Question

A 48-year-old female client is admitted to a telemetry unit after a syncopal episode. She is married, has two elementary school children, and works for the public defender's office. Her past medical history includes atrial fibrillation, dyspepsia, chronic back pain, and a recent urinary tract infection. She denies alcohol or cigarette use and jokes that she is addicted to caffeine. She drinks approximately eight 12-ounce carbonated beverages daily. Her home medication list includes warfarin. The client is diagnosed as having probable peptic ulcer disease. The report from the emergency department includes the following assessment data: - Alert and oriented ×3 - Speech clear and appropriate - Heart rate =104beats/min - Atrial fibrillation - Blood pressure =99/46 mmHg - Oxygen saturation =94% (on room air) - Denies dizziness or lightheadedness - Reports abdominal discomfort - Stool positive for occult blood and H. pylori bacteria - Hemoglobin =15 g/dl.(150 g/L) - Hematocrit =38%(0.38) - INR =2.5 Based on the above assessment data, which priority questions will the nurse include in an initial assessment?

A. "Are you experiencing burning from your urinary infection?"
B. "How long have you been taking warfarin?"
C. "Does your indigestion keep you from sleeping at night?"
D. "What is the cause of your chronic back pain?"
E. "Have you ever been told that you need to lose weight?"
F. "When did your abdominal discomfort start?"
G. "Did you experience cardiac palpitations or chest pain before you passed out?"
H. "How many meals do you eat every day?"
I. Select all that apply

Answer 1

The nurse should ask about the onset of abdominal discomfort, cardiac symptoms before syncopal episode, and duration of warfarin use.

Step-by-step explanation:

Based on the assessment data provided, the nurse should include the following priority questions in the initial assessment:

• Does your abdominal discomfort start? This question helps determine the onset of the symptom and provides important information for evaluating the cause.
• Did you experience cardiac palpitations or chest pain before you passed out? This question helps assess the cardiac status and potential contributing factors to the syncopal episode.
• How long have you been taking warfarin? This question is important to assess the client's anticoagulant therapy and potential interaction with other medications.