Adult Nephrolithiasis HESI Case Study 2023 with
complete solution
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.
Client reports to the nurse that he has a codeine allergy. When he had a cold last
winter, he was prescribed cough syrup with codeine and it gave him a rash all over his
body. The HCP advised his spouse to give him diphenhydramine 50 mg by mouth and it
got better in a couple of days. He states that he stopped taking the cough syrup and he
eventually got better. The nurse records the stated allergy in client's medical record and
prepares to speak with the HCP. Which information is important for the nurse to include
in the conversation with the HCP? (Select all that apply.)
complete solution
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.
Client reports to the nurse that he has a codeine allergy. When he had a cold last
winter, he was prescribed cough syrup with codeine and it gave him a rash all over his
body. The HCP advised his spouse to give him diphenhydramine 50 mg by mouth and it
got better in a couple of days. He states that he stopped taking the cough syrup and he
eventually got better. The nurse records the stated allergy in client's medical record and
prepares to speak with the HCP. Which information is important for the nurse to include
in the conversation with the HCP? (Select all that apply.)
