A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Ask the client to describe the pain.

Identify effective pain relief measures. C. Observe body language and movement.

Provide a numeric pain scale.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe the pain allows for a detailed assessment of the pain's quality, location, intensity, and any aggravating or alleviating factors. This information is crucial for tailoring pain management strategies to the client's specific needs.
B.   Identifying effective pain relief measures is important but comes after understanding the pain's characteristics.
C.   Observing body language and movement can provide clues about pain but is subjective and less accurate than direct communication.
D.   A numeric pain scale measures pain intensity but does not provide information about the quality or nature of the pain.

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Correct Answer is ["A","B","C","D","E","G"]

Explanation

A. Skin pale and diaphoretic: These can be signs of dehydration, infection, or other conditions.
B. Respiratory rate 36 breaths/minute - This is elevated, especially for a child, indicating potential respiratory distress or infection, particularly given the patient's history and current fever.
C. Blood pressure 140/86 mm Hg - This is high for a 7-year-old and could indicate fluid overload or other complications related to his chronic kidney disease.
D. Temperature 101.1° F (38.4° C) orally - Continued fever despite antipyretic treatment suggests ongoing infection or inflammation needing further evaluation.
E. Bilateral basilar crackles - This could suggest fluid in the lungs (pulmonary edema), which is critical given the patient's possible fluid overload and high blood pressure.
F. Bilateral bounding radial pulses is not necessarily a cause of concern in the above case.

G. Heart rate 117 beats/minute and irregular - An elevated and irregular heart rate in a child is concerning and could indicate cardiovascular stress or electrolyte imbalances, which need addressing given his elevated potassium levels.
H. Oxygen saturation 98% on room air: Normal oxygen saturation suggests adequate gas exchange.

A. Length of time of the exposure to tuberculosis. B. Current diagnosis of hepatitis B. C. History of intravenous drug abuse. D. Conversion of the client's purified protein derivative (PPD) skin test from negative to positive.

Correct Answer is B

Explanation

A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.

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A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

Correct Answer is ["A","B","C","D","E","G"]

Explanation

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is B

Explanation

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