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/).

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C.The patient should remove the old patch before applying a new one to avoid overdose and adverse effects of fentanyl.Fentanyl patches are designed to deliver a constant amount of opioid analgesic over a period of time, usually 72 hours.

Therefore, changing the patch every other day (choice A) would result in inadequate pain relief and withdrawal symptoms.

Applying the patch to a hairy area (choice B) would interfere with the absorption of the drug and reduce its effectiveness.

Cutting the patch in half (choice D) would damage the integrity of the patch and cause erratic or rapid release of the drug, which could be fatal.Fentanyl patches should be applied to a clean, dry, hairless area of intact skin on the upper torso or upper arm.

A. Take the medication with food or milk B. Report any signs of bleeding or bruising C. Avoid taking other NSAIDs concurrently D. Discontinue the medication if tinnitus occurs E. Use enteric-coated tablets to reduce gastric irritation.

Correct Answer is ["A","B","C","E"]

Explanation

The correct answer is choice A, B, C and E.Aspirin is a medication that can prevent cardiovascular events by inhibiting platelet aggregation and reducing inflammation.

However, aspirin also has some side effects that the patient should be aware of and report to the doctor if they occur.

Choice A is correct because taking aspirin with food or milk can reduce the risk of stomach irritation and ulcers that aspirin can cause.

Choice B is correct because aspirin can increase the risk of bleeding and bruising due to its antiplatelet effect.The patient should monitor for signs of bleeding such as black, tarry stools, bloody or cloudy urine, vomiting of blood or material that looks like coffee grounds, and unusual bleeding or bruising.

Choice C is correct because taking other NSAIDs (nonsteroidal anti-inflammatory drugs) concurrently with aspirin can increase the risk of stomach ulcers and bleeding.

NSAIDs include ibuprofen, naproxen, diclofenac, and others.

Choice D is wrong because tinnitus (ringing in the ears) is a sign of aspirin toxicity and should not be ignored.The patient should stop taking aspirin and seek medical attention if they experience tinnitus, confusion, hallucinations, rapid breathing, or seizures.

Choice E is correct because enteric-coated tablets can reduce the gastric irritation caused by aspirin by delaying its release until it reaches the small intestine.However, enteric-coated tablets may not be as effective as regular tablets in preventing cardiovascular events.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?

Correct Answer is C

Explanation

A nurse is educating a patient who has been prescribed aspirin for the prevention of cardiovascular events. Which of the following instructions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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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.)