A nurse is caring for an older adult client who has difficulty communicating verbally due to aphasia following a stroke.
Which of the following strategies should the nurse use to assess this client’s pain? (Select all that apply.)
Ask yes or no questions
Use a visual analog scale (VAS)
Observe for nonverbal cues
Use open-ended questions
Involve family members or caregivers (Source: https://quizlet.com/580119875/pain-management-ati-flash-cards/).
Correct Answer : A,B,C,E
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”. The client can point to a position on the line that corresponds to their pain intensity. VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain. Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain. They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia. The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D) “Aspirin can cause gastrointestinal bleeding.”
This is because aspirin is a salicylate that works by reducing substances in the body that cause pain, fever, and inflammation, but also prevents blood clots from forming in the arteries.This can increase the risk of bleeding, especially in the stomach or gut.
Choice A) “Aspirin can be taken with alcohol.” is wrong because alcohol can also increase the risk of bleeding and interact with aspirin.
Choice B) “Aspirin can be taken on an empty stomach.” is wrong because aspirin can irritate the stomach lining and cause heartburn, nausea, or vomiting.It is better to take aspirin with food or water.
Choice C) “Aspirin can be taken with antacids.” is wrong because antacids can reduce the effectiveness of aspirin and interfere with its absorption.It is better to avoid taking antacids within two hours of taking aspirin.
Correct Answer is A
Explanation
The correct answer is choice A) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.
Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.
The normal respiratory rate for adults is 12 to 20 breaths/min.
Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.
Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.
Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.
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