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 D

Explanation

The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.

Serum bilirubin is a marker of liver function and damage.

A high level of serum bilirubin indicates jaundice, a sign of liver injury.

Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.

Choice B is wrong because serum potassium is not directly affected by acetaminophen.

Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.

Choice C is wrong because serum albumin is a protein that is synthesized by the liver.

Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.

Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.

Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.

Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.

Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.

A. “Aspirin can be taken with alcohol.” B. “Aspirin can be taken on an empty stomach.” C. “Aspirin can be taken with antacids.” D. “Aspirin can cause gastrointestinal bleeding.”.

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.

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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

The nurse is caring for a client who has been prescribed acetaminophen, a non-opioid analgesic, for mild pain. Which laboratory test result should the nurse monitor closely in this client?

Correct Answer is D

Explanation

Which statement made by a client taking aspirin indicates an understanding of its use?

Correct Answer is D

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.)

The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

A patient with chronic back pain is prescribed gabapentin as an adjuvant analgesic. The nurse should instruct the patient to report which of the following adverse effects?

A nurse is teaching a client who has chronic pain about nonpharmacological pain management techniques. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

A patient who is addicted to heroin is admitted to the hospital for treatment of an infection. The patient is prescribed methadone (Dolophine) as part of a detoxification program. What is the rationale for using methadone in this patient?

A nurse is teaching a client who has cancer pain about the use of oral oxycodone with acetaminophen (Percocet). Which statement by the client indicates a need for further teaching?

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.)

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.)