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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice a) is correct because copies of insurance cards can help clients access medical care and claim compensation in case of a disaster. Insurance cards can also serve as a form of identification if other documents are lost or damaged.
Choice b) is correct because a whistle can help clients signal for help or locate each other in case of an emergency. A whistle can also deter potential atackers or wild animals.
Choice c) is incorrect because antibiotics are not recommended to be included in a disaster readiness supply kit or “go bag”. Antibiotics are prescription drugs that should only be used under the guidance of a health care provider. Using antibiotics without proper indication, dosage, or duration can cause adverse effects, such as allergic reactions, resistance, or superinfection.
Choice d) is correct because household bleach can be used to disinfect water, surfaces, or wounds in case of a disaster. Household bleach can also be used to create chlorine gas, which can be used as a weapon or a deterrent.
Choice e) is correct because pencil and paper can be used to write down important information, such as contact numbers, medical history, or evacuation plans. Pencil and paper can also be used to communicate with others, especially if there is no access to phone or internet services.
Correct Answer is B
Explanation
Choice a) is incorrect because calcium levels are not directly affected by hemodialysis. Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction. Hemodialysis does not remove calcium from the blood, but it may cause low calcium levels if the dialysate fluid has a lower concentration of calcium than the blood.
Choice b) is correct because potassium levels are decreased by hemodialysis. Potassium is an electrolyte that is essential for nerve and muscle function, especially the heart. Hemodialysis removes excess potassium from the blood, which can build up in people with kidney failure and cause irregular heartbeats, muscle weakness, or even cardiac arrest.
Choice c) is incorrect because protein levels are not decreased by hemodialysis. Protein is a macromolecule that is composed of amino acids and performs various functions in the body, such as building and repairing tissues, transporting substances, and regulating processes. Hemodialysis does not remove protein from the blood, but it may cause low protein levels if the client has a poor diet or loses protein through other means, such as urine or wounds.
Choice d) is incorrect because RBC count is not decreased by hemodialysis. RBCs are red blood cells that carry oxygen throughout the body. Hemodialysis does not remove RBCs from the blood, but it may cause low RBC count if the client has anemia, which is a common complication of kidney failure. Anemia can be caused by reduced production of erythropoietin (a hormone that stimulates RBC production), iron deficiency, or blood loss.
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