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 D
Explanation
Choice D
This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.
Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.
Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.
Correct Answer is C
Explanation
The nurse should first discuss with the client her meaning of heroic measures.
This will help the nurse to understand the client’s wishes and preferences for her care.
Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.
Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.
Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.
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