The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)
Explanation & Rationale
A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain. B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction. C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain. D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary. E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.