A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Pulse and blood pressure findings

Scheduled treatments and client illness

A self-report pain rating scale

Behavioral indicators and aﬀect

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.

Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.

Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineﬀective atrial contractions and variable ventricular response.

Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not aﬀect the heart rate or rhythm, and does not cause any symptoms.

A. The pain usually lasts longer than 20 min. B. The pain persists with rest and organic nitrates. C. Pain can often be relieved by sitting up. D. Exertion and anxiety can trigger the pain.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.

Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.

Choice C Reason: This is incorrect. Anginal pain is not aﬀected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.

Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.

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A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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