HESI Case Study: Adult Nephrolithiasis
Client quietly paces in the ED waiting area with his hands on his hips and rubbing his mid-lower left side. He has a flat facial expression. Which factor is most important for the nurse to consider when interpreting this client's pain behavior?Client's cultural identity.
The nurse takes client to the triage area and performs a focused assessment of his nontraumatic, mid-lower flank pain. If a client has symptoms of tenderness at the costovertebral angle (CVA), what should be the nurse's priority?Assess for bladder distention.
The triage nurse continues to assess client's pain. Which elements should be included in the assessment when using the PQRST assessment method? (Select all that apply.) Quality.
Severity.
Timing.
In 5 minutes, the triage nurse takes the client and his wife to a treatment room, where the ED nurse interviews client about his health history. Which reported chronic condition in his health history is most significant to his acute condition and the reason for this visit?Gouty arthritis.
In 20 minutes, the healthcare provider (HCP) visits client and orders one tablet of hydrocodone/acetaminophen 5 mg/300 mg by mouth (PO) to be given now as a preliminary pain medication. Which data in the client's medical record is important for the nurse to review before administering hydrocodone/acetaminophen? (Select all that apply.) Allergies.
Home medications.
Liver enzymes.
Vital signs.
Client's medical record has no allergies listed. Which action is the best intervention for the nurse to perform next?Confirm with the client if he has no food or drug allergies.
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