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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.

B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.

C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.

D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.

A. Respiratory rate 8/min B. SaO2 94% C. Pain level of 6 on a scale from 0 to 10 D. Sleepy, but arousing when her name is called

Correct Answer is A

Explanation

A. Respiratory rate 8/min: Morphine sulfate is an opioid that can depress respiratory function. A respiratory rate of 8/min is dangerously low and indicates opioid-induced respiratory depression, a serious adverse effect that requires immediate intervention.

B. SaO2 94%: A SaO2 of 94% is within the normal range for many clients and does not indicate an immediate issue.

C. Pain level of 6 on a scale from 0 to 10: This is an expected finding after morphine administration, as it typically reduces pain but may not eliminate it entirely.

D. Sleepy, but arousing when her name is called: Sedation is a common side effect of morphine, but the client being arousable when their name is called is not an alarming sign.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a hospitalized client who is experiencing sensory overload due to the hospital environment. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Correct Answer is A

Explanation

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