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. "Tell me about the visit with your significant other.". B. "I can see that you are feeling lonely.". C. "Would you like to talk for a while?". D. "What did you enjoy about your visit tonight?".

Correct Answer is C

Explanation

This response shows that the nurse is willing to listen and provide support to the client.

It also allows the client to decide if they want to talk and share their feelings.

Choice A is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.

Choice B is not correct because it is not the most therapeutic response.

While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.

Choice D is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.

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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

Which response by the nurse is most therapeutic?

Correct Answer is C

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?