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 B
Explanation
The correct answer is choice B.Methadone blocks the euphoric effects of heroin and discourages its use.Methadone is a synthetic opioid analgesic that produces a cross-tolerance to other narcotics, thereby preventing the user from feeling the high of heroin.Methadone also reduces withdrawal symptoms and cravings for heroin.
Choice A is wrong because methadone does not prevent withdrawal symptoms, but rather reduces them.
Choice C is wrong because methadone does not stimulate opioid receptors, but rather occupies them and blocks their activation by heroin.
Choice D is wrong because methadone does not reverse the respiratory depression caused by heroin overdose, but rather carries a risk of overdose itself.
Correct Answer is D
Explanation
The correct answer is choice D. The patient will experience improved mental status and oxygenation.This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing.Naloxone can be given as a nasal spray or an injection.
Choice A is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
Choice B is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
Choice C is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose.
Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.
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