HESI Registered Nurse EXIT Practice Exam

What should the nurse do first for an 85-year-old client who complains of generalized muscle aches and pains?

1. Assess the severity and location of the pain

2. Obtain an order for an analgesic

3. Reassure him that this is not unusual for his age

4. Encourage him to increase his activity

The correct answer is: Assess the severity and location of the pain

The first action a nurse should take when an 85-year-old client complains of generalized muscle aches and pains is to assess the severity and location of the pain. This step is critical because identifying the specific characteristics of the pain—such as its intensity, duration, and location—can provide valuable information about its potential causes and help guide further interventions. In this situation, a comprehensive pain assessment allows the nurse to better understand the client's experience and to gather relevant information that might indicate underlying conditions, such as musculoskeletal disorders, neurological issues, or even systemic problems. Conducting a thorough assessment also helps to establish a baseline, which can be useful for tracking changes in the client's condition over time and evaluating the effectiveness of any interventions implemented later. After completing the assessment, the nurse will be in a better position to determine appropriate actions, including whether a medication such as an analgesic may be needed or if encouraging activity might be beneficial for the client’s overall health and mobility. Therefore, prioritizing the assessment of the pain is crucial for ensuring that the subsequent care is tailored to the client's specific needs.