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. Use written communication to supplement verbal instructions and ensure the client understands the information. B. Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively. C. Avoid standing in front of the client while speaking, D. Speak loudly and slowly to the client to ensure they can hear you clearly.

Correct Answer is A

Explanation

A. "Use written communication to supplement verbal instructions and ensure the client understands the information." Written communication supports understanding, especially when hearing impairment may limit verbal communication.

B. "Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively." Lip reading alone is insufficient for most hearing-impaired clients. Combining gestures, speech, and written communication is more effective.

C. "Avoid standing in front of the client while speaking." Standing in front of the client is crucial to ensure visibility for lip-reading or interpreting gestures.

D. "Speak loudly and slowly to the client to ensure they can hear you clearly." Speaking too loudly may distort sounds, and slow speech does not always enhance comprehension. Instead, normal tone and clear enunciation are recommended.

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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?

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