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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

A. Basilar lung sounds that are diminished in the left lung. B. Contraction of the left pupil when light shines in the right eye. C. Capillary refill of 2 seconds in the lower right foot. D. Active bowel sounds in the lower right quadrant.

Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is D

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

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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?