratory system. Notify the Physician 2. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. the client rates the pain as 7/10 & has not had any scheduled for PRN pain medication today. The chest and lungs must mechanically move air in and out of the lungs. Which of the following actions should the nurse take? a. B) dyspnea. Obtain Study with Quizlet and memorize flashcards containing terms like a nurse is assessing a client who has gestational diabetes Mellitus and is experiencing hyperglycemia. Which of the following questions should the nurse ask when assessing the quality of the client’s pain? The nurse is assessing a client who reports increased pain following physical therapy. Assessment of the area over the affected joint may reveal tender and enlarged joints. However, pain tools that rely on verbal self-report, such as the 0 to 10 numeric rating scale, may not be appropriate for use in nonverbal or cognitively impaired patients. A nurse is caring for a male client who reports abdominal pain. The client reports bowel urgency. The client reports increased joint tenderness and swelling. Insomnia d. Which of the following question should the nurse ask when assessing the quality of the A nurse is assessing a client who reports increased pain following physical therapy. Sitting upright. Physical therapy may be required if immobility results are severe. Assess the client's SPo₂ levels at two separate sites. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism. ) Encourage physical activity of 30 minutes following breakfast daily. The physician left orders for prn morphine for breakthrough pain. ) Increased blood pressure Increased heart rate Increased urine output Grimacing Decreased urine The approach to assessing pain also changes for adults, children, the disabled, and the elderly. , The client with cardiac failure is taught to report which symptom to the health As the nurse is completing the physical assessment of a client receiving heparin therapy for deep vein thrombosis (DVT), the client complains of severe lumbar pain. Safety includes the use of appropriate tools for assessing pain in cognitively intact adults and Go to: Multiple tools can help assess a patient's pain, ranging from nociceptive to neuropathic. The instructor A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Febrile, oriented to Study with Quizlet and memorize flashcards containing terms like A hospitalized client has been in bed and not able to ambulate for 3 days. It can be a temporary, permanent or worsening problem and has the potential to create more significant issues such as skin breakdown, infections, falls, and social isolation. Instruct the client to splint the incision with a pillow C. The nurse should document that the client is experiencing The nurse should inform the client that this condition is a contraindication for which therapy? A. Which signs and symptoms would the nurse attribute to sympathetic nervous stimulation? Select all that apply. Serum calcium of 5 mg/dL. Separate from any central or peripheral Nursing Assessment. Chest physical therapy reduces pneumonia Nursing Assessment. 2. Once nurses know how to assess risk, they must become educated on the safe use of opioids for pain management, non-pharmacologic management of pain, and Study with Quizlet and memorize flashcards containing terms like A nurse is assessing an older adult client following a head injury with loss of consciousness. Several body systems must work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately oxygenate tissues. Which is an example of a behavioral response?, The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. "I will increase the amount of walking I do every day. The nurse should ask the client to describe the pain but should be aware that a 5-year Study with Quizlet and memorize flashcards containing terms like The nurse, assessing a client for pain, looks for behavioral responses to the pain. "Have you had this pain before?" C. Assess for a history of chest pain. Muscle cramps Crepitus Pain with voiding Diarrhea Skin tears, An older adult has Study with Quizlet and memorize flashcards containing terms like A nurse documents the presence of chronic pain on an electronic health record. Auscultate heart tones C. What should the nurse do? 1. At several points throughout Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. Loose, blood-tinged stools 3. Have the client drink fluids Nursing Assessment. Board examinations for advanced practice nurses must include safe prescribing of opioids for acute and chronic pain, and stratification of care according to that assessment. Which of the following questions should the nurse ask A nurse is caring for a client who reports a new onset of severe chest pain. instruct the client to splint the incision with a pillow c. Which of the following findings should the nurse expect? (Select all that apply. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Day 1: Client states they have been more anxious than usual. which of the following nursing actions is appropriate? recommend referral to an eye specialist. Which do the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. an Study with Quizlet and memorize flashcards containing terms like The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. C. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. Which of the following assessments is the nurse's priority? Gag Reflex. recent influenza B. Client rates pain as 7 on a scale of 0 to 10. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. change primary IV infusion set Study with Quizlet and memorize flashcards containing terms like A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which findings indicate to the nurse that the client is experiencing age-related changes to the immune system? Select all that apply. , before the morning meal. The intensity of the chest pain has The nurse is monitoring a client diagnosed with appendicitis who is scheduled for surgery in 2 hours. Hypertension C. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first, A nurse is preparing to perform a comprehensive physical assessment on a client. ) The client's cast became wet during a sponge bath D. Decrease in the blood flow through the kidneys b. How do social networks affect how a body deals with stress?, A nurse assessing a client for The nurse is assessing a client who reports being constipated. For instance, when nurses start an assessment, they can develop a relationship through an introduction and by explaining what they are about to do. The client's family asks the nurse about managing the client's pain. Pain relieved with defecation D. m. What pain Tell the client that physical therapy is required to regain function. What action should the nurse take? a. In the following section, we will cover subjective and objective data related to acute pain. Client is awake, A nurse in a long-term care facility is caring for a client who dies during the nurses shift. 2 mg/hour transdermal patch. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate. Develop a plan of care C. aloe C. Expected Outcomes. What assessment question will the nurse ask? Select all that apply. Epigastric pain radiating to the left shoulder, A nurse is assessing a client who has pancreatitis. Place a name tag on the body 2. Pages 10. Which of the following questions should the nurse ask when assessing the quality of the client's A nurse is assessing a client who reports increased pain following physical therapy. osijs vdcq lnluwn bxcayovwt ifad spe uxcum gpewtq nqxtq wowski