An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain.
To assess the intensity of the client's pain, which approach should the nurse use?
Ask the client to describe the pain.
Provide a numeric pain scale.
Identify effective pain relief measures.
Observe body language and movement.
The Correct Answer is B
The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.
According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.
Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.
Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.
Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.
This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.
Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.
Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.
Correct Answer is A
Explanation
After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.
This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.
Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.
Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.
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