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 A
Explanation
The correct answer is choice A. Serum calcium.Etidronate is a bisphosphonate that inhibits bone resorption and reduces the risk of skeletal complications in patients with cancer-related bone pain.However, it can also cause hypocalcemia (low serum calcium levels) as a side effect, which can lead to muscle spasms, numbness, tingling, seizures, and cardiac arrhythmias.
Therefore, the nurse should monitor the patient’s serum calcium levels regularly and supplement with calcium and vitamin D if needed.
Choice B. Serum potassium is wrong because etidronate does not affect potassium levels.Potassium is mainly regulated by the kidneys and can be altered by renal impairment, dehydration, acid-base imbalance, or medications such as diuretics or potassium-sparing agents.
Choice C. Serum creatinine is wrong because etidronate does not affect creatinine levels.
Creatinine is a waste product of muscle metabolism that is excreted by the kidneys.It reflects the glomerular filtration rate (GFR) and can be elevated in renal dysfunction or dehydration.
Choice D. Serum albumin is wrong because etidronate does not affect albumin levels.
Albumin is a protein that is synthesized by the liver and helps maintain fluid balance and transport substances in the blood.It can be decreased in liver disease, malnutrition, inflammation, or protein-losing conditions.
Correct Answer is A
Explanation
The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10.This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.
Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.
Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.
Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.
Normal ranges for vital signs are:
• Respiratory rate: 12-20 breaths per minute
• Blood pressure: <120/80 mm Hg
• Pulse oximetry: >95%
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today