A nurse is conducting a pain assessment for a client who reports discomfort. Which of the following actions is the most appropriate for the nurse to take to obtain a comprehensive understanding of the client's pain?
Observe the patient's facial expressions and body language for signs of discomfort.
Measure the patient's vital signs and note any changes.
Review the patient's medical history for past pain management interventions and their outcomes.
Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity.
The Correct Answer is D
A. Observe the patient's facial expressions and body language for signs of discomfort: While observation is important, it doesn't provide a complete picture of the client's pain experience and may not capture all aspects, such as intensity or location.
B. Measure the patient's vital signs and note any changes: Vital signs are important but can be nonspecific indicators of pain and are not as reliable for assessing pain intensity or quality.
C. Review the patient's medical history for past pain management interventions and their outcomes: While this is useful, it does not directly address the client's current pain experience.
D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity. A comprehensive pain assessment requires the client's self-report to fully understand the pain's characteristics. A pain scale (e.g., 0-10) helps quantify the intensity, and asking about its location, duration, and type allows for a thorough understanding of the pain's impact.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Religion is a personal belief system, while spirituality involves organized practices and rituals: This reverses the definitions of religion and spirituality.
B. Religion is exclusively concerned with personal growth and self-improvement, whereas spirituality focuses on adherence to institutional doctrines: This is inaccurate as religion often involves doctrine and spirituality includes personal growth.
C. Religion and spirituality are synonymous and can be used interchangeably in-patient care assessments: They are related but not interchangeable concepts.
D. Religion often includes organized practices, rituals, and community involvement, whereas spirituality is a more personal and individual experience that may or may not include organized practices. Religion is structured and involves established practices, rituals, and communal participation. Spirituality is broader, often focusing on personal meaning, connection, and values, which may exist independently of organized religion.
Correct Answer is A
Explanation
A. Autonomy: Respecting a client’s right to make their own decisions, including the refusal of a protein and calorie supplement, demonstrates the ethical principle of autonomy.
B. Fidelity: Fidelity involves being faithful to commitments and responsibilities, but this scenario focuses on the client’s decision-making rights rather than the nurse’s loyalty.
C. Veracity: Veracity refers to truth-telling, which is not directly related to the client refusing the supplement.
D. Beneficence: Beneficence involves acting in the client’s best interest, but forcing treatment would conflict with respecting autonomy.
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