A nurse is caring for a who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the worse take to determine the client's level of pain?
Use the FACES pain scale to gauge the client's level of pain.
Use a communication board to interact with the client.
Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level.
Ask an assistive personnel who speaks the same language as the client to interpret.
The Correct Answer is C
Choice A Reason:
Using the FACES pain scale to gauge the client's level of pain is appropriate. This scale relies on the client's ability to understand and communicate using a specific language, which might not be possible if there is a language barrier.
Choice B Reason:
Using a communication board to interact with the client is inappropriate. While communication boards can be helpful, they might not effectively gauge the client's level of pain, especially if the client's primary language isn't available on the board.
Choice C Reason:
Using the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level is appropriate. The FLACC scale is a pain assessment tool that evaluates pain in nonverbal patients or those who can't communicate effectively. It assesses facial expressions, leg movement, activity level, crying, and consolability to determine the level of pain the patient is experiencing.
Choice D Reason:
Asking an assistive personnel who speaks the same language as the client to interpret is inappropriate. Relying on an interpreter, even if they speak the same language as the client, might not be the best approach for pain assessment, as nuances related to pain expression and interpretation might be better captured through a standardized pain assessment tool like the FLACC scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Pushing the skin down while gently removing the tape is incorrect. Pushing the skin while removing tape could cause unnecessary discomfort or trauma to the skin and the incision area. Gentle removal of tape without pulling the skin is recommended to avoid skin injury.
Choice B Reason:
Drying the incision with sterile gauze pads is incorrect. Generally, it's advisable not to dry the incision site with sterile gauze pads as this might cause trauma or disruption to the healing tissues. Patting the incision site dry or allowing it to air dry gently after cleansing is preferable.
Choice C Reason:
Lifting the soiled dressing so that the underside faces the client is correct. Lifting the soiled dressing in a manner that the underside faces the client helps prevent potential contamination of the wound by minimizing contact between the external surface of the dressing and the incision site. This technique reduces the risk of introducing pathogens into the wound during the dressing change.
Choice D Reason:
Cleaning around the drain site using horizontal strokes is incorrect. When cleaning around the drain site, it's typically recommended to use gentle and careful motions without specific emphasis on strokes, as this might cause friction or trauma to the area around the drain. Instead, using gentle circular motions or dabbing around the site is often advised for wound care.
Correct Answer is D
Explanation
A. Devout practitioners of Buddhism prefer a ritual bath prior to burial.
Explanation: In Buddhism, the funeral customs can vary widely depending on the cultural and regional practices. Some Buddhists may prefer cremation, while others may choose burial. There isn't a strict requirement for a ritual bath, and practices can differ.
B. Devout practitioners of Judaism prefer to be buried 5 days after death.
Explanation: In Judaism, there is a tradition of burying the deceased as soon as possible, ideally within 24 hours. Waiting for 5 days is not consistent with Jewish burial practices.
C. Devout practitioners of Hinduism prefer to be buried after death and not cremated.
Explanation: In Hinduism, cremation is a common practice. Hindus believe in the cycle of reincarnation, and cremation is seen as a way to release the soul from the body. Burial is not a typical practice in Hinduism.
D. Devout practitioners of Islam prefer to have their heads turned toward Mecca at death.
Explanation: In Islam, it is a common practice to bury the deceased with their right side facing the Qiblah, which is the direction of the Kaaba in Mecca. This is part of the Islamic funeral rites.
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